J Rehabil Med 2016 (Jan); 48 (1): 56–64 ~ FULL TEXT
Maria Landén Ludvigsson, MSc, Gunnel Peterson MSc, Ĺsa Dedering, PhD and Anneli Peolsson, PhD
Department of Medical and Health Sciences,
Division of Physiotherapy,
SE-581 83 Linköping, Sweden.
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.
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.
Keywords: whiplash; chronic; exercise; randomized; follow-up study; spine; behaviour therapy.
Clinical Trial Registration: Clinical Trials.gov, NCT01528579
The FULL TEXT Article:
At 1 year post-injury, 50% of people with whiplash-associated
disorders (WAD) still report neck pain.  Despite the significant impact of WAD, there is still no clear evidence regarding which treatment is most effective. [2–4] Persistence of symptoms in individuals with WAD has been attributed to both physical and psychosocial factors.  It is therefore reasonable to assume that a behavioural approach may be of benefit in the management of chronic WAD, as in chronic back pain.  However, impairments and altered patterns of muscle activation [7–11] and muscle deformation [12, 13] in the cervical spine are also features of chronic WAD, suggesting that treatments aimed at improving muscle function might also be of importance. Although exercise is considered a safe treatment for neck pain, with temporary and benign side-effects, its efficacy in the context of chronic WAD remains unclear. [2, 3]
Short-term pain reduction
may be achieved , but there is no evidence regarding the
optimal exercise approach for WAD.  Although prescription
of physical activity (PPA) (i.e. self-directed general physical
activity outside the healthcare system) is often recommended
for patients with chronic pain , the relative effectiveness of
different exercise regimens in relieving chronic WAD remains
unknown.  Regarding chronic WAD grades 1–2, Michaleff
et al. found that a comprehensive exercise programme including
neck-specific exercise was not more effective for pain reduction
than advice alone.  Another randomized controlled trial previously
reported by our group found that patients with chronic
WAD grades 2–3 experienced greater reductions in neck pain
and neck-related disability after neck-specific exercise, with or
without the addition of a behavioural approach, compared with
PPA.  However, those results were only analysed up to 6
The aim of this study was to explore whether, after 1 and
2 years, neck-specific exercise with or without a behavioural
approach has long-term benefits over PPA regarding pain,
self-rated functioning/disability, and self-efficacy in the management of grade 2 or grade 3 chronic WAD.
This is a 1– and 2–year follow-up of a multi-centre, prospective,
randomized clinical trial with assessor and group allocation blinding
(Clinical Trials.gov, NCT01528579 ). Short-term results have
been presented previously.  The study, conducted in accordance
with the Declaration of Helsinki, was approved by the Regional Ethics
Committee of Linköping University, Sweden.
Participants and settings
A total of 216 individuals with chronic WAD were recruited between
February 2011 and May 2012, including 142 (65%) women and 74
(35%) men with a mean age of 40 (range 18–63, SD 11.4) years (Table I). Inclusion criteria were age 18–63 years, and a grade 2 or 3 whiplash
injury according to the Quebec Task Force  in the preceding
6–36 months that was nominated as the cause of current symptoms.
Additional inclusion criteria were a Neck Disability Index score (NDI)  of at least 10/50 points, and/or an average pain rating on the
visual analogue scale (VAS) of > 20/100 mm (where 0 = no pain and
100 = worst imaginable pain)  for the preceding week. Exclusion
criteria were: signs of traumatic brain injury, previous neck trauma with
unresolved symptoms, more dominant pain elsewhere, neck pain causing
more than 1 month of absence from work in the year preceding the
whiplash injury, myelopathy, spinal infection or tumour, previous neck
surgery, conditions that were potentially detrimental to completing the
study interventions (e.g. severe psychiatric disorders or known drug
abuse) or insufficient knowledge of the Swedish language. Experienced
physiotherapists conducted the interventions in a primary care setting.
The physiotherapists were provided with standardized oral information
about their interventions. Those in charge of physiotherapist-led interventions
participated in a 1–day workshop of standardized practical
and theoretical training held by the project leaders.
A total of 170 patients (79%) completed the 1–year follow-up, and 123
patients (57%) completed the 2–year follow-up (Figure 1). With imputed
values (see statistics), data were available from 193 participants (89%) at
1 year and from 184 (85%) participants at 2 years. There was no baseline
difference (p > 0.27 for all) between those who completed the questionnaires
and drop-outs at either time-point regarding allocation, gender,
WAD grade, pain or pain bothersomeness, NDI (1 year only), or age (2
years only). Drop-outs at 1 year were somewhat younger (age 37 (SD 11)
years) than those who completed the study (age 41 (SD 11) years, p = 0.04).
Drop-outs at 2 years reported more baseline disability than those who
completed the study (NDI 17.9 (SD 6.9) vs NDI 15.7 (SD 6.5), p < 0.04).
At 2 years, drop-outs and completers did not differ regarding preceding
improvement from baseline to 1 year (NDI and neck pain VAS, p > 0.94).
Potential participants were identified from the healthcare registries of
6 Swedish counties, including primary healthcare centres and hospital
outpatient services. Participants were screened for eligibility through
the following 4–step process (Fig. 1): (i) an initial screening letter that
contained study information, basic inclusion/exclusion criteria (Fig.1),
NDI  and Pain VAS (P-VAS) measures; (ii) a telephone interview
with 1 of the project leaders; (iii) a review of medical records, if
needed due to any uncertainties; and (iv) a physical examination by
an experienced physiotherapist (mean 18 years’ experience) to confirm
findings consistent with either WAD grade 2 (neck pain and clinical
findings) or WAD grade 3 (addition of neurological signs). 
All participants received verbal and written information about the study.
Informed consent and baseline measurements were collected before allocation.
Allocation from a computer-generated randomization list was made
by an independent researcher, who also put the individual results in sealed
opaque envelopes for further distribution to the treating physiotherapists.
Collection and entering of data were made by staff blinded to allocation.
First, all patients were examined by their treating physiotherapist.
All 3 interventions were undertaken during a 12–week period, and
participants were encouraged to continue exercising on their own after
the interventions. The interventions, as previously described in more
detail , were: physiotherapist-led
- neck-specific exercise (NSE),
- NSE with the addition of a behavioural approach (NSEB), or
- prescribed physical activity (PPA).
serious adverse events were reported.
Neck-specific exercise (NSE). Participants in the NSE group undertook
supervised, neck-specific exercise twice weekly. They initially also
practiced daily at home, focusing on activity of the deep cervical
muscles. Next, gym exercise within participants’ symptom tolerance
was gradually introduced, with progressive head resistance training
that focused on low load endurance in flexion, extension, rotation, and
lateral flexion. Exercise-related pain provocation was not accepted in
this group. A detailed description of the exercises can be found at the
Academic Archive On-line.  Participants also received a written
individualized exercise programme that contained exercises from the
interventions and general physical activity towards the end of the
Neck-specific exercise with a behavioural approach (NSEB). The protocol
of exercises in the NSEB group was the same as that undertaken
by the NSE group, with the addition of a behavioural approach. The
behavioural approach aimed to be basic and manageable by experienced
physiotherapists in primary care with some previous knowledge
of behavioural approaches. In accordance with the concept of graded
exercise, patients were encouraged not to focus on temporary increases
in neck pain. They also received physiotherapist-guided behavioural
interventions, including education and introduction to activities aimed
at pain management and problem-solving. Time-frames and specific
components of the interventions have been described previously. 
Prescribed physical activity (PPA). Participants in the PPA group
initially underwent a short motivational interview with a physiotherapist.
Based on this interview and a physical examination they were
prescribed individualized general physical activity to be performed
independently. The purpose of this prescription was to increase overall
physical activity, either with individualized home exercise or activities
performed in public gyms or elsewhere, outside the healthcare system.
Neck-specific exercises that included any form of head resistance
were not prescribed in this group. A single follow-up visit or phone
call was encouraged. Participants in this group were also encouraged
to continue exercise post-interventions.
All measurements were recorded at baseline and after 1 and 2 years.
The individually chosen activities were recorded verbally in the Patient-Specific Functional Scale (PSFS) by a blinded investigator in connection with other clinical tests, to ensure that they were individually
standardized with regard to time and/or repetitions.
Disability and functioning. The primary outcome measurement was
the Neck Disability Index (NDI) , which consists of 10 items that grade neck disability
from 0 (no activity limitations) to 5 (major activity limitations), with
a total maximum score of 50 points.  A higher score represents a
greater level of disability. The NDI is considered a reliable and valid
measurement of disability in patients with neck pain disorders. 
The PSFS was used to measure functioning. For the PSFS, each
patient nominated 3 individual activities related to work, leisure, and
physical activity/exercise that they were unable to do or experienced
difficulty performing because of their neck condition. These activities
were ranked according to functional level on a scale from 0 (unable to
do) to 10 (functional level equal to pre-injury status), and the mean of
the scores was calculated. The PSFS has been shown to have excellent
reliability  and responsiveness in the chronic WAD population. 
Pain. Current neck pain intensity was measured using a Pain VAS (PVAS)
anchored by 0 = no pain, and 100 = worst imaginable pain. 
Bothersomeness of neck pain (B-VAS) was recorded for the preceding
24 h (anchored by 0 = not bothersome at all, 100 = extremely bothersome).
Pain bothersomeness is reportedly more responsive than pain
intensity in individuals with WAD.  Patients also recorded whether
they used analgesics to manage their neck pain (yes/no).
Self-efficacy. The participants’ confidence in their ability to perform
activities despite pain was evaluated using the Self-Efficacy Scale
(SES). [26, 27] The SES is a reliable instrument in WAD populations [5, 28]; it consists of 20 different physical and psychosocial activity
items that are scored from 0 = not confident at all, to 10 = very confident,
thus generating a total score from 0–200.
Adherence. Participants were asked to estimate their adherence to
their post-intervention prescribed exercise on a 4–point scale: full,
fair, some, or no adherence. Participants who reported some to full
adherence were classified as adherent in the analysis.
Clinical relevance. The Initiative on Methods, Measurement and Pain
Assessment in Clinical Trials (IMMPACT) concluded that it is impossible
to provide specific guidelines for determining whether a group difference
is clinically meaningful.  Therefore, we also calculated the proportion
of patients that achieved clinically important improvement where such
cut-offs have been established. The minimal clinically important difference
(MCID) of the NDI score is suggested to be 3.5–5/50 points ,
with a reduction of 5 set as the cut-off score in this study. This exceeds the
measurement error in this study sample, as previously reported (minimum
detectable change (MDC) of 3.3/50 points.  In the PSFS, the MCID
is reported as 2.3 and the MDC is reported as 2.1.  An increase of
2.3 was set as the cut-off score in this study. A reduction in pain intensity
of ≥ 50% is suggested to indicate substantial improvement or treatment
success according to IMMPACT recommendations.  This level is
also used in this study to define clinically important improvement. To
our knowledge, the MCID has not been established in the SES.
The required sample size for the original randomized controlled trial
was determined on the basis of the expected difference between the
3 groups (alpha 5%, power 80%) for main outcome, NDI (3.5/50, SD
7), and allowing for a 10% drop-out rate, rendering a sample size
of 216. If only 1 item of data was missing from the NDI scores or 2
items were missing from the SES, the missing data were substituted by
the mean item score of the questionnaire for that participant. If more
data items were missing, that particular score was omitted from the
analysis. Missing scores were considered missing at random (MAR),
such that the closest match is considered a reliable and efficacious
imputation method in repeated measures data. Closest match replaces
a participant’s missing time-point with a value obtained from another
participant who has similar scores on the same measure assessed at
other time-points. 
Only participants with complete measurements
from 3 time-points served as possible donors, and participants with
missing data served as recipients. The score obtained by the donor at
that time-point was imputed to the missing time-point for the recipient.
Closest match was defined as all donors with less than 15% absolute
differences between the recipient’s scores and donor’s scores at all
other time-points for which data were present, and with the same
trend over time (better, worse, or unchanged). Priority was given
to absolute matches, and each outcome was analysed and imputed
separately. When more than one possible donor was identified, the
computer (SPSS version 22) selected the closest match donor at random
from the possible donors. Because baseline adherence data cannot be
measured, these values were not imputed. The presented results are
from the imputed data set. Use of imputed vs non-imputed values in
the analysis did not cause a significant difference in the results.
The primary analysis was conducted using SPSS version 22 on an
intent-to-treat basis, including all patients completing each measurement
and imputed data. Descriptive statistics were calculated,
and between-group comparisons were evaluated with the Kruskal–
Wallis test for non-parametric data, with the Mann-Whitney U test
for post-hoc, or with 1–way analysis of variance (ANOVA) for normally
distributed parametric data. In binary outcomes, χ2 tests were
used. Within-group differences at baseline, 6, 12 and 24 months were
calculated using a Friedman’s ANOVA with post-hoc Wilcoxon’s
signed rank test. Correlations were calculated using Spearman’s rho.
To determine the proportion of responders in each group, sub-analyses
of participants who had reached the predefined cut-off values were
performed, as described previously. Statistical significance was set at
p < 0.05 (with Bonferroni post-hoc correction at 0.017). To aid comparability
to previous and other publications in this field, all outcomes
are presented with both mean and median values, and data are also
presented for separate WAD grades.
Disability and functioning
Between-group analysis indicated that both physiotherapist-led
neck-specific exercise groups reported greater reductions in
neck disability and improved functioning (p < 0.01) than the
PPA group at the 1–year follow-up. At 2 years, the NSEB group
reported significant reduction in neck disability compared with
the prescribed physical activity (PPA) group (p ≤ 0.02); however, the NSE group reported significant improvement in functioning compared with the PPA group (p = 0.02) (Table II). There was, however, no difference between the 2 physiotherapist-led groups. A greater proportion of individuals in the 2 physiotherapist-led neck-specific groups than in the PPA group experienced clinically relevant improvement in disability/functioning at 1 year (p < 0.01) and 2 years (disability p = 0.01); however, the difference regarding functioning was not statistically significant at 2 years (p = 0.32) (Figure 2).
Within-group results indicated that both neck-specific
exercise groups (but not the PPA group) improved over time
(disability p = NSE 0.01, NSEB < 0.001, PPA 0.13, functioning
p = NSE/NSEB < 0.001, PPA 0.22). The improvements were
gained in the first 6 months  and were maintained over
time (Table III).
There were no significant between-group differences (p ≥ 0.15)
regarding reduction in neck pain or pain bothersomeness at the
1–year or 2–year follow-up (Table II). Although significantly fewer
participants in the 2 neck-specific groups reported taking analgesics
for neck pain (NSE 47%, NSEB 50%, PPA 69%, p = 0.04) at
1 year, the difference was non-significant at 2 years (NSE 44%,
NSEB 53%, PPA 61%, p = 0.31). However greater proportions of
individuals in the 2 physiotherapist-led neck-specific groups reported
clinically relevant improvements in pain/pain bothersomeness
after 1 year, as indicated by 50% pain reduction (p ≤ 0.02);
but the difference was non-significant at 2 years (p ≥ 0.11; Fig. 2).
The within-group results showed that current pain and pain
bothersomeness improved significantly over time in both neckspecific
groups (p = NSE, NSEB ≤ 0.001). Pain bothersomeness
improved in the PPA group (p = 0.02), although current pain
did not (p = 0.07). The improvements were gained in the first
6 months (17) and maintained over time without significant
changes thereafter for either outcome (Table III).
There were no significant between-group differences regarding
self-efficacy (p < 0.17) at the 1–year or 2–year follow-up. The
within-group results demonstrated improvement for the NSE
group only over time (p = NSE 0.02, NSEB 0.07, PPA 0.86),
and there were no changes in any of the groups after 6 months
(p > 0.12) (Table III).
At the 1–year follow-up, there was no between-group difference
regarding self-reported adherence to post-intervention
prescribed exercise (p = 0.23). Seventy-nine percent of the
patients in the NSE and PPA group and 69% of patients in
the NSEB group reported some to full adherence. At 2 years
there was a significant difference (p = 0.02): the PPA group
reported the highest percentage of some to full adherence to
post-intervention exercise (NSE 69%, NSEB 60%, PPA 74%).
The results of this study indicate that a substantial number of
individuals with chronic WAD (mean duration 20 months) can
obtain long-lasting symptom reduction, particularly following
neck-specific exercise. The 2 neck-specific exercise groups
reported greater improvements regarding disability/functioning
than the PPA group, which reported no improvement over
time. Pain bothersomeness was reduced in all 3 groups over
time, but current pain was reduced only in the NSE/NSEB
groups; however, there was no difference among mean group
results. However, regarding clinically important improvement,
defined as the proportion of participants reaching the MCID
of the NDI, PSFS, or VAS, greater proportions of participants
in the 2 neck-specific groups displayed clinically important
improvements regarding pain, disability, and functioning at
1 year; the NSE group reported the greatest proportion (up
to 61%). At 2 years, the between-group difference was only
significant regarding disability, although the 2 neck-specific
groups exhibited clear trends toward greater proportions of
participants with clinically important improvement in all outcomes (40–59%), compared with the PPA group (12–33%).
The lack of significance may be because of the lower number
of participants in this subanalysis after excluding non-adherent
patients. Neck-specific exercise did not produce any significant
differences regarding any outcomes when applied alone vs in
combination with a behavioural approach.
Our findings are in contrast with those of Michaleff et al. , who observed similar improvements for both treatment
arms, whereas in our study the improvements seen in the PPA
group were generally smaller or non-existing. Stewart et al.
observed only short-term differences between groups.  Possible reasons may be that Michaleff et al. included lower WAD
grades (1–2) and did not include patients with WAD grade
3. WAD grade 3 has been associated with treatment success
in neck-specific exercise.  Disability improvements also
tended to be greater among patients with WAD grade 3 in the
neck-specific groups, while there was a trend toward deterioration
in the PPA group. The neck-specific exercise regimes
may also have differed somewhat, as Stewart et al.  did
not specify whether the endurance training was neck-specific.
Although Michaleff et al.  reported progressive training
in neck flexion/extension, it is unclear whether this included
resistance. In our study, endurance training included headresisted
neck exercise, and apart from flexion and extension,
rotation and lateral flexion were also part of the programme.
Consistent with our findings, the PSFS is reportedly more
sensitive to change than the NDI.  This difference in
sensitivity might be because the chosen activities are based
on what is most important to each individual. Therefore, the
results must be interpreted as changes of functioning regarding
meaningful individual activities for each participant. Even so,
the PSFS is suggested to be an appropriate measure for statistical
comparisons between groups in clinical research , and
can also complement the NDI.
The proportion of participants that reported clinical improvement
even after 2 years was high among those who continued
exercising to some degree, especially in the 2 neck-specific
groups. Whether this was because improvement led to greater
motivation to continue exercising, or continuous exercise
postulated improvement is uncertain. However, whether
all participants were included in the analysis (regardless of
adherence), the results were the same, except for a tendency
toward lower improvements and a significant between-group
difference favouring the 2 neck-specific groups regarding PVAS
in the complete set analysis.
Even though the PPA group reported better adherence to their
prescribed exercise activity than the NSEB group at 2 years, the
NSEB group still reported less disability. One reason might be
that the behavioural approach included the discussion of strategies
to handle relapse/periods of worsening. This may also be
a reason why the proportion of responders tended to increase
over time. It may also indicate that choice of exercise intervention
is important even after 2 years, even when continuous
adherence is not optimal. This is in accordance with findings by
Ylinen et al., who reported that improvements achieved through
long-term training in chronic neck pain were maintained at a
3–year follow-up despite faltering adherence. 
There were no improvements or between-group differences
in self-efficacy at the 1– or 2–year follow-ups. There was a large
variance that could not be explained by level of adherence. Selfefficacy
has previously been reported to increase with the completion
of an exercise programme ; however, there was no
correlation between either baseline SES score or change in SES
score and adherence (Spearman’s rho –0.10,–0.11, p > 0.23). One
reason might be the relatively high baseline level of self-efficacy
in this study, indicating that self-efficacy was not a major issue.
This might be because participants were recruited mainly from
primary care, not pain clinics. Patients in pain clinics reportedly
have higher levels of functional impairment and psychosocial
difficulties, but may thus not be as representative of individuals
in general who suffer from chronic pain. 
Opinions differ regarding whether rating scales and larger
scores from questionnaires should be analysed with nonparametric
or parametric statistics. We also checked our results
using parametric statistics, and observed no significant differences from the non-parametric results presented, in accordance with the policy of this journal.
Forty-three percent of the participants were lost to follow-up at
2 years, possibly because the clinical tests, in which they also
participated for up to 1 year, ended, which may have reduced
their motivation to continue answering questionnaires. This
scenario introduces possible bias into the results. However,
analysis indicated that the only difference between drop-outs
and completers was that drop-outs at 1 year were somewhat
younger than completers, and drop-outs at 2 years reported
more baseline disability than completers. As reported previously,
age was not associated with outcome; however, in this
study sample a higher NDI score at baseline was associated
with greater improvement regarding disability, but not pain.  Furthermore, the use of imputed vs non-imputed data in
the analyses did not significantly affect the results.
The closest match imputation method used in this study
did not substitute values in cases in which only baseline data
were available. This approach resulted in some missing values,
even after imputation. However, closest match is reported to
perform well even when missing data are substantial, and is
recommended over common methods such as last value carried
forward, which are reported to perform poorly.  There was
a small, but significant, baseline difference between randomization
groups regarding gender and age; however, neither factor
was associated with outcomes in this study sample. 
Although these results are promising, and the study sample
was representative regarding age, gender, and level of pain
compared with those who declined to participate in the study , the study should be repeated in another population. It is
also important for future studies to identify predictors of which
patients will benefit from which specific treatments. As seen
in this study, there were participants who exhibited clinically
important improvement in all groups (including the PPA group,
in which the mean disability rather tended to worsen slightly).
In conclusion, after 1–2 years, participants with chronic WAD
grade 2 or 3 who were randomized to neck-specific exercise
(with or without a behavioural approach) remained more improved
than participants who were prescribed general physical
activity. However, due to the loss to follow-up, the results must be interpreted with some caution.
The authors would like to thank all participants in this study, including WAD participants, physiotherapists, and staff involved at any stage of the study. Financial disclosure and conflicts of interest. This study was supported by funding from the Swedish government through the REHSAM Foundation, the Swedish Research Council, the regional Center for Clinical Research and the County Council of Östergötland, Centre for Clinical Research Sörmland at Uppsala University, the Medical Research Council
of Southeast Sweden, and the Uppsala-Örebro Regional Research Council, Sweden. The authors declare no conflicts of interest.
Carroll, LJ, Holm, LW, Hogg-Johnson, S et al.
Course and Prognostic Factors for Neck Pain in Whiplash-associated
Disorders (WAD): Results of the Bone and Joint Decade 2000-2010
Task Force on Neck Pain and Its Associated Disorders
Spine (Phila Pa 1976). 2008 (Feb 15); 33 (4 Suppl): S83–92
Hurwitz, EL, Carragee, EJ, van der Velde, G et al.
Treatment of Neck Pain: Noninvasive Interventions: Results of the
Bone and Joint Decade 2000–2010 Task Force on Neck Pain
and Its Associated Disorders
Spine (Phila Pa 1976). 2008 (Feb 15); 33 (4 Suppl): S123–152
Southerst D, Nordin M, Côté P, et al.
Is Exercise Effective for the Management of Neck Pain and
Associated Disorders or Whiplash-associated Disorders?
A Systematic Review by the Ontario Protocol for Traffic
Injury Management (OPTIMa) Collaboration
Spine J 2016 (Dec); 16 (12): 1503–1523
Soderlund A, Denison E.
Classification of patients with whiplash associated disorders (WAD):
reliable and valid subgroups based on the Multidimensional Pain Inventory (MPI-S).
Eur J Pain 2006; 10: 113–119.
Chou R, Huffman LH; American Pain Society.
Nonpharmacologic Therapies for Acute and Chronic Low Back Pain:
A Review of the Evidence for an American Pain Society/
American College of Physicians Clinical Practice Guideline
Annals of Internal Medicine 2007 (Oct 2); 147 (7): 492–504
Nederhand MJ, Hermens HJ, IJzerman MJ, Turk DC, Zilvold G.
Cervical muscle dysfunction in chronic whiplash-associated disorder
grade 2: the relevance of the trauma.
Spine (Phila Pa 1976) 2002; 27: 1056–1061.
Sterling M, Jull G, Vicenzino B, Kenardy J, Darnell R.
Development of motor system dysfunction following whiplash injury.
Pain 2003; 103: 65–73.
Jull G, Kristjansson E, Dall’Alba P.
Impairment in the cervical flexors:
a comparison of whiplash and insidious onset neck pain patients.
Man Ther 2004; 9: 89–94.
Woodhouse A, Vasseljen O.
Altered motor control patterns in whiplash and chronic neck pain.
BMC Musculoskelet Disord 2008; 9: 90.
Juul-Kristensen B, Clausen B, Ris I, Jensen RV, Steffensen RF, et al.
Increased neck muscle activity and impaired balance among females
with whiplash-related chronic neck pain: a cross-sectional study.
J Rehabil Med 2013; 45: 376–384.
Landén Ludvigsson M, Peterson G, Jull G, Trygg J, Peolsson A.
Mechanical properties of the trapezius during scapular elevation
people with chronic whiplash associated disorders -
A casecontrol ultrasound speckle tracking analysis.
Man Ther 2015 [Epub ahead of print].
Peterson G, Dedering A, Andersson E, Nilsson D, Trygg J, Peolsson M, et al.
Altered ventral neck muscle deformation for individuals with whiplash
associated disorder compared to healthy controls – a case-control ultrasound study.
Man Ther 2015; 20: 319–327.
Teasell RW, McClure JA, Walton D, Pretty J, Salter K, Meyer M, et al.
A research synthesis of therapeutic interventions for whiplashassociated
disorder (WAD): part 4 – noninvasive interventions for
Pain Res Manag 2010; 15: 313–322.
Professional Associations for Physical Activity, Swedish National Institute
of Public Health Physical activity in the prevention and treatment of disease.
Stockholm: Swedish National Institute of Public Health; 2010 [cited 2015 Feb 10]. Available from:
Michaleff ZA, Maher CG, Lin CW, Rebbeck T, Jull G, Latimer J, et al.
Comprehensive physiotherapy exercise programme or advice for chronic
whiplash (PROMISE): a pragmatic randomised controlled trial.
Lancet 2014: 12; 384: 133–141.
Ludvigsson ML, Peterson G, O’Leary S, Dedering A, Peolsson A.
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.
Clin J Pain 2015; 31: 294–303.
Peolsson A, Ludvigsson ML, Overmeer T, Dedering A, Bernfort L, Johansson G, et al.
Effects of neck-specific exercise with or without a behavioural approach
in addition to prescribed physical activity for individuals with chronic
whiplash-associated disorders: a prospective randomised study.
BMC Musculoskel Dis 2013; 14: 311.
Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, Zeiss E.
Scientific Monograph of the Quebec Task Force on Whiplash-Associated Disorders
Redefining Whiplash and its Management
Spine (Phila Pa 1976). 1995 (Apr 15); 20 (8 Suppl): S1-S73
The Neck Disability Index: State-of-the-Art, 1991-2008
J Manipulative Physiol Ther 2008 (Sep); 31 (7): 491–502
Assessment of chronic pain. I.
Aspects of the reliability and validity of the visual analogue scale.
Pain 1983; 16: 87–101.
Landén Ludvigsson M, Peolsson A, Peterson G.
Neck-specific exercise program. [Cited 2015 Feb 9]. Available from:
MacDermid JC, Walton DM, Avery S, Blanchard A, Etruw E, McAlpine C, et al.
Measurement properties of the neck disability index: a systematic review.
J Orthop Sports Phys Ther 2009; 39: 400–417.
Westaway MD, Stratford PW, Binkley JM.
The patient-specific functional scale:
validation of its use in persons with neck dysfunction.
J Orthop Sports Phys Ther 1998; 27: 331–338.
Stewart M, Maher CG, Refshauge KM, Bogduk N, Nicholas M.
Responsiveness of pain and disability measures for chronic whiplash.
Spine (Phila Pa 1976) 2007; 32: 580–585.
Altmaier EM, Russell DW, Kao CF, Lehmann TR, Weinstein JN.
Role of self-efficacy in rehabilitation outcome among chronic low back pain patients.
J Counsel Psychol 1993; 40: 335–339.
Denison E, Ĺsenlöf P, Lindberg P.
Self-efficacy, fear avoidance, and pain intensity as predictors of disability
in subacute and chronic musculoskeletal pain patients in primary health care.
Pain 2004; 111: 245–252.
Bunketorp L, Carlsson J, Kowalski J, Stener-Victorin E.
Evaluating the reliability of multi-item scales: a non-parametric approach
to the ordered categorical structure of data collected with the Swedish version
of the Tampa Scale for Kinesiophobia and the Self-Efficacy Scale.
J Rehabil Med 2005; 37: 330–334.
Dworkin RH, Turk DC, McDermott MP, Peirce-Sandner S, Burke LB, et al.
Interpreting the clinical importance of group differences
in chronic pain clinical trials: IMMPACT recommendations.
Pain 2009; 146: 238–244.
Cleland JA, Fritz JM, Whitman JM, Palmer JA.
The reliability and construct validity of the Neck Disability Index
and patient specific functional scale in patients with cervical radiculopathy.
Spine (Phila Pa 1976) 2006; 31: 598–602.
Dworkin RH, Turk DC, Wyrwich KW, Beaton D, Cleeland CS, et al.
Interpreting the clinical importance of treatment outcomes
in chronic pain clinical trials: IMMPACT recommendations.
J Pain 2008; 9: 105–121.
Elliott P, Hawthorne G.
Imputing missing repeated measures data:
how should we proceed?
Aust N Z J Psychiatry 2005; 39: 575–582.
Stewart MJ, Maher CG, Refshauge KM, Herbert RD, Bogduk N, Nicholas M.
Randomized controlled trial of exercise for
chronic whiplash-associated disorders.
Pain 2007; 128: 59–68.
Landén Ludvigsson M, Peterson G, Dedering Ĺ, Falla D, Peolsson A.
Factors associated with pain and disability reduction
following exercise interventions in chronic whiplash.
Eur J Pain 2015 May 29 [Epub ahead of print].
Abbott JH, Schmitt JS.
The Patient-Specific Functional Scale was valid for
group-level change comparisons and between-group discrimination.
J Clin Epidemiol 2014; 67: 681–688.
Ylinen J, Hakkinen A, Nykanen M, Kautiainen H, Takala EP.
Neck muscle training in the treatment of chronic neck pain:
a three-year follow-up study.
Eura Medicophys 2007; 43: 161–169.
Jones F, Harris P, Waller H, Coggins A.
Adherence to an exercise prescription scheme: the role of expectations,
self-efficacy, stage of change and psychological well-being.
Br J Health Psychol 2005; 10: 359–378.
Mailis-Gagnon A, Yegneswaran B, Lakha SF, Nicholson K, Steiman AJ, Ng D, et al.
Pain characteristics and demographics of patients attending
a university-affiliated pain clinic in Toronto, Ontario.
Pain Res Manag 2007; 12: 93–99.
Return to WHIPLASH
Return to EXERCISE AND CHIROPRACTIC