Maria Landén Ludvigsson

The Effect of Neck-specific Exercise With, or Without a Behavioral Approach, on Pain, Disability, and Self-Efficacy in Chronic Whiplash-associated Disorders: A Randomized Clinical Trial

Objectives:The aim of this study was to compare the effect on self-rated pain, disability, and self-efficacy of 3 interventions for the management of chronic whiplash-associated disorders: physiotherapist-led neck-specific exercise (NSE), physiotherapist-led NSE with the addition of a behavioral approach, or Prescription of Physical Activity (PPA). Materials and Methods:A total of 216 volunteers with chronic whiplash-associated disorders participated in this randomized, assessor blinded, clinical trial of 3 exercise interventions. Self-rated pain/pain bothersomeness (Visual Analogue Scale), disability (Neck Disability Index), and self-efficacy (Self-Efficacy Scale) were evaluated at baseline and at 3 and 6 months. Results:The proportion of patients reaching substantial reduction in pain bothersomness (at least 50% reduction) was more evident (P<0.01) in the 2 NSE groups (29% to 48%) compared with the PPA group (5%) at 3 months. At 6 months 39% to 44% of the patients in the 2 neck-specific groups and 28% in the PPA group reported substantial pain reduction. Reduction of disability was also larger in the 2 neck-specific exercise groups at both 3 and 6 months (P<0.02). Self-efficacy was only improved in the NSE group without a behavioral approach (P=0.02). However, there were no significant differences in any outcomes between the 2 physiotherapist-led NSE groups. Discussion:NSE resulted in superior outcomes compared with PPA in this study, but the observed benefits of adding a behavioral approach to the implementation of exercise in this study were inconclusive.

Evaluation of physiotherapists as primary assessors of patients with musculoskeletal disorders seeking primary health care

OBJECTIVES To evaluate primary physiotherapist assessment and management of patients with musculoskeletal disorders in primary care, and to compare patient satisfaction with primary assessment by a physiotherapist or a general practitioner (GP). DESIGN An observational, retrospective cohort study reviewing medical records, and a separate consecutive non-randomised study of patient satisfaction. SETTING Primary healthcare centre. PARTICIPANTS Four hundred and thirty-two patients with musculoskeletal disorders, primarily assessed by a physiotherapist. Fifty-one of these patients primarily assessed by a physiotherapist and 42 patients assessed by a GP answered a patient satisfaction questionnaire. INTERVENTIONS Primary assessment and management of patients with musculoskeletal disorders. MAIN OUTCOME MEASURES Data from medical records within 3-month after the visit, and patient satisfaction questionnaire. RESULTS Eighty-five percent (367/432) of patients did not need to see a GP. Serious pathologies were found among the 6% (26/432) of patients who were referred to a GP by a physiotherapist, but no serious pathologies were found among the 9% (39/432) of patients who subsequently returned for a GP appointment for the same disorder. Patients assessed by a physiotherapist were more satisfied with the information received about their disorder and self-care than patients assessed by a GP. Patients also had higher confidence in the ability of physiotherapists to assess their disorder (P<0.002). CONCLUSION Physiotherapists can be considered primary assessors of patients with musculoskeletal disorders in primary care as few patients needed additional assessment by a GP, patients with confirmed serious pathologies were identified by the physiotherapists, and patients were satisfied with assessment by a physiotherapist.

One- and two-year follow-up of a randomized trial of neck-specific exercise with or without a behavioural approach compared with prescription of physical activity in chronic whiplash disorder

OBJECTIVE To explore whether neck-specific exercise, with or without a behavioural approach, has benefits after 1 and 2 years compared with prescribed physical activity regarding pain, self-rated functioning/disability, and self-efficacy in management of chronic whiplash. DESIGN Follow-up of a randomized, assessor blinded, clinical trial. PATIENTS A total of 216 volunteers with chronic whiplash-associated disorders, grades 2 or 3. METHODS Participants were randomized to 1 of 3 exercise interventions: neck-specific exercise with or without a behavioural approach, or physical activity prescription. Self-rated pain (visual analogue scale), disability/functioning (Neck Disability Index/Patient Specific Functional Scale) and self-efficacy (Self-Efficacy Scale) were evaluated after 1 and 2 years. RESULTS Both neck-specific exercise groups maintained more improvement regarding disability/functioning than the prescribed physical activity group at both time-points (p ≤ 0.02). At 1 year, 61% of subjects in the neck-specific group reported at least 50% pain reduction, compared with 26% of those in the physical activity prescription group (p < 0.001), but at 2 years the difference was not significant. CONCLUSION 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.

Perceived pain extent is associated with disability, depression and self-efficacy in individuals with whiplash-associated disorders.

Completion of a pain drawing is a familiar task in those presenting with whiplash‐associated disorders (WAD). Some people report pain almost over their entire body. Yet the reasons for larger pain extent have not been fully explored.

Effects of Neck-Specific Exercises Compared to Waiting List for Individuals With Chronic Whiplash-Associated Disorders: A Prospective, Randomized Controlled Study

OBJECTIVE To determine whether 3 months of neck-specific exercises (NSEs) could benefit individuals with chronic whiplash-associated disorder (WAD) who were on a waiting list (WL) for treatment. DESIGN A prospective, randomized controlled study. SETTING Primary health care. PARTICIPANTS Individuals (N=41; 31 women, 10 men; mean age ± SD, 38±11.2y) with chronic (6-36mo) WAD, grades 2 and 3, were analyzed. INTERVENTIONS Patients were randomly assigned to NSEs or no treatment for 3 months. MAIN OUTCOME MEASURES Neck-specific disability (Neck Disability Index [NDI]), neck pain (visual analog scale), general pain-related disability (Pain Disability Index [PDI]), self-perceived performance ability (Self-Efficacy Scale [SES]), and health-related quality of life (EuroQol 5 dimensions [EQ-5D]) were measured. RESULTS NSEs significantly improved the NDI, SES, and EQ-5D compared with WL (P<.01). There was significant improvement (P<.0001) over time in all outcomes for NSEs, and apart from the PDI, significant worsening (P=.002-.0002) over time for the untreated group. CONCLUSIONS NSEs were more beneficial than no intervention while on a WL for individuals with chronic WAD.

The Effect of 3 Different Exercise Approaches on Neck Muscle Endurance, Kinesiophobia, Exercise Compliance, and Patient Satisfaction in Chronic Whiplash

OBJECTIVE The purpose of this study was to compare the effects of 3 different exercise approaches on neck muscle endurance (NME), kinesiophobia, exercise compliance, and patient satisfaction in patients with chronic whiplash. METHODS This prospective randomized clinical trial included 216 individuals with chronic whiplash. Participants were randomized to 1 of 3 exercise interventions: neck-specific exercise (NSE), NSE combined with a behavioral approach (NSEB), or prescribed physical activity (PPA). Measures of ventral and dorsal NME (endurance time in seconds), perceived pain after NME testing, kinesiophobia, exercise compliance, and patient satisfaction were recorded at baseline and at the 3- and 6-month follow-ups. RESULTS Compared with individuals in the prescribed physical activity group, participants in the NSE and NSEB groups exhibited greater gains in dorsal NME (P = .003), greater reductions in pain after NME testing (P = .03), and more satisfaction with treatment (P < .001). Kinesiophobia and exercise compliance did not significantly differ between groups (P > .07). CONCLUSION Among patients with chronic whiplash, a neck-specific exercise intervention (with or without a behavioral approach) appears to improve NME. Participants were more satisfied with intervention including neck-specific exercises than with the prescription of general exercise.

The effect of neck-specific exercise with or without a behavioral approach on psychological factors in chronic whiplash-associated disorders: A randomized controlled trial with a 2-year follow-up.

Background:To investigate the effect of neck-specific exercise with (NSEB) or without (NSE) a behavioural approach and prescribed physical activity (PPA) on general pain disability and psychological factors in chronic whiplash-associated disorders (WAD), grade 2 and 3, with a 2-year follow-up. Methods:A randomized controlled multi-centre study of 3 exercise interventions (NSE, NSEB or PPA) including a 2-year follow-up. A total of 216 volunteers with chronic WAD were recruited and 194 were analyzed, mean age 40.4 (Standard Deviation [SD] 11.4). Measures of general pain disability, pain catastrophizing, anxiety and depression, and kinesiophobia were evaluated at baseline, and 3, 6, 12 and 24 months with linear mixed models. Results:General pain disability decreased by 28% in the NSEB group from baseline to 3 months (P < 0.001) and the improvements in disability were maintained over time (6, 12 and 24 months P < 0.01) compared to the NSE (P > 0.42) and PPA groups (P > 0.43). Pain catastrophizing decreased in the NSE group from baseline to 6 and 12 months (P < 0.01) and in the NSEB group from baseline to 3 and 24 months (P < 0.01) compared to the PPA group (P > 0.82) that showed no change over time. The NSE group improved in kinesiophobia over time from baseline to12 months (P < 0.01) compared to the NSEB (P = 0.052) and the PPA groups (P > 0.74). Anxiety decreased over time from baseline to 12 and 24 months in the NSE group (P > 0.02), but not in the NSEB (P > 0.25) or the PPA (P > 0.50) groups. The PPA had no effect on general disability or any of the measured psychological factors. Conclusion: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.

Balance, dizziness and proprioception in patients with chronic whiplash associated disorders complaining of dizziness: A prospective randomized study comparing three exercise programs

BACKGROUND Dizziness and unsteadiness are common symptoms following a whiplash injury. OBJECTIVE To compare the effect of 3 exercise programs on balance, dizziness, proprioception and pain in patients with chronic whiplash complaining of dizziness. DESIGN A sub-analysis of a randomized study. METHODS One hundred and forty subjects were randomized to either a physiotherapist-guided neck-specific exercise (NSE), physiotherapist-guided neck-specific exercise, with a behavioural approach (NSEB) or prescription of general physical activity (PPA) group. Pre intervention, 3, 6 and 12 months post baseline they completed the University of California Los Angeles Dizziness Questionnaire (UCLA-DQ), Visual Analogue Scales (VAS) for, dizziness at rest and during activity and physical measures (static and dynamic clinical balance tests and head repositioning accuracy (HRA)). RESULTS There were significant time by group differences with respect to dizziness during activity and UCLA-Q favouring the physiotherapy led neck specific exercise group with a behavioural approach. Within group analysis of changes over time also revealed significant changes in most variables apart from static balance. CONCLUSION Between and within group comparisons suggest that physiotherapist led neck exercise groups including a behavioural approach had advantages in improving measures of dizziness compared with the general physical activity group, although many still complained of dizziness and balance impairment. Future studies should consider exercises specifically designed to address balance, dizziness and cervical proprioception in those with persistent whiplash.

Factors associated with pain and disability reduction following exercise interventions in chronic whiplash

Some studies support the prescription of exercise for people with whiplash‐associated disorders (WAD); however, the response is highly variable. Further research is necessary to identify factors which predict response.

Factors associated with work ability in patients with chronic whiplash-associated disorder grade II-III : A cross-sectional analysis

OBJECTIVE To investigate the factors related to self-perceived work ability in patients with chronic whiplash-associated disorder grades II-III. DESIGN Cross-sectional analysis. PATIENTS A total of 166 working age patients with chronic whiplash-associated disorder. METHODS A comprehensive survey collected data on work ability (using the Work Ability Index); demographic, psychosocial, personal, work- and condition-related factors. Forward, stepwise regression modelling was used to assess the factors related to work ability. RESULTS The proportion of patients in each work ability category were as follows: poor (12.7%); moderate (39.8%); good (38.5%); excellent (9%). Seven factors explained 65% (adjusted R2 = 0.65, p < 0.01) of the variance in work ability. In descending order of strength of association, these factors are: greater neck disability due to pain; reduced self-rated health status and health-related quality of life; increased frequency of concentration problems; poor workplace satisfaction; lower self-efficacy for performing daily tasks; and greater work-related stress. CONCLUSION Condition-specific and psychosocial factors are associated with self-perceived work ability of individuals with chronic whiplash-associated disorder.