Exercise for chronic whiplash: does it matter how we do it?

In the grand scheme of things there is a dearth of high quality research evaluating the effectiveness of treatments for people with a chronic whiplash injury. Much of what has been done has been directed to investigating the effectiveness of exercise interventions. ‘Exercise’ for chronic whiplash has taken many forms including neck specific exercise [1-3], graded whole body activity program [4], or a combination of these two approaches [5]. Regardless of the approach exercise has consistently been found to have, at best, a modest effect on chronic whiplash pain and disability compared to a usual care or a minimal intervention. What these studies can’t tell us however is which type of exercise is most effective for people with chronic whiplash.

Our friends from Sweden and their one Aussie counterpart recently published this well conducted, three arm randomised controlled trial which aimed to answer this exact question. Two hundred and sixteen people with chronic whiplash were randomised to receive:

  1. Physiotherapist led neck-specific exercise program (NSE): Isometric cervical spine exercises were supervised, individually prescribed and progressed in accordance with the participant’s capacity and symptomatic response (with the aim to avoid pain provocation). Participants received 2 physiotherapy sessions/week for 12 weeks in addition to an individualised home exercise program.
  2. Physiotherapist led neck-specific exercise program + behavioural approach (NSEB): The exercise protocol and number of treatment sessions were the same as outlined above however followed a more chronic pain approach where participants were encouraged not to focus on temporary increases in pain, rather improvements in exercise capacity. Participants also received basic behavioural training which included education about physiological and psychological aspects of pain, problem solving and pain management skills e.g. relaxation.
  3. Unsupervised individualised physical activity program (PPA): An individualised whole body (excluding neck specific exercises) program was prescribed by a physiotherapist to increase overall physical activity. Exercises were unsupervised completed at home or in a public gym. Following the initial review, participants received a maximum of one follow up visit or phone call.

As you can see this study really tried to shed light on a number of aspects related to the prescription of exercise for people with chronic whiplash. In particular, should exercise programs be focussed specifically on the neck or the whole body, and are there any added benefits to incorporating a chronic pain behavioural approach.

So what did they find? The physiotherapist led neck-specific exercise program with behavioural approach (NESB) was found to improve neck disability scores more than the unsupervised program (PPA) at both 3 and 6 month follow ups. At 6 months, the difference in change scores was 3.5 points on a 0-50 scale. No between group differences were found for any of the secondary outcomes (current pain, pain bothersomeness and self-efficacy). As we would expect compliance with the exercise intervention was higher in the two supervised groups compared to the unsupervised program. Participants in the unsupervised physical activity program were also found to use significantly more analgesics at both 3 and 6 months.

The findings of this study differ from the results of our recent RCT where we found no difference between a 20 session comprehensive exercise program and a single advice session for people with chronic whiplash associated pain and disability. This difference is probably due to the course of symptoms in the minimal intervention groups in the two studies. Ludvigsson et al reported virtually no change over time in the PPA group, while in our study people receiving the single session of advice improved over the follow up period.

How does this study fit in with what we already know about exercise as a treatment for people with chronic whiplash? This study adds to the growing body of evidence which suggests that neck specific exercise delivered with, or without, a behavioural approach has a modest effect on chronic whiplash pain and disability [4, 6], compared to a minimal intervention involving education and advice about exercise. While neck specific exercise with or without a behavioural approach does not appear to be ‘the answer’ to the complex and heterogeneous condition of chronic whiplash, it does appear to be the best option we currently have. Further, any benefit to be gained from these approaches depends on good engagement from the patient, so measures to maximise compliance are also important.

 About Zoe Michaleff

Zoe MichaleffZoe completed her physiotherapy undergrad at The University of Sydney and a PhD at the George Institute for Global Health in Sydney. She has since migrated north to the warmer and sunnier Queensland shores where she works in a split clinical and research position at Ipswich Hospital and The Royal Brisbane Women’s Hospital. Zoe’s research interests include the diagnosis and management of musculoskeletal conditions primarily whiplash and spinal pain, research methodologies and improving the translation of research evidence into practice. A strong focus of Zoe’s research is to ensure that her work has direct clinical relevance and application to practice. Outside school hours you will find Zoe out running, having fun in the sun, surf or snow and once the sun goes down whipping up a feast in the kitchen!

References

[1] Jull G, Sterling M, Kenardy J, & Beller E (2007). Does the presence of sensory hypersensitivity influence outcomes of physical rehabilitation for chronic whiplash?-A preliminary RCT. Pain, 129 (1-2), 28-34 PMID: 17218057

[2] Fitz-Ritson D (1995). Phasic exercises for cervical rehabilitation after “whiplash” trauma. Journal of Manipulative and Physiological Therapeutics, 18 (1), 21-4 PMID: 7706955

[3] Vikne J, Oedegaard A, Laerum E, Ihlebaek C, & Kirkesola G (2007). A randomized study of new sling exercise treatment vs traditional physiotherapy for patients with chronic whiplash-associated disorders with unsettled compensation claims. Journal of Rehabilitation Medicine, 39 (3), 252-9 PMID: 17468795

[4] Stewart, M., Maher, C., Refshauge, K., Herbert, R., Bogduk, N., & Nicholas, M. (2007). Randomized controlled trial of exercise for chronic whiplash-associated disorders Pain, 128 (1-2), 59-68 DOI: 10.1016/j.pain.2006.08.030

[5] Michaleff ZA, Maher CG, Lin CW, Rebbeck T, Jull G, Latimer J, Connelly L, & Sterling M (2014). Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial. Lancet, 384 (9938), 133-41 PMID: 24703832

[6] Soderlund A, Lindberg P. Cognitive behavioural components in physiotherapy management of chronic whiplash associated disorders (WAD)- a randomised group study. Physiother Theory Pract. 2001; 17:229-38.