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Publicly Available Published by De Gruyter September 27, 2021

Exercise therapy for whiplash-associated disorders: a systematic review and meta-analysis

  • Bruno Chrcanovic , Johan Larsson , Eva-Maj Malmström , Hans Westergren ORCID logo and Birgitta Häggman-Henrikson ORCID logo EMAIL logo
From the journal Scandinavian Journal of Pain
https://doi.org/10.1515/sjpain-2021-0064
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Abstract

Objectives

Acute as well as chronic pain syndromes are common after whiplash trauma and exercise therapy is proposed as one possible intervention strategy. The aim of the present systematic review was to evaluate the effect of exercise therapy in patients with Whiplash-Associated Disorders for the improvement of neck pain and neck disability, compared with other therapeutic interventions, placebo interventions, no treatment, or waiting list.

Content

The review was registered in Prospero (CRD42017060356) and conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search in PubMed, Scopus and Cochrane from inception until January 13, 2020 was combined with a hand search to identify eligible randomized controlled studies. Abstract screening, full text assessment and risk of bias assessment (Cochrane RoB 2.0) were conducted by two independent reviewers.

Summary

The search identified 4,103 articles. After removal of duplicates, screening of 2,921 abstracts and full text assessment of 100 articles, 27 articles that reported data for 2,127 patients were included. The included articles evaluated the effect of exercise therapy on neck pain, neck disability or other outcome measures and indicated some positive effects from exercise, but many studies lacked control groups not receiving active treatment. Studies on exercise that could be included in the random-effect meta-analysis showed significant short-term effects on neck pain and medium-term effects on neck disability.

Outlook

Despite a large number of articles published in the area of exercise therapy and Whiplash-Associated Disorders, the current evidence base is weak. The results from the present review with meta-analysis suggests that exercise therapy may provide additional effect for improvement of neck pain and disability in patients with Whiplash-Associated Disorders.

Keywords: exercise therapy; neck pain; randomized controlled trials; rehabilitation; systematic review; whiplash injuries

Introduction

Whiplash-associated disorder (WAD) is the term given for a constellation of symptoms that are triggered by indirect trauma to the neck with an acceleration–deceleration mechanism, such as falls, car crashes or by direct trauma to the neck, e.g. from hyper-flexion/extension caused by falling objects or during sport events. The annual incidence of whiplash trauma related to car accidents is reported as 2–3 per 1,000 inhabitants [1, 2]. Even if many affected individuals recover, there is still a significant number that develop chronic pain syndromes. During the recovery phase many different interventions have been proposed and this systematic review covers exercise therapy as one possible intervention strategy.

Suffering after neck trauma has been recognized as a large global health problem [3] with a considerable percentage (16–63%) of the injured individuals still reporting symptoms and disability months and years after the injury [4], [5], [6]. However, the term WAD is not defined on a structural level and can emerge from different types of trauma, with varying structures affected, leading to different functional disabilities, in individuals with different biomechanical preconditions and with diverse prerequisites for recovery and healing. So, how might a structured but still individually adaptable intervention facilitate recovery for these patients in a way that provide for sustainable recovery? Although there is a lack of standardized protocols for this heterogeneous patient group, studies suggest that an active involvement and intervention for patients exposed to whiplash trauma can be both less costly, more effective and thereby superior compared to a standard intervention in reducing experienced pain and sick leave [7, 8]. Exercise therapy has been suggested as a promising treatment strategy but the supporting evidence is still ambiguous. Exercise therapy is a concept used to describe interventions with a wide range of different exercises carried out by the patient, most often supervised by a physiotherapist. Theoretically, exercise therapy might be one intervention that promotes normalization of structural changes, remediates function, changes the attitude of the patients’ concept of physical activity, as well as enhances self-efficacy and enablement [9].

In order to provide the best clinical practice, systematic reviews can provide updates on the current evidence base in order to guide the clinician. This is especially relevant in a field where a broad range of therapies is used on a heterogenous patient group. There are several earlier systematic reviews and meta analyses on whiplash-associated disorders and exercise [8, 10], the latest of which include publications up to the years 2013 and 2015 respectively. Since then, however, several new publications have emerged that may add new evidence for treatment and rehabilitation strategies with regard to possible benefit of exercise in the acute or chronic stages after whiplash trauma. And this, together with the fact that both reviews suffered from a paucity of research and, in the case of the latter review [8], a restriction to the WAD II subgroup of patients, demonstrates the need for a new systematic review.

The aim of the present systematic review was to evaluate the existing evidence base for exercise therapy as an effective therapeutic approach for the improvement of neck pain and neck disability as well as for quality of life, psychological well-being, and work capacity after whiplash trauma. The review focused on studies reporting the effect of exercise therapy in patients with WAD compared with other interventions, placebo interventions, no treatment or waiting list.

Methods

The review was carried out in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [11]. A study protocol was published on the International prospective register of systematic reviews (PROSPERO: CRD42017060356) prior to the start of the review.

Participants

Inclusion criteria:

  1. Whiplash-associated disorders, defined as neck pain or disability resulting from a vehicle collision or similar neck trauma

  2. WAD grade I-III [12]

Exclusion criteria:

  1. Malignant diseases

  2. Traumatic brain injuries

  3. Neck pain and disability from abuse, domestic violence, or scuffles

  4. WAD grade IV (fractures) [12]

Studies

Inclusion criteria:

  1. Randomized controlled studies with true (non-quasi) randomized allocation, such as simple, block, or stratified randomization

Exclusion criteria:

  1. Conference abstracts

  2. Grey literature or similar non-peer-reviewed articles

  3. Non-English literature

Intervention and comparator

Interventions were included if they met the criteria for therapeutic exercise set forward by Brody and Hall [9] in Therapeutic Exercise: Moving Toward Function, wherein exercise is defined as “the systematic performance or execution of planned physical movements, postures, or activities intended to enable the patient/client to (a) remediate or prevent impairments, (b) enhance function, (c) reduce risk, (d) optimize overall health, and (e) enhance fitness and well-being.”

Comparators included all other interventions fitting the definition above, or other treatment, no treatment, waiting list, or placebo interventions.

Outcomes

The primary outcomes were

  1. neck pain

  2. neck disability

  3. self-rated recovery

  4. return-to-work (or other activities)

  5. quality of life

  6. emotional outcomes

  7. psychological outcomes.

The only secondary outcome was adverse events.

Search strategy

A search strategy was developed for PubMed in cooperation with an information specialist using a combination of MESH and free text terms (Table 1) and then adapted to Scopus and Cochrane. We targeted randomized controlled trials via the sensitive version of NCBI’s Clinical Queries Filter for Therapy in addition to population- and intervention-specific keywords. All databases were searched from inception. The initial search was carried out March 4, 2017 and updated January 13, 2020.

Table 1:

The initial search query that was developed for PubMed. Mesh terms are denoted by [mh] and title and abstract searched by [tiab]. Asterisks (*) represent wildcards that were used in conjunction with truncated words to increase the sensitivity of the search.

Search terms
#9 #1 AND #5 AND #8
#8 #6 OR #7
#7 physical therapy modalities[mh] OR physical therapists[mh] OR physiotherap*[tiab] OR physical therapy specialty[mh] OR kinesio*[tiab] OR (physical[tiab] AND therap*[tiab])
#6 exercise[mh] OR rehabilitation[mh] OR rehabilitat*[tiab] OR exercis*[tiab] OR train*[tiab]
#5 #2 OR (#3 AND #4)
#4 cervical[tiab] OR neck muscles[mh] OR neck[tiab] OR neck[mh]
#3 injur*[tiab] OR trauma*[tiab] OR traffic[tiab] OR accidents[mh] OR sprains and strains[mh] OR sprain*[tiab]
#2 whiplash injuries[mh] OR whiplash[tiab]
#1 (clinical[tiab] AND trial[tiab]) OR clinical trials as topic[mh] OR clinical trial[pt] OR random*[tiab] OR random allocation[mh] OR therapeutic use[sh]

Study selection

Abstract screening was conducted independently by three researchers (BC, JL, BHH) and any abstracts deemed potentially eligible were included in the full text assessment. For the full-text assessment, the same researchers pairwise independently assessed articles for eligibility applying the inclusion and exclusion criteria. Any disagreements were resolved pairwise by discussion, and if necessary by a third researcher (EMM).

Data collection

Data extraction included participant characteristics, baseline data, features of intervention and control conditions, study population characteristics, intervention, outcomes, main findings and adverse events, and other properties that might matter in terms of the study’s risk of bias. Data extraction was carried out by one researcher (BC or JL) and checked by a second researcher (BHH or BC).

Quality assessment

Two researchers (JL, BHH) independently assessed risk of bias and any disagreements were resolved by discussion. The quality of each publication was rated using the Cochrane Risk of Bias 2.0 Tool, revision 2016. The assessment included grading selection bias, performance bias, detection bias, attrition, and reporting bias.

Statistics

Weighted mean differences were used to construct forest plots of the outcomes, which were both continuous. Whenever outcomes of interest were not clearly stated, the data were not used for analysis. The I2 statistic was used to express the percentage of the total variation across studies due to heterogeneity, with 25% corresponding to low heterogeneity, 50% to moderate and 75% to high. The inverse variance method was used for random-effects or fixed-effects model. Where statistically significant (p<0.10) heterogeneity is detected, a random-effects model was used to assess the significance of treatment effects. Where no statistically significant heterogeneity is found, analysis was performed using a fixed-effects model [13]. The estimates of relative effect for continuous outcomes were expressed in mean difference (MD), with a 95% confidence interval (CI). Only if there were studies with similar comparisons reporting the same outcome measures was meta-analysis to be attempted. Since the minimum of 10 studies eligible for the meta-analyses was not reached, funnel plots (plot of effect size vs. standard error) were not presented. Asymmetry of the funnel plot may indicate publication bias and other biases related to sample size, although the asymmetry may also represent a true relationship between trial size and effect size. The data were analyzed using the statistical software Review Manager (version 5.3.3, The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark, 2014).

Results

The literature search identified 4,103 articles. After removal of duplicates, 2,921 abstracts were screened. Of these, 100 articles were reviewed in full text and after exclusion of 73 articles that did not fulfil the eligibility criteria (Table 2), 27 articles based on 21 study populations reporting data from 2,127 patients with WAD were included in the review (Figure 1).

Table 2:

Excluded studies at full text assessment (n=73).

Main reason for exclusion Articles
Not RCT/peer-reviewed full paper (including conference abstracts, editorials, grey literature, study protocols etc.) Amirfeyz 2009, Armstrong 2005, Castaldo 2017, Florio 1999, Goodman 2000, Landen Ludvigsson 2015, Ludvigsson 2016a+b, Pennie 1990, Peolsson 2013, Peolsson 2016, Rosenfeld 2001, Rushton 2017, Ryan 2002, Scholten-Peeters 2003, Söderlund 2001a+b, Sterling 2001, 2009, Sterner 2001, Turk 2003, Williams 2015, Williamsson 2009 [41, 43, 44, 63, 65], [66], [67], [68], [69], [70], [71], [72], [73], [74], [75], [76], [77], [78], [79], [80], [81], [82], [83]
Inadequate randomization Conforti 2013, Nyström 2016, Faux 2015 [84], [85], [86]
Participants (some or all) did not have whiplash-associated disorders Häkkinen 2007, Humphreys 2002, Lange 2013, Park 2015, Suni 2017 [87], [88], [89], [90], [91]
No intervention consisted of exercise therapy Borchgrevink 1998, Brison 2005, Ehrenborg 2010, Pena-Salinas 2017, Rydman 2020, Svensson 2018, Ventegodt 2004, Wicksell 2008, 2010 [47, 92], [93], [94], [95], [96], [97], [98], [99]
Exercise therapy conflated with other, substantial interventions Antolinos-Campillo 2014, Bonk 2000, Bring 2016, Cote 2019, Dehner 2009, Fernández-De-Las-Pefias 2004, Jull 2013, Lamb 2013, McKinney 1989a, Mealy 1986, Pato 2010, Provinciali 1996, Vassiliou 2006, Wangkham 2019, Vikne 2007 [62, 100], [101], [102], [103], [104], [105], [106], [107], [108], [109], [110], [111], [112], [113]
Exercise intervention did not differ between groups Sterling 2015 [114]
Inadequate eligibility criteria Ekvall Hansson 2006, Stewart 2008, Rebbeck 2006 [115], [116], [117]
Dual publication, overlap in populations or secondary analyses outside the scope of the review Lamb 2012, Ludvigsson 2016, Landén Ludvigsson 2017, 2018a, McKinney 1989b, Peterson 2015, 2018, Rosenfeld 2000, Scholten-Peeters 2006, Treleaven 2016 [40, 42, 118], [119], [120], [121], [122], [123], [124], [125]
Non-English publication Galvez-Hernandez 2016, Giebel 1997, McKinney 1994, Schnabel 2002 [126], [127], [128], [129]
Figure 1: PRISMA flowchart of included and excluded studies.
Figure 1:

PRISMA flowchart of included and excluded studies.

All studies were assessed for risk of bias, and for all but one of the 27 studies some concerns were found (Figure 2A). For a majority of the studies the main concerns related to the selection of reported results, the randomization process and the measurement of outcomes (Figure 2B). Eight studies were deemed to have a high risk of bias. All studies were retained for the qualitative synthesis.

Figure 2A: Assessments of risk of bias for the included studies (n=27).
Figure 2A:

Assessments of risk of bias for the included studies (n=27).

Figure 2B: A summary of risk of bias assessments for the included studies (n=27).
Figure 2B:

A summary of risk of bias assessments for the included studies (n=27).

For all included studies (n=27) [7, 14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], participant characteristics, baseline data, features of intervention and main findings are summarized in Table 3. Thirteen of the included studies, based on seven study populations, incorporated an exercise program of 10 weeks or more.

Table 3:

Qualitative synthesis based on the Interventions (I) and Comparisons (C) of the included studies (n=27).

Author

Year

Reference		 Population

n (age)

Males/females		 Interventions Drop-outs

Follow-up

Analysis		 Results Authors’ conclusions Risk of bias

Comments
Ahadi et al. 2019

Iran [14]		 WAD grade I–III

n=40 (15–64 yrs)

M: 25, F: 15		 I. Vestibular-balance rehabilitation

n=20: 6 wks (2 sessions/wk × 50 min) Exercises included: Standing (foam surface) + head turning, walking (inclined plane) + head turning, standing (trampoline) + side eye movements, heel-to-toe walk on a line, standing on one leg.

C. No intervention n=20		 Drop-outs: DNA

Lost follow-up: DNA

Mean time follow-up.

I: 32 ± 5.6 mo

C: 34 ± 5.0 mo

ITT analysis		 I vs. C, mean (SD)

Smooth pursuit gain

Before: 0.84 (0.01) vs. 0.82 (0.01), p=0.432

After: 0.85 (0.01) vs. 0.82 (0.01), p=0.098

Smooth pursuit neck torsion test

Before: 0.66 (0.01) vs. 0.66 (0.02), p=0.757

After: 0.77 (0.01) vs. 0.66 (0.02), p<0.0001

Dizziness handicap inventory

Before: 43.1 (2.1) vs. 50.8 (3.6), p=0.071

After: 29.6 (2.9) vs. 46.9 (2.0), p<0.0001		 Vestibular-balance rehabilitation exercises can be an effective treatment for dizziness and improving the quality of life of a person suffering from whiplash-associated disorder, followed by the reduction in dizziness caused by disability. Some concerns for bias

Considerable sex imbalance

No study protocol

Mean follow-up but no information on drop-outs
Ardern et al. 2016

Sweden [15]		 WAD grade II–III

Duration 6–36 mo

n=216 (18–63 yrs)

M: 74, F: 142

Primary care setting, healthcare registers in primary and hospital outpatient care		 IA. Neck-specific exercise (NSE)

n=76: 3 mo (2 sessions/wk) + home exercises 2–3 times/day. Deep neck muscle and motor control training + resistance training (pulley weights/guild board), low individualized loads, progression, prescription physical activity

IB. Neck-specific exercise with behavioral component n=71: 3 mo (2 sessions/wk)

Same as IA + behavioral approach

C. Prescription physical activity (PPA) n=69: 3 mo (≥2 sessions/wk)

Motivational interview, physical activity outside of care system, optional follow-up		 Drop-outs: DNA

Lost follow-up:

3/6/12 mo

IA 12/18/18

IB 5/14/14

C 11/16/16

ITT analysis		 Satisfaction with treatment (OR [95% CI])

IA vs. C: OR 1.10 [1.04; 1.17], p=0.002

IB vs. C: OR 1.11 [1.05; 1.18], p<0.001

Enablement (mean change)

IA vs. C: 2.33 units [0.85; 3.81], p=0.002

IB vs. C: 2.71 units [1.11; 4.31], p=0.001

Expectation fulfillment (OR [95% CI])

IA vs. C: OR=4.10 [2.07; 8.13], p<0.001

IB vs. C: OR=4.28 [2.24; 8.19], p<0.001

IA vs. IB: OR=1.04 [0.5; 1.92], p=0.89

No serious adverse events.		 Exercise interventions for chronic WAD led to increased satisfaction for 12 months following treatment that was unrelated to the type of exercise intervention received. Some concerns for bias

Considerable sex imbalance

Carers aware of allocation but no clear-cut control group

The outcome was not included in the study protocol
Ask et al. 2009

Norway [16]		 WAD

Duration 1.5–3 mo

n=25 (18–67 yrs)

M: 11, F: 14

Emergency department (recruitment), hospital clinic (treatment)		 IA. Motor control

n=11: 6 wk (1–2 sessions/wk × 30 min) 6–10 total sessions

IB. Endurance + strength training

n=14: same as A		 Drop-outs:

IA: 2, IB: 6

Lost follow-up:

6 wk/12 mo

IA 0/0

IB 0/0

ITT (shown here) + PP analyses		 IA vs. IB: (median (IQR))

NDI (0–50): 6 wk: 8 (3–17) vs. 10 (4–13.3), p=0.912

12 mo: 11 (7–18) vs. 13.5 (7–18.5), p=0.783

Pain drawing (0–120):6 wk: 6.0 (0–10) vs. 4.2 (2–8), p=0.60

12 mo: 7.0 (3–9) vs. 5.5 (1.8–10.3), p=0.740

Pain morning VAS (0–100) 6 wk: 13.0 (6–38) vs. 23.5 (8–45.5), p=0.227; 12 mo: 37.0 (3–54) vs. 15.5 (−3.3–32), p=0.352

Pain evening VAS (0–100) 6 wk: 27.0 (10–30) vs. 26.5 (9.8–48.3), p=0.622; 12 mo: 52.0 (12–56) vs. 36.5 (8.3–77.3), p=0.565

Tender points ACR (0–18) 16 wk: 6.0 (3–10) vs. 6.5 (2–11), p=0.978; 12 mo: 11.0 (2–13) vs. 9.5 (2.8–13.0), p=0.330		 The changes associated with motor control training and endurance/strength training of neck muscles were similar for reduced disability, pain and for improving physical performance. With a low number of participants and no control group, however, we cannot be sure whether the improvements are due to interventions or other reasons. Some concerns for bias

No study protocol and no reference to ethical review
Bunketorp et al. 2006

Sweden [17]		 WAD

Duration 1.5–3 mo

n=47 (18–61 yrs)

M: 17, F: 30

Rehabilitation center		 IA + IB:

Pamphlet, ergonomic advice, recommended low-intensity exercise twice/wk, exercise diary.

IA. Supervised training

n=24: unclear duration (2 sessions/wk × 60–90 min)

IB. Home training

n=25: unclear duration (2 sessions/day)

Optional bi-weekly counselling		 Drop-outs.

IA: 4, IB: 5

Lost follow-up:

3/9 mo

IA 2/2

IB 0/0

ITT (shown here) + PP analyses		 IA vs. IB, difference proportion patients improved [95% CI]

Self-efficacy 3 mo: p=0.53; 9 mon: p=0.09

Kinesiophobia

3 mo: 30 [3.9; 56.1], p=0.03; 9 mo: −7 [−25.6; 11.8], p=0.48

Pain disability index

3 mo: 23 [−5.2; 50.2], p=0.12; 9 mo: 14 [−8.3, 37.1], p=0.23

Pain intensity (VAS)

3 mo: 12 [−16.5; 39.7], p=0.43; 9 mo: −9 [−37.6; 19.4], p=0.54

Painometer, sensory 3 mo: p=0.12; 9 mo: p=0.54

Painometer, affective 3 mo: p=0.56; 9 mo: p=0.99

Painometer, pain location 3 mo: p=0.89; 9 mo: p=0.21

Painometer, pain duration 3 mo: p=0.68; 9 mo: p=0.72

Palpometer, right side of neck 3 mo: p=0.35; 9 mo: p=0.99

Palpometer, left side of neck 3 mo: p=0.36; 9 mo: p=0.45

Sick-leave

3 mo: 6 (−22.0, 35.2), p=0.66; 9 mo: −2 (−31.0; 26.2), p=0.87

Frequency of consumption of analgesics

3 mo: 32 (4.4, 58.8), p=0.03; 9 mo: −10 (−39.0; 18.0), p=0.47		 The findings indicate a treatment approach that is feasible in the rehabilitation of patients with subacute whiplash-associated disorders in the short term, but additional research is needed to extend these findings and elucidate treatment strategies that also are cost effective. Some concerns for bias

Roughly half of the participants in both groups received concomitant interventions No study protocol Results dichotomized and outcome data omitted
Crawford et al. 2004

UK [18]		 WAD

Within 48 h trauma

n=108 (≥18 yrs)

M: 40, F: 68

Emergency department		 I + C: Initial soft cervical collar + NSAIDs at emergency department

I. Early mobilization

n=55: advise to drop collar + self-mobilization regime

C. Collar

n=53: soft collar 3 wk, then mobilization as I		 Drop-outs:

IA: 2, C: 6

Lost follow-up:

3w/3/12mo

I 0/8/24

C 0/13/22

ITT analysis		 I vs. C, mean scores

Activities of daily living: 3 wk: 7.01 vs. 5.92, p=0.07;

12 wk: 7.43 vs. 7.04, p=0.43; 52 wk: 9.22 vs. 9.33, p=0.62

Pain intensity (VAS): 3 wk: 5.09 vs. 5.62, p=0.24;

12 wk: 3.07 vs. 3.79, p=0.11;

52 wk: 1.79 vs. 1.12, p=0.07

Return to work: 17 vs. 34 days		 Treatment with a soft collar was found to have no obvious benefit in terms of functional recovery after neck injury and was associated with a prolonged time period off work. This study supports the use of an early mobilisation regime following soft tissue injuries of the neck. Some concerns for bias

No study protocol

Missing variability measure for outcome data
Fitz–Ritson 1995

Canada [19]		 WAD

≥3 months

n=30 (19–57 yrs)

M: 19, F:11

Chiropractic treatment 3 mo without resolution of symptoms		 IA + IB: Chiropractic treatment

2 mo (5 sessions/wk)

IA. Rehabilitation exercises

n=15 (M: 11, F: 4)

4 levels, each level 2 wk:

ROM, stretching, isometric–toning, isokinetic strengthening IB. Phasic exercises n=15 (M: 8, F: 7)

2 levels, each level 4 wk: neck–eye coordination exercises		 Drop-outs: DNA

Lost follow-up:

2m

IA 0

IB 0

Unknown type of analysis		 NDI (0–100)

IA vs. IB difference: 26 [95% CI 20; 32], Z=4.5928, p<0.001 (favored IB).

(Wilcoxon-Mann-Whitney test computed from data in article)		 It would appear that any rehabilitation program for chronic neck-injured patients should involve exercises that address the following: eye-head-neck-arm coordinated movements, coordination of the entire vertebral column, and return the “phasic” component of the musculature to functional levels. Additional studies will address the effect of these exercises on the strength, range of motion and pain improvement of the cervical spine in normal, acute and chronic patients. Some concerns for bias

No study protocol
Hansson et al. 2013

Sweden [20]		 WAD + dizziness

n=29 (22–79 yrs)

M: 9, F: 20

Private practice, orthopedic clinics etc.		 I. Vestibular rehabilitation

n=16: 6 wk (12 sessions)

C. No intervention

n=13		 Drop-outs:

I: 8, C: 3

Lost follow-up:

6w/3mo

I 8/8

C 4/3

ITT (shown here) + PP analyses		 I vs. C, median [95% CI difference in median]

VAS pain

6 wk: 64 vs. 62 [0; 1.0], p=0.35

3 mo: 42 vs. 61 [0.0; 6.0], p=0.18		 Neck pain intensity and CROM was not influenced by vestibular rehabilitation. Importantly, the programme did not appear to increase pain or decrease neck motion, as initially thought. Neck pain intensity and CROM correlated with self-perceived dizziness handicap. CROM also correlated with 1 balance measure High risk for bias

Only half of the group completed the intervention

Control group was aware of but received no intervention

No study protocol
Jull et al. 2007

Australia [21]		 WAD grade II

Duration 3–24 mo

n=71 (18–65 yrs)

M: 20, F: 51

Advertising or GP referral, stratification according to pain processing		 IA + IB: 10 wk

IA. Multimodal physical therapy

n=36: 10–15 sessions physical therapist. Low-load neck-shoulder exercises, posture, functional activities, retraining kinaesthetic sense, low-velocity manipulative therapy, education, ergonomic advice.

IB. Self-management program

n=35: Information, education, ergonomic advice, advice to stay active and assurance of recovery, exercise program similar to A.		 Drop-outs:

IA: 0, IB: 0

Lost follow-up:

10w

IA 0

IB 2

ITT analysis		 IA vs. IB: mean change (SD)

Northwich Park neck pain index

−10.4 (14) vs. −4.6 (8.8), p=0.04, Cohen’s d=0.48 (favoring A)

General health questionnaire 28

−5.5 (6.3) vs. −2.7 (8.1), p=0.28

TAMPA scale of kinesiophobia

−1.3 (4.3) vs. −3.4 (4.3), p=0.02 (favoring B)

Impact of events scale

−4.8 (11.6) vs. −1.5 (15.1), p=0.15

No post-hoc analyses of stratified groups		 Post-hoc observations however suggested that relief was marginal in the subgroup with both widespread mechanical and cold hyperalgesia. Further research is required to test the validity of this sub-group observation and to test the effect of the intervention in the long term Some concerns for bias

No study protocol
Klobas et al. 2006

Sweden [22]		 WAD grade II–III

+Temporo-mandibular disorders

Duration ≥6 mo

n=55

M: 16, F: 39

Referral from social insurance workers and county councils		 IA. Rehabilitation program

n=30, 1 month (unclear frequency/length)

General rehabilitation program, pain management, occupational and body awareness therapy, relaxation therapy, postural training, hydrotherapy, electrical stimulation, massage, home exercise.

IB. Same as A + jaw exercises

n=25, 3 sessions/day: therapeutic jaw exercises (relaxation, movements, dynamic + static resistance training and stretching)		 Drop-outs: DNA

Lost follow-up:

3/6mo

IA 1/3

IB 1/5

Unknown type of analysis (ITT or PP)		 Anamnestic dysfunction index score

No significant differences.

Clinical dysfunction index score

No significant differences		 In conclusion, the therapeutic jaw exercises, in addition to the regular whiplash rehabilitation program, did not reduce symptoms and signs of temporomandibular disorders in patients with chronic whiplash-associated disorders Some concerns for bias

No study protocol

No variability measures and inexact p-values
Kongsted et al. 2007

Denmark [23]		 WAD symptoms

≤72 h, examined ≤10 days

n=458 (18–70 yrs)

M: 28%, F: 72%

Referral from emergency departments and general GPs		 All: 6 wk: Information pamphlet (good prognosis for most, simple advice, mild analgesic medication)

CA. Immobilization: semi-rigid neck collar 2 wk, consultation physical therapist after 2 wk, followed by active mobilization program 4 wk (as in C), 0–2 treatment sessions/wk with physical therapist (as in C).

CB. Act-as-usual

1 h information + recommendation to stay active, checklist-based information about WAD, attempt to reduce fear, pain education.

I. Active mobilization

6 wk, 0–2 sessions/wk with physical therapist. Repetitive movements directed by pain response, 3 wk after accident instructed light, repetitive rotational movements each 10 waking hours, posture education, passive mobilization + soft-tissue techniques if insufficient response		 Drop-outs:

CA: 4, CB: 2, I: 4

Lost to follow-up:

3/6/12mo

CA 28/25/12

CB 49/51/27

I 40/41/9

ITT analysis		 No significant differences between any group at any time.

Neck pain (box scale) (median (IQR))

3 mo: p=0.5; 6 mo: p=0.2

12 months, A: 3 (1–7) vs. B: 4.5 (0–8) vs. C: 3 (0–6), p=0.1

Headache intensity (box scale) (median (IQR))

3 mo: p=0.6; 6 mo: p=0.1

12 mo: 4 (0–7) vs. 3.5 (0–7) vs. 2 (0–7), p=0.3

Copenhagen neck functional disability scale

3 mo: p=0.7; 6 mo: p=0.8

12 m: 9 (2–18) vs. 6 (2–18) vs. 7 (2–14), p=0.4

Any analgesic used (% (95% CI))

12 mo: 59 [49; 68] vs. 62 [52; 72] vs. 48 [38; 58], p=0.1

Strong analgesics used 5–7 days (% (95% CI))

12 mo: 6% [2; 11] vs. 11% [5; 18] vs. 4% [0; 8], p=0.1

Affected work ability (% (95% CI))

12 mo: 28% [20; 36] vs. 25 [17; 33] vs. 22 [15; 30], p=0.6

Physical health summary, SF-36 (median [IQR])

12 mo: 46 [34; 56] vs. 46 [35; 54] vs. 46 [36; 55]

Mental health summary, SF-36 (median [IQR])

12 mo: 55 [47; 58] vs. 54 [41; 58] vs. 54 [43; 58]		 Immobilization, “act-as-usual,” and mobilization had similar effects regarding prevention of pain, disability, and work capability 1 year after a whiplash injury. High risk of bias

Large dropout rate
Landén Ludvigsson et al. 2016

Sweden [27]		 See Ardern et al. 2016 [15] See Ardern et al. 2016 [15]

IA. Neck-specific exercise

vs.

IB. Neck-specific exercise with behavioral component

vs.

C. Prescription physical activity		 Drop-outs:

IA: 6, IB: 3, C: 5

Lost follow-up:

12/24 mo

IA 18/37

IB 11/24

C 17/32

ITT analysis		 IA vs. IB vs. C. Mean of change scores (SD)

NDI: 12 mo: −2.8 (7.0) vs. −3.9 (6.5) vs. 0.2 (5.8), p<0.001

24 mo: −1.8 (6.1) vs. −3.7 (6.4) vs. 0.6 (5.7), p=0.001

Patient-specific functional scale

12 mo: 2.3 (2.4) vs. 2.1 (2.7) vs. 0.9 (2.1), p<0.01

24 mo: 1.7 (2.4) vs. 1.5 (2.7) vs. 0.5 (2.3), p=0.02

Pain VAS: 12 mo: −13 (23) vs. −12 (25) vs. −6 (23), p=0.15

24 mo: −14 (25) vs. −14 (22) vs. −10 (26), p=0.67

Pain bothersomeness VAS

12 mo: −15 (27) vs. −13 (26) vs. −8 (24), p=0.29

24 mo: −12 (29) vs. −14 (26) vs. −12 (28), p=0.85

Self-efficacy scale: 12 mo: 6 (26) vs. 8 (31) vs. 0 (36), p=0.41

24 mo: 5 (24) vs. 7 (36) vs. −3 (25), p=0.17		 After 1–2 years, participants with chronic whiplash who were randomized to neck-specific exercise, with or without a behavioural approach, remained more improved than participants who were prescribed general physical activity. High risk of bias

Considerable sex imbalance

Participants with higher disability at baseline dropped out more frequently
Landén Ludvigsson et al. 2015

Sweden [28]		 See Ardern et al. 2016 [15] See Ardern et al. 2016 [15]

IA. Neck-specific exercise

vs.

IB. Neck-specific exercise with behavioral component

vs.

C. Prescription physical activity		 Drop-outs:

IA: 6, IB: 3, C: 5

Lost follow-up:

3/6 mo

IA 12/19

IB 5/14

C 11/16

ITT analysis		 IA vs. IB vs. C. Mean of change scores (SD)

NDI: 3 mo: −2.2 (5.9) vs. −2.7 (4.7) vs. −0.3 (4.3), p=0.02

6 mo: −2.5 (6.0) vs. −3.7 (5.8) vs. −0.2 (5.6), p<0.01

Pain VAS: 3 mo: −10 (28) vs. −9 (24) vs. −2 (25), p=0.17

6 mo: −10 (24) vs. −16 (24) vs. −8 (20), p=0.18

Pain bothersomeness VAS

3 mo: −13 (28) vs. −10 (23) vs. 3 (26), p=0.09a

6 mo: −15 (26) vs. −17 (23) vs. −9 (25), p=0.20

aSignificant for grade 2 WAD in subgroup analysis

Self-efficacy scale: 3 mo: 10 (25) vs. 6 (24) vs. 6 (25), p=0.61

6 mo: 11 (27) vs. 1 (31) vs. 4 (37), p=0.22		 NSE resulted in superior outcomes compared with PPA in this study, but the observed benefits of adding a behavioural approach to the implementation of exercise in this study were inconclusive. Some concerns for bias
Landén Ludvigsson et al. 2019a

Sweden [24]		 See Ardern et al. 2016 [15] See Ardern et al. 2016 [15]

IA. Neck-specific exercise

vs.

IB. Neck-specific exercise with behavioral component

vs.

C. Prescription physical activity		 Drop-outs: DNA

Lost follow-up:

3/6/12 mo

IA 15/24/22

IB 4/11/13

C 45/20/19

ITT analysis		 IA vs. IB vs. C, mean (SD) [95% CI]

EQ-5D 3L: 3 mo: 0.68 (0.23) [0.63–0.74] vs. 0.69 (0.21) [0.63–0.74] vs. 0.62 (0.29) [0.54–0.70]

6 mo: 0.68 (0.29) [0.61–0.75] vs. 0.70 (0.25) [0.64–0.77] vs. 0.63 (0.28) [0.55–0.71]

12 mo: 0.71 (0.24) [0.64–0.77] vs. 0.67 (0.28) [0.60–0.74] vs. 0.62 (0.29) [0.54–0.64]

EQ-VAS:

3 mo: 70 (18) [63–74] vs. 66 (20) [61–73] vs. 61 (21) [54–66]

6 mo: 70 (21) [65–76] vs. 71 (20) [66–78] vs. 64 (20) [59–70]

12 mo: 70 (21) [64–76] vs. 71 (20) [67–78] vs. 62 (21) [55–67]

SF-36 physical score: 3 mo: 45.44 (7.40) [43.24–47.63] vs. 44.85 (6.76) [42.98–46.91] vs. 42.95 (9.20) [40.23–45.68]

6 mo: 45.93 (7.93) [43.24–47.23] vs. 45.46 (7.25) [43.49–47.42] vs. 43.89 (7.70) [41.63–46.14]

12 mo: 46.01 (8.46) [43.65–48.54] vs. 46.22 (7.56) [44.15–48.28] vs. 42.72 (8.47) [40.21–45.23]

SF-36 mental score: 3 mo: 49.37 (12.74) [44.35–54.38] vs. 49.20 (10.05) [46.14–52.26] vs. 47.37 (11.42) [43.02–51.73]

6 mo: 49.75 (9.63) [45.98–53.53] vs. 49.48 (11.23) [46.16–52.80] vs. 46.09 (13.57) [40.85–51.32]

12 mo: 50.71 (10.82) [46.56–54.87] vs. 48.71 (13.44) [44.54–52.89] vs. 46.21 (12.74) [41.39–51.04]		 Neck-specific exercise, particularly with a behavioural approach, may have a more positive impact on HRQoL than physical activity prescription in chronic WAD grades 2 and 3. HRQoL is however complex, and other factors also need to be considered. Factors associated with HRQL and improvements in HRQoL following exercise are multidimensional. Some concerns for bias

Considerable sex imbalance

Carers aware of allocation but no clear-cut control group
Landén Ludvigsson et al. 2019b

Sweden [25]		 See Ardern et al. 2016 [15]

Subgroup with headache n=188		 See Ardern et al. 2016 [15]

IA. Neck-specific exercise

n=64

IB. Neck-specific exercise with behavioral component

n=63

C. Prescription physical activity

n=61		 Drop-outs: DNA

Lost follow-up:

3/6/12 mo

IA 17/11/15

IB 14/3/10

C 15/9/15

ITT analysis		 Headache IA vs. IB vs. C, median (IQR)

Bothersomeness: 3 mo: 11 (0–46) vs. 22 (3–50) vs. 15 (4–53)

6 mo: 10 (1–51) vs. 24 (3–48) vs. 25 (5–54)

12 mo: 16 (81–44) vs. 10 (2–39) vs. 22 (9–61)

Maximum: 3 mo: 30 (6–67) vs. 39 (12–80) vs. 46 (20–80)

6 mo: 42 (5–67) vs. 39 (12–73) vs. 47 (14–80)

12 mo: 39 (7–69) vs. 30 (8–72) vs. 49 (15–74)

Current: 3 mo: 10 (1–30) vs. 9 (1–43) vs. 16 (2–48)

6 mo: 6 (0–46) vs. 8 (1–27) vs. 13 (2–35)

12 mo: 9 (0–40) vs. 10 (1–49) vs. 14 (1–47)		 Headache in chronic WAD, may be reduced with neck-specific exercise with or without a behavioral approach. Chronic headache was associated with neck pain and dizziness regardless of aspect tested. Other factors associated with headache in chronic WAD were mainly physical rather than psychosocial. Some concerns for bias

Considerable sex imbalance

Carers aware of allocation but no clear-cut control group
Lo et al. 2018

Sweden [26]		 See Ardern et al. 2016 [15] See Ardern et al. 2016 [15]

IA. Neck-specific exercise

n=60

IB. Neck-specific exercise with behavioral component

n=57

C. Prescription physical activity

n=48		 Drop-outs: DNA

Lost follow-up:

3/6/12 mo

IA 17/20/22

IB 14/19/16

C 14/11/15

ITT analysis		 IA vs. IB vs. C, raw value (% change from baseline)

Work ability index score: BL: 35.3 vs. 36 vs. 34.9

3 mo: 36.87 (4.5) vs. 37.04 (2.9) vs. 34.28 (1.8)

6 mo: 37.6 (6.5) vs. 37.19 (3.3) vs. 33.64 (3.6)

12 mo: 37.07 (5.0) vs. 38.73 (7.6) vs. 33.49 (4.1)		 This study found that neck-specific exercise with a behavioural approach intervention was better at improving self-reported work ability than neck-specific exercise or prescribed physical activity. Improvement in work ability is associated with a variety of factors. Some concerns for bias

Considerable sex imbalance

Carers aware of allocation but no clear-cut control group
Michaleff et al. 2014

Australia [29]		 WAD I–II

Duration 3 mo–5 yrs

n=172 (18–65 yrs)

M: 64, F: 108

Recruitment by advertising and insurance companies		 I + C: patient educational booklet with simple exercise routine and advice

C. Advice: 30-min consultation physical therapist, booklet, exercises (minimum guidance), answered questions, opportunity to contact physical therapist twice thereafter.

I. Comprehensive exercise program

3 mo: 20 individual sessions × 1 h

2 mo: 2 sessions/wk; 1 mo: 1 session/wk

Aerobic exercise, specific cervical spine exercises, scapular training, posture re-education, sensorimotor exercises, manual therapy. Week 4–6 functional whole-body exercises, week 7 graded activity program including upper and lower limb muscle strength and endurance, functional tasks.		 Drop-outs

C: 2, I: 6,

Lost follow-up

114wk/6/12 mo

C 9/14/11

I 4/11/9

ITT analysis		 C vs. I, point estimates of effect (95% CI)

Pain during previous week: 14 wk: 0.0 [−0.7; 0.7];

6 mo: 0.2 [−0.5; 1.0];

12 mo: −0.1 [-0.8; 0.6]

Pain during previous 24 h 14 wk: 0.3 [−0.4; 1.0];

6 mo: 0.5 [−0.2; 1.2];

12 mo: 0.2 [−0.4; 0.9]

Self-rated recovery: 14 wk: 0.7 [0.3; 1.1];

6 mo: 0.9 [0.3; 1.6];

12 mo: 0.8 [0.1; 1.4]

NDI (%): 14 wk: −1.2 [−4.9; 2.4];

6 mo: −1.1 [−4.8; 2.6];

12 mo: −0.1 [−3.8; 3.5]

Whiplash disability questionnaire: 14 wk: 2.3 [−4.6; 9.2];

6 mo: 3.8 [−3.2; 10.9];

12 mo: 3.2 [−3.7; 10.2]

SF-36 physical score: 14 wk: 0.3 [−2.3; 2.9];

6 mo: 0.7 [−1.9; 3.3];

12 mo: 1.2 [−1.4; 3.8]

SF-36 mental score: 14 wk: 2.4 [−1.0; 5.8];

6 mo: 0.0 [−3.4; 3.4];

12 mo: 0.4 [−3.6; 3.9]

Functional ability: 14 wk: 1.0 [0.3; 1.7];

6 mo: 0.7 [0.0; 1.5];

12 mo:: 0.6 [−0.1; 1.4]		 We have shown that simple advice is equally as effective as a more intense and comprehensive physiotherapy exercise programme. The need to identify effective and affordable strategies to prevent and treat acute through to chronic whiplash associated disorders is an important health priority. Future avenues of research might include improving understanding of the mechanisms responsible for persistent pain and disability, investigating the effectiveness and timing of drugs, and study of content and delivery of education and advice. Some concerns of bias
Overmeer et al. 2016

Sweden [30]		 See Ardern et al. 2016 [15] See Ardern et al. 2016 [15]

IA. Neck-specific exercise

vs.

IB. Neck-specific exercise with behavioral component

vs.

C. Prescription physical activity		 Drop-outs: DNA

Lost follow-up:

3/6/12/24 mo

IA 3/10/9/29

IB 2/12/8/20

C 2/7/7/23

+22 all follow-ups

ITT analysis		 IA vs. IB vs. C. Group-by-time interaction effects

Pain disability index: F=2.0, p<0.05 (favoring B)

Pain catastrophizing: F=2.3, p>0.03 (favoring A and B)

Anxiety: F=1.6, p>0.13

Depression: F=1.6, p=0.16

Kinesiophobia: F=2.9, p=0.01 (favoring A)		 This randomised controlled trial with a 2-year follow-up shows that physiotherapist-led neck-specific exercise with or without the addition of a behavioural approach had superior outcome on general disability and most psychological factors compared to the mere prescription of physical activity Some concerns of bias
Peolsson et al. 2016

Sweden [31]		 WAD grade II–III

Duration 6–36 mo

n=60 (18–62 yrs)

M: 18, F: 42

Physical therapy clinic		 I. Neck-specific exercise

n=31, 3 mo (2 sessions/wk)

Deep neck muscle/motor control training + resistance training (pulley weights/guild board)

Low, individualized loads progression.

C. Waiting list

n=29, 3 mo, no intervention		 Drop-outs:

I: 9, C: 11

Lost follow-up:

3m

A 9

B 11

ITT analysis		 I vs. C, median scores at follow-up [IQR], d = Cohen’s d

NDI: 18 (22.5) vs. 30 (12.0), p=0.009, d=0.88

Neck pain (VAS): 20 (49.5) vs. 52 (48.0), p=0.14, d=0.46

Pain disability Index: 8 (14.2) vs. 18 (11.0), p=0.29, d=0.23

Self-efficacy scale: 180 (49) vs. 154 (31), p<0.001, d=1.26

EQ-5d: 0.73 (0.07) vs. 0.69 (0.47), p=0.009, d=0.37		 Neck-specific exercises were more beneficial than no intervention while on a waiting list for individuals with chronic WAD High risk of bias

Unknown reasons for most drop-outs
Picelli et al. 2011

Italy [32]		 WAD grade I–II

Symptoms ≤72 h

n=18 (18–60 yrs)

M: 7, F: 11

Neurological rehabilitation unit		 I. Mobilization and exercise

n=9

C. Facial manipulation technique

n=9		 Drop-outs:

I: 0, C: 0

Lost follow-up:

2w

I 0

C 0

ITT analysis		 No between-group comparisons of relevant outcomes.

No adverse events		 The fascial manipulation technique may be a promising method to improve cervical range of motion in patients with subacute whiplash associated disorders. Some concerns of bias

No study protocol

No central tendency or variance measurements for pertinent outcomes
Rosenfeld et al. 2003

Sweden [33]		 WAD grades I–II

≤96 h of trauma

n=97

M: 29, F: 59

Recruitment from primary care, emergency departments, private clinics		 CA. Standard intervention within 96 h

n=21, information injury mechanisms, advice activities, posture, rest neck first weeks, a collar could be helpful, instructions active movements 2–3 times/day after a few weeks.

IA. Active intervention after 2 weeks n=23, initial phase: Information, postural control + cervical rotation exercises. If symptoms unresolved for 20 days, 2nd phase treatment McKenzie principles for 6 weeks.

CB. Standard intervention after 2 weeks n=22, as A but delayed 2 weeks.

IB. Active intervention within 96 h

n=22, as B but initiated within 96 h		 Drop-outs

CA: 1, IA: 0, CB: 4, IB: 0

Lost follow-up:

3mo/3yrs

CA 1/3

IA 3/2

CB 2/4

IB 2/4

ITT analysis		 CA + CB vs. IA + IB; ANOVA/Friedmann’s test

Change in pain intensity (VAS)

6 mo: p<0.001/<0.001; 3 yrs: p=0.02/0.026 (favoring A/C)

Sick leave days ns/p=0.03 (favoring A/C)		 In patients with whiplash-associated disorders, active intervention is more effective in reducing pain intensity and sick leave, and inretaining/regaining total range of motion than a standard intervention. Active intervention can be carried out as home exercises initiated and supported by appropriately trained health professionals. Some concerns for bias
Rosenfeld et al. 2006

Sweden [7]		 See Rosenfeld et al. 2003 [33] See Rosenfeld et al. 2003 [33] See Rosenfeld et al. 2003 [33] ANOVA/Friedmann’s test

Sick-leave days

6 mo: p>0.05/>0.05; 3 yrs: p>0.05/=0.03 (favoring A/C)

Costs

6 mo: p>0.05/p>0.05; 3 yrs: p>0.05/<0.01 (favoring A/C)		 For patients exposed to whiplash trauma in a motor vehicle collision, an active involvement and intervention were both less costly and more effective than a standard intervention. Some concerns for bias.
Schnabel et al. 2004

Germany [34]		 WAD grade I–II, symptoms ≤48 h

n=200 (≥18 yrs)

M: 77, F: 123

Trauma clinic		 I + C: Diclofenac 50 mg 3/day

C. Collar therapy

n=97, 1 wk continually

I. Exercise therapy

n=103, 2–5 visits with physical therapist

Exercises for mobilization		 Drop-outs: DNA

Lost follow-up:

6w

C 35%

I 15%

Unclear type of analysis.		 C vs. I

Neck pain (VAS), mean (SD)

1.60 (2.15) vs. 1.04 (1.81), p=0.047

Neck pain and disability (NDI), mean (SD)

1.56 (2.22) vs. 0.92 (1.70), p=0.042		 Early exercise therapy is superior to the collar therapy in reducing pain intensity and disability for whiplash injury. High risk of bias

Pseudo-random allocation

Large and unbalanced dropout rate
Scholten-Peeters 2006

The Netherlands [35]		 WAD I–II

Symptoms ≤48 h prevailing 4 wk

n=80 (18–55 yrs)

M: 27, F: 53

Primary care, emergency departments		 I + C: Advice maintain usual activities, not use soft collar, use analgesics/NSAIDs, dynamic biopsychosocial treatment protocol.

Max duration 9 mo, no limit on number of sessions. Treatment until treatment goals reached or no prospect of positive results.

C. General practitioner care n=42

10 min education, advice graded activity

I. Physical therapy

n=38, 30 min education, advice, graded activity, exercise therapy, progressive loading for neck and shoulder, posture, balance. Functional activities. Manual techniques permitted but not first choice.		 Drop-outs:

I: 0, C: 0

Lost follow-up:

8/12/26/52 wk

I 0/0/0/0

C 0/0/0/0

ITT (shown here) + PP analyses		 Mean difference C vs. I (95% CI)

Neck pain intensity (VAS 0–100)

8 w: 0.5 (−10.6–11.6); 12 w: −10.2 (−22.6–2.2);

26 w: 3.8 (−8.5–16.1); 52 w: −0.2 (−12.2–11.9)

Headache intensity (VAS 0–100)

8 w: 1.6 (−11.8–15.0); 12 w: 2.8 (−11.8–17.4);

26 w: 9.0 (−6.6–24.6); 52 w: 11.5 (−4.0–26.9)

Work activities (VAS 0–100)

8 w: 7.9 (−6.0–21.8); 12 w: 8.8 (−5.0–22.7);

26 w: 15.9 (−1.5–33.3); 52 w: 23.5 (7.6–39.3), p≤0.01

Tampa scale 12 w: 0.3 (−3.0–3.6); 52 w: −1.0 (−3.9–1.8)

NDI (0–50) 12 w: −0.1 (−3.1–3.0); 52 w: 1.9 (−1.2–5.1)

Social activities (VAS 0–100) 12 w: 12.1 (1.5–22.6), p≤0.01; 52 w: 12.7 (1.9–23.5); p≤0.01

SF-36: 12 w: 5.7 (−1.1–12.4); 52 w: 5.9 (−1.3–13.1)

PCI: 12 w: 0.8 (−3.1–4.7); 52 w: 2.6 (−1.4–6.5)		 We found no significant differences for the primary outcome measures. Treatment by GPs and PTs were of similar effectiveness. The long-term effects of GP care seem to be better compared to physiotherapy for functional recovery, coping, and physical functioning. Physiotherapy seems to be more effective than GP care on cervical range of motion at short-term follow-up. High risk for bias

Some patients received co-interventions
Seferiadis et al. 2016

Sweden [36]		 WAD I–III

Symptoms ≥1 year

n=113 (mean 48 yrs)

M: 32, F: 81

Recruitment medical records

Primary health care		 I + C: 10 wk (2 sessions/wk × 90 min)

Group-based (max 12 patients/group)

I. Exercise therapy

n=57

45 min: muscle strengthening, aerobic exercise, and coordination exercise

15 min: stretching

20 min: progressive muscle relaxation

C. Basic body-awareness therapy

n=56

Exercises based on activities of daily living, meditation, Tai-Chi-inspired exercises.		 Drop-outs:

I: 9, C: 7

Lost follow-up:

0/3 mo

I 1/1

C 3/3

ITT analysis		 I vs. C, mean change, [95% CI], Cohen’s d

NDI (0–50) BL: d=0.37, p=0.07

3 mo: −1 [−2.5; 0.4] vs. −2 [−3.5; −0.5], d=0.18, p=0.37

Physical functioning BL: d=−0.54, p=0.032; 3 mo: d=−0.48, p=0.96

Role – physical BL: d=−0.11, p=0.57; 3 mo: d=0.04, p=0.96

Bodily pain BL: d=−0.31, p=0.11; 3 mo: d=−0.4, p=0.044

General health BL: d=−0.27, p=0.16

3 mo: 4.5 [−0.1; 9] vs. 7.5 [2.4; 12.6], d=−0.4, p=0.044

Vitality BL: d=−0.3, p=0.12; 3 mo: d=−0.08, p=0.69

Social functioning BL: d=−0.33, p=0.10

3 mo: 3.5 [−3; 9.9] vs. 13.3 [6.6; 19.9], d=−0.41, p=0.037

Role – emotional BL: d=−0.03, p=0.44; 3 mo: d=−0.12, p=0.53

Mental health BL: d=0.03, p=0.86; 3 mo: d=−0.09, p=0.64

Adverse events: 1 partial calf muscle rupture		 The present trial indicates that body-awareness therapy led to greater improvements than exercise therapy for the patients with chronic WAD. Some concerns for bias.

Body awareness scale and Tampa scale not reported despite included in study protocol
Söderlund et al. 2000

Sweden [39]		 WAD after traffic accident, notable symptoms

n=66 (18–60 yrs)

M: 24, F: 35

Emergency department (recruitment), hospital clinic (treatment)		 I + C: Instructions alternate rest/activities, keep neck from getting cold, regular strolls, posture, 3 movement exercises 3 times/day.

C. Regular treatment

n=32

I. Additional treatment

n=34

Kinaesthetic retraining exercise 3 times/day		 Drop-outs:

C: 3, I: 4

Lost follow-up:

3/6 mo

C 6/6

I 7/7

Unclear type of analysis		 C vs. I, mean (SD)

No significant group differences or treatment × time interaction

Pain disability index (0–70) 3 mo: 15.6 (14.8) vs. 19.6 (16.5);

6 mo 15.1 (13.8) vs. 15.8 (13.9)

Self-efficacy scale (0–200) 3 mo: 161.5 (34.2) vs. 157.8 (35.7);

6 mo 163.6 (31.3) vs. 160.1 (40.6)

Pain intensity (VAS 0–10) 3 mo: 2.2 (2.0) vs. 2.6 (2.4);

6 mo: 2.0 (1.7) vs. 1.8 (1.9)		 This home exercise programme, including training of neck and shoulder ROM, relaxation and general advice seems to be sufficient treatment for acute WAD patients when used on a daily basis. Additionally, patients reporting low self-efficacy and high disability levels may profit from more attention initially, as these psychological factors are significant predictors of pain at long-term follow-up. Some concerns for bias

Baseline data only available on a few variables
Sterling et al. 2019

Australia [37]		 WAD grade II–III

Duration ≤4 wk

n=108 (18–65 yrs)

M: 41, F: 67		 IA + IB: Educational booklet, participants asked not to change medications for the 6-wk intervention period.

Exercises: 2 sessions/wk (wk 1–4) + 1 session/wk (wk 5–6)

Exercises: to improve movement, strength and endurance of the neck and shoulder girdle muscles, as well as exercises to improve eye/head coordination. Exercises progressed in terms of increasing difficulty and load. Patients advised to return to normal activities including work and on undertaking general aerobic exercise in a submaximum and progressive manner.

IA. Stress inoculation training and exercise

n=53

6 weeks

1 session/week

Strategies to assist managing acute stress responses

IB. Standard physiotherapy exercise

n=55

The exercises described above.		 Drop-outs

IA: 1, IB: 3

Lost follow-up:

6wk/6/12mo

IA 1/3/2

IB 1/3/4

ITT analysis		 IA vs. IB, mean (SD)

NDI (0–100) BL: 44.9 (13.9) vs. 41.7 (11.2); 6 wk: 25.5 (18.5) vs. 33.1 (16.4); 6 mo: 24.8 (19.9) vs. 27.9 (16.2); 12 mo: 23.6 (20.2) vs. 28.7 (17.1)

Posttraumatic stress diagnostic scale (0–51) BL: 20.9 (12.2) vs. 16.0 (10.3); 6 wk: 12.1 (12.0) vs. 13.1 (10.3); 6 mo: 9.5 (12.2) vs. 10.2 (10.3); 12 mo: 11.2 (12.4) vs. 10.7 (9.6)

DASS-stress (0–42) BL: 15.8 (10.1) vs. 14.2 (9.6); 6 wk: 10.5 (8.7) vs. 15.4 (9.4); 6 mo: 11.0 (9.7) vs. 13.7 (8.5); 12 mo: 12.4 (10.1) vs. 13.1 (8.9)

DASS-anxiety (0–42) BL: 12.0 (10.3) vs. 7.6 (8.3); 6 wk: 7.0 (8.4) vs. 7.0 (7.9); 6 mo: 7.5 (7.8) vs. 7.5 (7.7); 12 mo: 9.3 (9.8) vs. 7.0 (6.9)

DASS-depression (0–42) BL: 12.7 (10.7) vs. 9.4 (9.3); 6 wk: 7.8 (8.8) vs. 9.7 (8.7); 6 mo: 8.0 (9.1) vs. 9.7 (8.6); 12 mo: 9.7 (10.5) vs. 9.7 (9.9)

PCS (0–52) BL: 17.5 (12.8) vs. 16.7 (13.2); 6 wk: 8.8 (9.7) vs. 11.3 (11.3); 6 mo: 9.9 (13.1) vs. 10.7 (10.5); 12 mo: 10.0 (12.1) vs. 10.6 (12.4)

Pain self-efficacy questionnaire (0–60) BL: 27.5 (14.0) vs. 32.8 (13.7); 6 wk: 41.5 (15.4) vs. 41.7 (15.1); 6 mo: 38.4 (19.5) vs. 41.6 (15.0); 12 mo: 41.1 (18.4) vs. 39.5 (15.8)

SF-36 physical score BL: 36.5 (8.4) vs. 38.4 (7.8); 6 wk: 43.0 (10.6) vs. 45.2 (9.7); 6 mo: 43.7 (11.5) vs. 46.7 (9.2); 12 mo: 44.7 (11.1) vs. 45.1 (9.8)

SF-36 mental score BL: 33.2 (12.7) vs. 37.8 (11.3); 6 wk: 40.1 (12.6) vs. 35.5 (13.1); 6 mo: 40.9 (13.6) vs. 38.3 (11.3); 12 mo: 40.6 (13.5) vs. 39.5 (11.5)

Average pain intensity in the past 24 h (0–10)

BL: 5.4 (1.8) vs. 5.2 (1.9); 6 wk: 2.5 (2.2) vs. 3.7 (2.4); 6 mo: 2.6 (2.4) vs. 3.4 (2.5); 12 mo: 2.9 (2.3) vs. 3.7 (2.7)

Global recovery (−5 to +5) 6 wk: 2.9 (1.8) vs. 1.3 (2.5); 6 mo: 2.5 (2.3) vs. 1.8 (2.4); 12 mo: 2.5 (2.3) vs. 1.5 (2.3)		 A physiotherapist-led intervention of stress inoculation training and exercise resulted in clinically relevant improvements in disability compared with exercise alone—the most commonly recommended treatment for acute WAD. This contributes to the case for physiotherapists to deliver an early psychological intervention to patients with acute WAD who are otherwise at high risk of a poor outcome. Some concerns for bias

Sex imbalance
Stewart et al. 2007

Australia [38]		 WAD I–III

≤1 month of trauma

n=134 (mean 43 yrs)

M: 45, F: 89

Recruitment through claimants

Physical therapy clinics		 C. Advice

n=68, standardized education, reassurance, encouragement. One consultation, 2 follow-up phone calls, written report.

I. Graded exercise and advice

n=66, 6 wk: 3 sessions/wk (wk 1–2)

2 sessions/wk (wk 3–4)

1 session/wk (wk 5–6)

60 min/session (30 min supervised)

Individualized, progressive, submaximal exercise program with focus on functional activities. Aerobic exercise, stretching, trunk and limb strengthening. Principles of cognitive behavioral therapy.		 Drop-outs: DNA

Lost follow-up

6wk/12mo

C 2/6

I 0/3

ITT analysis		 C vs. I, mean change [95% CI]

Pain (box scale 0–10)

6 wk: −1.1 [−1.8; −0.3], p=0.005; 12 mo −0.2 [−1.0; 0.5], p=0.59

Bothersomeness (box scale 0–10)

6 wk: −1.0 [−1.9; −0.2], p=0.019; 12 mo: 0.3 [−0.6; 1.3], p=0.48

PSFS (0–10)

6 wk: 0.9 [0.3; 1.6], p=0.006; 12 mo: 0.6 [−0.1; 1.4], p=0.100

NDI (0–50)

6 wk: −2.7 [−4.5; −0.9], p=0.004; 12 mo: −2.3 [−4.9; 0.3], p=0.08

SF-36 physical summary (0–100)

6 wk: 3.6 [1.3; 6.0], p=0.003; 12 mo: 1.9 [−1.4; 5.1], p=0.260

SF-36 mental summary (0–100)

6 wk: 4.6 [1.4; 7.9], p=0.005; 12 mo: 1.8 [−1.8; 5.4], p=0.330

Global perceived effect (−5–5)

6 wk: 0.9 [0.3; 1.6], p=0.006; 12 mo: 0.3 [−0.5; 1.0], p=0.480		 High levels of baseline pain intensity were associated with greater treatment effects at 6 weeks and high levels of baseline disability were associated with greater treatment effects at 12 months. In the short-term exercise and advice is slightly more effective than advice alone for people with persisting pain and disability following whiplash. Exercise is more effective for subjects with higher baseline pain and disability. High risk of bias

Treatment credibility significantly lower in advice group

  1. p-values in bold indicate statistical significance. WAD, Whiplash Associated Disorders; DNA, Data not available; ITT, Intention to treat; NSE, Neck specific exercises; PPA, Prescription physical activity; CI, Confidence Interval; IQR, Interquartile range; PP, per protocol; NDI, Neck Disability Index; VAS, Visual Analogue Scale; ACR, American College of Rheumatology; NSAIDs, Non-steroidal anti-inflammatory steroids; ROM, Range of movement; CROM, Cervical range of movement; SF-36, 36-Item Short Form Survey; EQ-5D 3L, Euro Quality of Life five-dimensional instrument 3-level version; HRQoL, Health related quality of life; BL, Baseline; PCI, Pain Coping Inventory; DASS, Depression, Anxiety and Stress Scale; PCS, Pain Catastrophizing Scale; PSFS, Patient-Specific Functional Scale.

Interventions

Exercise therapy as defined by Brody and Hall [9] is met in varying degrees in the included articles. Thus, the exercises span from a single primary exercise, cervical rotation [7, 33], to sets of exercises addressing different functions, commonly affected in the target population [31, 40], [41], [42], [43], [44]. In some of the primary studies cognitive aspects are explicitly addressed, directly or indirectly. Some studies favour individualization with progression built into the concept, whereas others have more standardized setups, where individual adaptations of the original plan were not allowed [36]. In some studies, training in between the scheduled or supervised sessions was emphasized, whereas in other studies the participants’ activities in between sessions were not described. A wide range of exercises, including postural adjustments, graded activities, coordination, strength and aerobic exercises, as well as therapies encompassing empowerment, motivational aspects, and counselling were used not only in intervention-groups but also in some control groups. In general, specific exercises seem to be more common in the acute stage, whereas (body) awareness seem to add benefits at later stages. Cognitive and psychological modalities are also integrated in some interventions as additional amplification [15, 24], [25], [26], [27], [28], [29].

Study populations

The patient cohorts in the primary studies vary from those in acute stages to chronic conditions, with a history of single or multiple whiplash trauma. Also, the symptom presentation varies between different studies, from localized to combined with other symptoms. Gender distribution were skewed in many of the included studies with more women than men.

The type of patients included in the primary studies varied, adding to the complexity of the already known heterogenicity among patients with WAD. Whereas some studies recruited only patients who still had symptoms or restrictions in work-related activities some weeks [16, 17, 35] or months after whiplash trauma [15, 21, 22, 24], [25], [26], [27], [28], [29], [30], [31, 36, 38], other studies only included acute or subacute patients [7, 18, 23, 32], [33], [34, 37, 39], or did not provide information regarding this matter [14, 20].

Outcome measures

Most of the included studies in the present review reported changes in cervical range of motion and pain intensity. Other commonly used outcome measures were NDI and the 36-Item Short Form Survey (SF-36), covering functional health-physical functioning, physical role functioning, bodily pain, general health, vitality, social functioning, emotional role functioning, mental health and disability. Less commonly used outcome measures concerned quality of life, eye tracking movement analyses, visual disturbances, dizziness disability handicap, kinaesthetic sensibility, pain and headache bothersomeness, recovery expectations, self-efficacy, enablement, experienced improvement, kinesiophobia, CNS hyperexcitability, psychological distress, anxiety and depression, coping strategies, pain catastrophizing, analgetic consumption, adherence, ADL and work capacity, sick leave, disability in social activity, health care consumption and monetary compensation status.

Two studies [27, 28] reported that neck-specific exercises provided by a physiotherapist were better than general physical activity whereas other studies did not show additional effects from active mobilization program compared to no intervention [23] or from physiotherapy exercise program compared to advice only [29].

For the reduction of sick leave an active involvement and intervention was more costly and only marginally more effective than home training alone [17]. When comparing early neck mobilization to the use of soft collar, no differences regarding recovery of function was seen, but the soft collar group took significantly longer to return to work [18].

Meta-analysis

A total of 5 out of the 27 included studies could be included also in the meta-analysis. All of these included the outcome measure pain intensity [29, 31, 34, 35, 38], and four studies were also included in the meta-analysis for neck disability [29, 31, 35, 38]. The most common reasons for studies not being eligible for the meta-analysis were lack of control groups not receiving active treatment, as a majority of studies either did not have a control group, or included a control group that also carried out some type of exercise. Given that less than 10 studies were included in the meta-analysis, it was not deemed suitable to assess publication bias by presenting a funnel plot.

The random effects meta-analysis showed a significant effect from exercise on neck pain intensity at 6–8 weeks after treatment, but no significant effect after 10–12 weeks (Figure 3). For neck disability, the meta-analysis based on four studies showed a significant effect (Figure 4). This result was mainly driven by the study by Peolsson et al. [31].

Figure 3: Random-effect meta-analysis for effect on neck pain intensity for exercise groups compared to non-exercise groups at 6–8 weeks (n=3) and 12–14 weeks (n=2).
Figure 3:

Random-effect meta-analysis for effect on neck pain intensity for exercise groups compared to non-exercise groups at 6–8 weeks (n=3) and 12–14 weeks (n=2).

Figure 4: Random-effect meta-analysis for effect on neck disability for exercise groups compared to non-exercise groups at 6 weeks (n=1) and 12 weeks (n=3).
Figure 4:

Random-effect meta-analysis for effect on neck disability for exercise groups compared to non-exercise groups at 6 weeks (n=1) and 12 weeks (n=3).

Discussion

The objective of this study was to assess if exercise therapy can be effective in treating subjects with WAD in comparison to other therapeutic approaches. Since the studied target populations were heterogenous both regarding types of trauma, timing, outcome measures covering different aspects of consequences and different treatment strategies, no firm consensus that can be drawn from this updated state of the art. However, based on the results from the included studies, there are some helpful aspects to consider, as discussed below.

Study populations

Gender distribution were skewed in many of the included studies with more women than men, a phenomenon reflecting gender differences described in several other reports about neck-trauma consequences, especially in the chronic phase [45]. There was also a large variation with regard to the time elapsed since trauma. This could have influenced the results by adding to the heterogeneity between the included studies. Ten of the included 27 studies were published 2015 or later showing a continued effort to evaluate the effect of exercise for this patient group. One aspect of evidence based medicine is to stay updated on the current evidence base in order to provide the best clinical practice. Systematic reviews can provide such updates, however, from the studies that could be included in the present meta-analysis, the more recent studies (published after 2015) did not deviate from the results of the studies published before 2015.

Control groups and natural course

Many of the primary studies lacked an untreated control group, making it impossible to know how the participants’ condition would have developed if left untreated. Such studies can only support conclusions based on the relative differences between active treatment groups and cannot show to what extent treatment has improved the natural course after trauma. Many patients recover from whiplash injuries within a few weeks or months as a result of spontaneous recovery [12, 46, 47], although a considerable proportion may still have pain and disability one year after the trauma [16, 46]. Several studies indicated that the improvement of neck disability and pain is greatest during the first weeks after injury, but less noticeable in the period after the intervention and additional months of follow-up [15], [16], [17, 38]. This may suggest that improvements in enablement achieved early are maintained over time [15], but that patients still symptomatic after 2 months are more likely to suffer prolonged disability [48]. One systematic review reported that more than half of individuals continue to report symptoms six months after injury [49] and it has been shown that persistent symptoms at six months are associated with varying degrees of physical and psychological symptoms [50], [51], [52].

Outcome measures

When conducting clinical trials, the task to cover all varying consequences after neck trauma in a structured but still individualized way is a challenge, recently addressed by the CATWAD group [53]. The large selection of outcome measures in the present review reflects the wide range of possible consequences after whiplash trauma and highlights the complexity in designing and evaluating structured interventions suitable for all patients. Changes between intervention and control groups, and over time, are mostly described in absolute values, including statistical significance but not necessarily minimal detectable changes or clinically important differences. This further complicates comparisons between different studies and interventions and the possibility to draw firm conclusions. Even though the primary outcomes pain intensity and neck pain disability are the most commonly used, there are other multidimensional outcome measures such as the Neck OutcOme Score (NOOS) that could have been advantageous [54].

Trauma can have an impact on health-related quality of life, with a reported relation between higher disability and lower quality of life [55]. It was reported that neck-specific exercises, may have a more positive impact on the quality of life than general physical activity prescription [24]. The use of neck collar had inferior results for reduction of pain intensity and disability compared to exercise [34] and even a lack of effect on the duration or degree of pain following whiplash trauma [56] and it was concluded that the use of neck collar may delay recovery and that prolonged inactivity is negative for the recovery [18]. Taken together, the use of a neck collar has been discouraged as a standard approach [23]. Work disability could be influenced by a range of external and internal factors, including the benefit system, work characteristics and physical complaints. It has however been suggested that work disability after whiplash trauma could be more related to recovery from cognitive, rather than physical, complaints [57].

Patients who received regular support provided by a physiotherapist during exercise therapy showed better results regarding neck pain and disability when compared with patients who met with a physiotherapist only once [15], patients who were in a home exercise [17] or self-management programs [21], patients who received advice only [38], or patients on a waiting list [31]. However, education and advice from general practitioners were reported to be of similar effectiveness as active exercise therapy provided by physiotherapists [35]. According to the included studies, a more comprehensive care provided by a physiotherapist, designed specifically to address WAD, has varying and sometimes only small additional benefit. The complexity of WAD, including the presence of central nociceptive hyper-excitability and post-traumatic stress symptoms, might be one reason why such treatment programs are not showing larger benefits [29].

The psychological status should be considered in the management of WAD, as patients present varying levels of post-traumatic stress symptoms [58]; symptoms that contribute to both the development and persistence of pain [58] and are associated to poor long-term recovery [59, 60]. Moreover, some patients may have the belief that if they have suffered a serious injury, rest and allowing time to heal is the best approach [34]. Self-efficacy and perceived disability are psychological factors that should be taken into consideration in the rehabilitation of patients with WAD, as these factors are significant predictors of long-term pain. For the reduction of sick leave an active involvement and intervention was more effective and cost-saving in comparison to advice only [7, 33], but more costly and only marginally more effective than home training alone [17]. Non-symptomatic patients at six months follow-up after whiplash trauma were characterized by initially having lower disability, better self-efficacy and behavioural coping strategies when compared with symptomatic patients [39]. Although some studies report that adding a behavioural approach to neck specific exercises did not improve clinical outcomes [28, 30], it has been suggested that adding stress inoculation training to physiotherapy can provide clinically relevant improvements in disability when compared to exercise alone [37].

Meta-analysis

The relatively small number of participants in some of the studies, limit their statistical power and make it difficult to draw conclusions based upon the results of the individual studies. Despite the divergence of the results of the included primary studies, by combining data from multiple studies into a meta-analysis, a consensus on the most appropriate treatment could guide the choice between specific exercises in relation to care as usual. However, although we identified many RCTs that evaluated exercise therapy, direct comparisons were difficult as many studies assessed different outcomes, and even when they did assess the same outcome(s), different therapeutic approaches were used or the control groups were not comparable. This paucity of studies for direct comparisons meant that meta-analyses were possible only for neck disability and neck pain, and only including four studies for the former and five for the latter. The results from the meta-analysis do however suggest that exercise therapy may be a better approach than usual care or advice for short-term improvement of neck pain and for medium-term improvement of neck disability in WAD patients.

Study limitations

The present review only included posttraumatic neck pain and not the broader perspective of chronic neck pain with WAD patients as a subgroup. Although WAD patients do not clinically deviate considerably from chronic neck pain patients [61], some differences in clinical presentation in patients with pure degenerative disorders i.e. spondylosis without trauma vs. those who had trauma to the neck i.e. WAD patients has been suggested [45]. Even so, a broader perspective could have been advantageous but was beyond the scope of the present review.

Issues and confounding factors that might have affected the results in the individual studies include poor compliance to treatment [23, 39], the frequent use of treatment other than prescribed [23], the risk of more patients lost to follow-up in the “non-intervention” groups due to dissatisfaction with perceived lack of treatment [23], and patients with different initial levels of pain and disability [38]. Such differences in initial levels of pain and disability after trauma also complicates the comparisons between different studies. Patients with good potential for recovery, meaning lower levels of pain and disability, would be more likely to recover even with less intensive intervention [37]. On the other hand, subjects with higher initial levels of pain and disability may potentially experience a greater treatment effect than subjects with lower levels [38], although for patients with chronic WAD, high levels of pain and disability are related to a worse prognosis [62, 63]. Seven of the included studies reported results based on the same patient cohort of 216 patients with chronic WAD, with different articles detailing different outcomes, different follow-up times, secondary analysis, as well as analysis of subgroups [15, 24], [25], [26], [27], [28, 30].

The incorporation of sufficient length of the respective exercise programs will also influence the interpretations of the findings, with 13 of the included studies, based on seven study populations, utilizing an exercise program of 10 weeks or more. Furthermore, in the present review, the Cochrane RoB tool was used to assess risk of bias. It could have been of value also to include a more specific quality assessment with regard to the reporting of exercise, such as Consensus on Exercise Reporting Template (CERT) [64]. For the included primary studies included our assessment is that four studies would have a lower score [14, 19, 32, 34], whereas the remaining 23 of 27 studies would receive a CERT score above 50%, corresponding to fulfilling at least 9 of 18 criteria.

In summary, exercise therapy is a concept of strategies that also include the patient’s active involvement in the rehabilitation process after trauma. The negative consequences after the initial injury and ensuing healing processes cover a wide range of mechanisms and impairments, here demonstrated by a wide variation of training concepts and a wide span of outcome measures. Sometimes additional interventions made the outcomes more successful and sometimes individualized approaches were beneficial.

Conclusions

It is difficult to draw firm overall conclusions on the effectiveness of exercise therapy after whiplash trauma as there were differences between the included studies in outcome measures, therapeutic approaches and also in the time elapsed since the trauma. Together with a lack of control groups, this meant that only a few studies were eligible for a meta-analysis. Therefore, despite a large number of articles published in the area of exercise therapy and WAD, the evidence base remains weak. The results from this meta-analysis suggests that exercise therapy may be a better approach than care as usual for improvement of neck pain and disability in patients with WAD. However, the effectiveness of exercise therapy in general, about specific intervention methods, and about timing of the treatment in relation to the varying consequences and stages of WAD, still remain unanswered.

Corresponding author: Birgitta Häggman-Henrikson, Department of Orofacial Pain and Jaw Function, Malmö University, Malmö, Sweden, E-mail:

Funding source: Folksam Research Foundation

  1. Research funding: The study was supported by grants from the Folksam Research Foundation.

  2. Author contributions: BHH, EMM, HW and JL contributed to the concept and design of the review. BC, BHH and JL conducted the abstract screening and risk of bias assessment. BC, BHH, JL and EMM conducted the full text assessment. BC and JL analyzed the data. and BC performed the meta-analysis. All authors interpreted the results. BC and JL drafted the manuscript. All authors critically reviewed the manuscript and approved the final version.

  3. Competing interests: Authors state no conflict of interest.

  4. Ethical approval: Not applicable.

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Received: 2021-03-31
Accepted: 2021-09-02
Published Online: 2021-09-27
Published in Print: 2022-04-26

© 2021 Walter de Gruyter GmbH, Berlin/Boston

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From the journal
Scandinavian Journal of Pain
Scandinavian Journal of Pain
Volume 22 Issue 2

Journal and Issue

Articles in the same Issue

Frontmatter
Systematic Reviews
Psychological interventions in preventing chronicity of sub-acute back pain: a systematic review
Sex differences in interdisciplinary pain rehabilitation outcomes: a systematic review
Exercise therapy for whiplash-associated disorders: a systematic review and meta-analysis
Reliability of conditioned pain modulation in healthy individuals and chronic pain patients: a systematic review and meta-analysis
Clinical Pain Researchs
Experiences with an educational program for patients with chronic widespread pain: a qualitative interview study
Guided self-determination in treatment of chronic pain – a randomized, controlled trial
What does low psychological distress mean in patients with no mental disorders and different pains of the musculoskeletal system?
Prolonged exposure for pain and comorbid PTSD: a single-case experimental study of a treatment supplement to multiprofessional pain rehabilitation
Standing time and daily proportion of sedentary time are associated with pain-related disability in a one month accelerometer measurement in adults with overweight or obesity
Stratifying workers on sick leave due to musculoskeletal pain: translation, cross-cultural adaptation and construct validity of the Norwegian Keele STarT MSK tool
An investigation of implicit bias about bending and lifting
Observational Studies
Prevalence of fibromyalgia 10 years after infection with Giardia lamblia: a controlled prospective cohort study
Building evidence to reduce inequities in management of pain for Indigenous Australian people
Original Experimentals
Participants’ experiences from group-based treatment at multidisciplinary pain centres - a qualitative study
The induction of social pessimism reduces pain responsiveness
The interaction between pain and cognition: on the roles of task complexity and pain intensity
The effect of one dry needling session on pain, central pain processing, muscle co-contraction and gait characteristics in patients with knee osteoarthritis: a randomized controlled trial
Importance of blinding and expectations in opioid-induced constipation: evidence from a randomized controlled trial
Educational Case Report
Successful weaning from mechanical ventilation after Serratus Anterior Plane block in a chest trauma patient
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