Pain 2017 (May); 158 (5): 980–987 ~ FULL TEXT
Michael Sullivan, Heather Adams, Pascal Thibault, Emily Moore, Junie S Carriere, Christian Larivière
Faculty of Health and Behavioural Sciences,
The University of Queensland,
This study examined the relation between return to work and the maintenance of treatment gains made over the course of a rehabilitation intervention. The study sample consisted of 110 individuals who had sustained whiplash injuries in rear collision motor vehicle accidents and were work-disabled at the time of enrolment in the study. Participants completed pre- and post-treatment measures of pain severity, disability, cervical range of motion, depression, posttraumatic stress symptoms, and catastrophizing. Pain severity was assessed again at 1–year follow-up. At 1–year follow-up, 73 participants had returned to work and 37 remained work-disabled. Analyses revealed that participants who returned to work were more likely to maintain treatment gains (77.5%) than participants who remained work-disabled (48%), x2 = 6.3, P < 0.01.
The results of a regression analysis revealed that the relation between return to work and the maintenance of treatment gains remained significant (β = 0.30, P < 0.01), even when controlling for potential confounders such as pain severity, restricted range of motion, depression, and pain catastrophizing. The Discussion addresses the processes by which prolonged work-disability might contribute to the failure to maintain treatment gains. Important knowledge gaps still remain concerning the individual, workplace, and system variables that might play a role in whether or not the gains made in the rehabilitation of whiplash injury are maintained. Clinical implications of the findings are also addressed.
Keywords: Return to work, Work-disability, Pain, Disability, Whiplash
The FULL TEXT Article:
Return to work is considered a desirable treatment objective for
individuals who have sustained whiplash injuries. The position or policy statements of many injury insurers and clinical practice
guidelines argue for placing return to work as a priority in the
physical rehabilitation of a wide range of musculoskeletal
injuries. [6, 7, 29, 33, 52] Evidence highlighting the deleterious health and mental health consequences of prolonged unemployment is frequently marshalled to support the view that return to work should be a central objective of a rehabilitation plan. [35, 47]
The health benefits of returning to work following a whiplash
injury have been inferred more than they have been demonstrated.
The bulk of research in this area has focused on the
deleterious consequences of prolonged unemployment rather
than the health benefits of returning to work.  Research from several countries shows that prolonged unemployment is associated with a wide range of adverse health and mental health outcomes. [4, 28, 32, 53] However, research showing a relation between prolonged unemployment and negative health or mental health outcomes cannot be taken as evidence that returning to work following a period of work-disability will yield positive health or mental health benefits.
In this study, the health benefits of return to work were
assessed in relation to the maintenance of treatment gains made
following participation in a rehabilitation program for whiplash
injury. Rehabilitation interventions for whiplash injury have been shown to yield significant reductions in pain and disability. [3, 10, 47] Following participation in rehabilitation interventions, a certain percentage of individuals with whiplash injuries will return to work, whereas others will remain work-disabled. [14, 38, 39, 47] The distribution of return-to-work outcomes following completion of a rehabilitation intervention provides an ideal context for
assessing the potential health benefits of returning to work. On
the basis of research pointing to the adverse consequences of
prolonged unemployment, it can be predicted that return to work
will be associated with a greater likelihood that treatment gains will be maintained. [36, 40] However, it is also possible that treatment gains might be less likely to be maintained in individuals who return to work. This prediction would be based on the notion that excessive demands on a musculoskeletal system that has been compromised by injury might lead to worsening of symptoms.  Finally, return to work could be shown to have no relation to the probability of maintaining treatment gains. To date, no study has examined the relation between return to work and the probability of maintaining treatment gains in individuals with whiplash injuries.
This study examined the relation between return to work and
the maintenance of treatment gains following participation in
a rehabilitation intervention for whiplash injury. Treatment gains were operationally defined as reductions in the severity of pain symptoms and self-rated improvement. Work-disabled individuals with whiplash injuries completed pre- and post-treatment measures of pain severity. Maintenance of treatment gains was assessed at 1–year follow-up. Predictive analyses controlled for potential confounders (eg, psychosocial variables, symptom severity, and disability) of the relation between return to work and the maintenance of treatment gains.
The study sample consisted of 110 (62 men, 48 women)
individuals who had sustained whiplash injuries in rear collision
motor vehicle accidents and were work-disabled at the time of
recruitment. The mean age of the sample was 36.6 years with
a range of 25 to 60 years. The mean duration of work disability
was 18.3 weeks with a range of 8 to 40 weeks. The majority of
participants (82%) had completed at least 12 years of education.
Approximately, half of the sample (46%) was married or living with
a common-law partner. At the time of enrolment in the study, all
participants were work-disabled and receiving salary indemnity
through a no-fault provincial insurance system (Socie´ te´ de
l’assurance automobile du Que´ bec).
Participants were recruited between June 2010 and August 2013
from one of 2 rehabilitation centres in Montreal, Canada. The
clinics from which patients were recruited were part of a network
of rehabilitation centres providing services for the state motor
vehicle insurer. A 7–week standardized program of intervention
was offered at each rehabilitation centre. The programs were
characterized by a functional restoration and activity reintegration
orientation focusing on education, mobilisation and exercise, and
the development of self-management skills. The program of
rehabilitation offered by the clinics from which patients were
recruited is described in more detail elsewhere. 
Eligibility criteria included a diagnosis of a whiplash-associated
disorder (grade II) and being work-disabled at the time of
recruitment. Advertisements were placed in the collaborating
clinics, and interested individuals were instructed to contact the
clinic coordinator. Volunteers signed a consent form as a condition
of participating in the study. The research was appred by
the Ethics Review Committee of McGill University.
Participants completed measures of pain severity, depression,
posttraumatic stress, pain catastrophizing, and functional disability.
Physical function evaluation included assessment of active
range of motion. The variables included in the study were
intended to provide indices of health and mental health status that
might impact on the probability of maintaining treatment gains.
The choice of variables was also guided by the results of previous
research on determinants of recovery trajectories following
whiplash injury. [1, 2, 12, 42] Assessments were completed during
the first and final weeks of the 7–week rehabilitation program.
Participants were contacted by telephone 1 year after completion
of the rehabilitation intervention and were asked to respond to
questions about their present pain severity, the changes in their
health condition during the previous 12 months, the treatments
they had received during the previous 12 months, and their
Demographic and injury-related variables
Participants were asked to respond to questions concerning their
age, sex, marital status, education, occupation, and medication
use. Crash-related characteristics (ie, speed of collision, use of
head rest, and use of seat belt) were also assessed.
Participants were asked to rate the severity of their pain on an
11–point numerical rating scale (NRS) with the endpoints (0) no
pain and (10) excruciating pain. The total number of pain sites
(range 5 0–4) was computed from a body drawing (neck, back,
upper extremity, and lower extremity).
Range of motion
The maximum active cervical range of motion (CROM; flexion and
extension, left and right lateral flexion, and left and right rotation)
was assessed with a CROM device.  Measurement of active
CROM has high intra- and inter-rater reliability and has been
shown to predict long-term outcomes in patients with whiplash
injuries. [21, 42]
Posttraumatic stress symptoms
The Impact of Events Scale—Revised (IES-R) was used to assess
symptoms of posttraumatic stress. On this measure, respondents
are asked to rate the degree of distress they experience with
different cognitive and emotional aspects of posttraumatic stress
on a 5–point rating scale with the endpoints (0) not at all and (4)
extremely. The IES-R has been shown to be a reliable and valid
index of posttraumatic symptoms. [11, 54] Scores on the IES-R have
been shown to discriminate between individuals with and without
a diagnosis of posttraumatic stress disorder. 
The Beck Depression Inventory II (BDI-II)  was used as a selfreport
measure of depressive symptom severity. The BDI-II
consists of 21 statements describing various symptoms of
depression and respondents choose the statement that best
describes how they have been feeling over the past 2 weeks.
Responses are summed to yield an overall index of severity of
depressive symptoms. The BDI-II has been shown to be a reliable
and valid index of depressive symptoms in patients with chronic
pain and primary care medical patients. 
The Pain Catastrophizing Scale (PCS)  was used to assess
catastrophic thinking related to pain. On this measure, respondents
rate the frequency with which they experience each of the 13
different thoughts and feelings when in pain. The PCS has been
shown to have high internal consistency (coefficient alpha 5
0.87), and to be associated with pain experience, pain behavior,
and disability. [45, 49]
The Neck Disability Index (NDI) was used as a measure of selfrated
disability associated with neck pain.  The NDI consists of
10 groups of statements describing levels of disability resulting
from neck pain in different domains of daily life. Responses are
summed to produce an overall index of disability where higher
scores reflect greater disability. The NDI has been shown to be
a reliable and valid index of disability associated with cervical
spine disorders. [34, 51, 57]
One-year follow-up interview
One year following the termination of the rehabilitation intervention,
participants were contacted by telephone and interviewed
about their current pain symptoms, their perceived improvement
since the termination of treatment, their employment status, and
their health care utilisation since treatment termination.
Follow-up pain severity
Participants were asked to verbally rate the severity of their pain
on an 11–point NRS with the endpoints (0) no pain and (10)
Follow-up self-rated improvement
Participants responded to a question about the degree of
improvement in their condition they had experienced since the
termination of the rehabilitation intervention in which they had
been enrolled. Participants were asked to choose one of the
following response options (1) condition improved, (2) condition
worsened, or (3) condition remained the same.
Follow-up employment status
Participants were asked whether they had returned to work since
the termination of the rehabilitation intervention in which they
were enrolled. The date at which they had returned to work,
whether they had been able to maintain work, and the nature of
their employment was also recorded. For the purposes of this
article, current employment status was categorized as having
resumed; (1) full-time work, (2) part-time work, or remained (3)
Follow-up treatment involvement
Participants were asked to report the different treatments (eg,
physiotherapy, occupational therapy, and psychotherapy) they
had received since the termination of the rehabilitation intervention.
The total number of interventions reported was used
as index of health care utilisation. Participants also reported the
different types of pain medications they were currently taking (eg,
NSAIDs, opiates, and psychoactive drugs). Each class of
medication was dichotomised as yes or no reflecting whether
participants had, or had not, been prescribed the medication.
Follow-up treatment involvement
Data analytic approach
Only limited information was available on participants who did not
volunteer to participate (N = 36) in the study. Analyses of
demographic information (age, sex, and education), pain
duration, pretreatment pain severity, and self-rated disability
revealed no significant differences between individuals who
volunteered and who declined participation in the study.
One hundred forty-eight individuals agreed to participate in this
study. Of these, 10 participants (6%) did not complete the
posttreatment evaluation. Information regarding the cause of the
missing data was not available. Twenty-eight participants (19%)
could not be reached for the 1–year follow-up interview. Analyses
were conducted to compare participants with complete (n = 110)
and incomplete data (n = 38) on sex, age, education, pain duration,
pretreatment pain intensity, and self-reported disability. No
significant differences were found on any of these comparisons.
Repeated measures analysis of variance was used to examine
how reductions in pain and maintenance of treatment gains
varied as a function of occupational re-engagement. Analyses
pertaining to the maintenance of treatment gains were also
conducted in relation to indices of “clinically meaningful” changes
in pain. Participants were classified as having shown clinically
meaningful improvement if their pain score decreased by 2 points
or more from pre- to post-treatment. The approach to defining
clinically meaningful response to treatment is consistent with
research on recommended cut scores on pain severity scales
and IMMPACT recommendations for interpreting pain treatment
outcomes. [17, 23] Chi-square analyses were used to address the
relation between occupational re-engagement and self-rated
improvement at follow-up.
The primary outcome variables were pain severity and selfrated
improvement. Because maintenance of treatment gains
could be influenced by the severity or complexity of participants’
whiplash injuries, a number of potential confounders were also
assessed. Indices of condition severity or complexity included
severity of disability (ie, CROM, self-rated disability), injury-related
psychosocial factors (ie, posttraumatic stress symptoms, depression,
and pain catastrophizing), medication use, and
T tests were used to compare occupationally re-engaged and
work-disabled participants on pre- and post-treatment measures,
and Pearson correlations were used to identify potential
confounders of the relation between return to work and the
maintenance of treatment gains. Multiple regression analysis was
used to assess the value of return-to-work status in predicting the
maintenance of treatment gains while controlling for potential
confounders. Tolerance coefficients for the regression analysis
were greater than 0.55 indicating no problem of multicollinearity.
All analyses were conducted with SPSS Version 23.
Demographic information, mean values, and SDs on all study
variables are presented in Table 1. On the basis of mean values
on the Pain NRS, the BDI-II, and the IES, the study sample would
be characterized as being in the early stages of chronicity, and
experiencing symptoms of pain, depression, and posttraumatic
stress of moderate severity. Most participants reported experiencing
pain in more than one bodily region. Mean scores on
measures of pain severity, self-reported disability, depression,
and posttraumatic stress symptoms are comparable with those
reported in previous studies examining recovery trajectories
following whiplash injury. [42, 43, 48]
Return to work and the maintenance of treatment gains
Following the rehabilitation intervention, 42 participants (38%)
returned to work full time, 31 participants returned to work part
time (28%), and 37 participants (34%) remained work-disabled.
On average, return to work occurred 2.2 weeks (range 1–8 weeks)
following termination of the rehabilitation intervention. The
majority of participants returned to their preinjury employment.
Two participants who had resumed part-time employment
later discontinued. These participants were reclassified as being
A repeated measures analysis of variance was conducted on
participants’ pain ratings to examine whether changes in pain
ratings over time varied as a function of occupational reengagement.
Participants were considered to be occupationally
re-engaged if they were currently working full or part time;
participants were considered to be work-disabled if they were
currently not working. The results of this analysis are presented in
Figure 1. The analysis yielded significant main effects for
occupational re-engagement, F(1,108) = 7.30, P < 0.01, and
time, F(2,216) = 52.1, P < 0.001. Main effects were qualified by
a significant 2–way interaction, F(2,216) = 4.5, P < 0.01.
Participants who resumed employment following the rehabilitation
intervention showed significant reductions in pain from preto
post-treatment, t(72) = 8.5, P < 0.001, and there was no
significant difference between their posttreatment and follow-up
pain ratings, t(72) = 0.96, P = 0.44. Participants who remained
work-disabled showed similar reductions in pain from pre- to
post-treatment, t(36) = 7.2, P < 0.001, but pain ratings increased
significantly from posttreatment to follow-up assessment, t(36) = 23.0, P < 0.01. On average, participants who remained workdisabled
lost 46% of the gains they had made through the course
of the rehabilitation intervention.
The relation between return to work and the maintenance of
treatment gains was also examined according to criteria for “clinically
meaningful” changes in pain (ie, reductions in pain of 2 points or
more). Participants who showed clinically meaningful improvement
were considered to have failed to maintain treatment gains if their
follow-up pain rating had increased by at least 2 points, relative to
the posttreatment evaluation. On this basis, 69 participants
(63%) showed clinically meaningful improvement in pain. Of the
participants who showed clinically meaningful improvement in pain,
24 (35%) failed to maintain treatment gains at 1–year follow-up. A x2
analysis revealed that participants who returned to work were more
likely to maintain treatment gains (77.5%) than participants who
remained work-disabled (48%), x2 = 6.3, P < 0.01. Only a minority
of participants (23%) who returned to work lost all the gains they
made in treatment, whereas the majority (76%) of participants who
remained work-disabled lost all the gains they had made in
treatment, x2 = 7.7, P < 0.01.
During the 1–year follow-up interview, participants were asked
to indicate whether their condition has improved, worsened, or
stayed the same since the termination of the rehabilitation
intervention. A x2 analysis was conducted to examine the relation
between return to work and participants’ retrospective appraisal
of the changes in their health condition over the previous 12
months. The results of a x2 are presented in Figure 2. The
analysis revealed that participants who returned to work were
significantly more likely (82%) than participants who remained
work-disabled (51%) to indicate that their condition had improved
since the termination of the rehabilitation intervention, x2 (2) 5
11.5, P < 0.01.
Controlling for confounders
A series of t tests were conducted to examine whether individuals
who returned to work differed from individuals who did not return
to work on various indices of clinical severity. These analyses
were conducted to address the possibility that the failure to
maintain gains by individuals who did not return to work was due
to the latter having a more serious or debilitating condition. As shown in Table 2, individuals who did not return to work were
more chronic at the time of admission, t(108) = 2.6, P < 0.01,
rated their pain as more intense at the time of admission, t(108) = 2.0, P < 0.05, showed reduced posttreatment neck flexion,
t(108) = 2.9, P <0.01, extension, t(108) = 3.0, P < 0.01, right lateral
flexion, t(108) = 2.3, P < 0.05, left lateral flexion, t(108) = 2.2, P < 0.05, right rotation, t(108) = 3.2, P < 0.001, left rotation, t(108) = 3.6, P < 0.001, reported more severe posttreatment depressive
symptoms, t(108) = 2.2, P < 0.05, more severe posttreatment
self-rated disability, t(108) = 3.6, P < 0.001, and obtained higher
PCS scores at posttreatment, t(108) = 3.0, P < 0.01.
Of the severity-relevant variables that distinguished between
occupationally re-engaged and work-disabled participants, only
the following were significantly correlated with change in pain
symptoms from posttreatment to 1–year follow-up: pretreatment
pain severity, right lateral flexion, right rotation, left rotation,
posttreatment BDI-II, posttreatment NDI, and post-treatment
PCS. As such, only the latter variables met criteria for
consideration as potential confounders.
A multiple regression analysis was conducted to examine
whether the relation between return to work and the maintenance
of treatment gains remained significant even when controlling for
potential confounders (Table 3). This analysis was conducted on
the subgroup (N = 68) of participants who showed clinically
meaningful improvement in pain through the course of the
rehabilitation intervention. In this analysis, the change in pain
ratings from posttreatment to 1–year follow-up was used as the
dependent variable. In step 1 of the analysis, the following
variables were entered as a block: pretreatment pain severity,
right lateral flexion, and right and left rotation. The variables
entered in step 1 of the analysis contributed significant variance to
the prediction of maintenance of treatment gains, F(4,63) = 4.9, P < 0.001. In step 2 of the analysis, the following variables were
entered: posttreatment scores on the BDI-II, NDI, and PCS. The
variables entered in step 2 of the analysis contributed significant
variance to the prediction of the maintenance of treatment gains,
F(3,60) = 2.9, P < 0.05. Return-to-work status at 1–year follow-up was entered in the final step of the analysis. Return-to-work status remained a significant predictor of changes in pain ratings following termination of the rehabilitation intervention, even when controlling for all potential confounders, F(1,59) = 6.4, P < 0.01.
This study sought to determine whether return to work conferred
any health benefits following rehabilitation of whiplash injury. The
main finding of the study was that individuals who returned to
work following participation in a rehabilitation intervention were
more likely to maintain treatment gains than individuals who did
not return to work. Return to work did not lead to amelioration in
pain symptoms, but rather, work absence contributed to
a worsening of pain symptoms.
The findings of this study are consistent with a large body of
research highlighting the deleterious health consequences of
prolonged work absence. Numerous investigations have shown
that unemployment is associated with increased all-cause
mortality. [28, 32, 53] Unemployment has also been associated with
increased risk of cardiovascular disease and suicide.  Many
population studies show that being out of work places someone
at increased risk of substance abuse, divorce, and violent
behaviour.  The findings of this study extend previous research in
showing that prolonged work absence following whiplash injury
impacts negatively on the maintenance of gains made following
participation in a rehabilitation intervention.
The relation between prolonged work absence and failure
to maintain treatment gains could not be explained in terms of
end-of-treatment differences in clinical severity. As expected,
participants who remained work-disabled had reduced physical
function as assessed by range of motion and self-rated disability.
Participants who remained work-disabled also obtained elevated
scores on measures of depression and pain catastrophizing.
However, the relation between return to work and the maintenance
of treatment gains remained significant even when controlling for
end-of-treatment differences in neck range of motion, self-rated
disability, depression, and pain catastrophizing.
Although the correlational nature of the study limits the strength
of conclusions that can be drawn about the direction of influence
among study variables, the temporal ordering of return to work
and the follow-up assessment favor an explanation where return
to work exerts an influence on the maintenance of treatment
gains. On average, participants who returned to work did so
within 2 weeks of termination of the rehabilitation intervention.
The follow-up assessment of pain severity used to determine
maintenance of treatment gains was conducted 1–year following
termination of the rehabilitation intervention. Because return to
work occurred on average 10 months before the final pain
assessment, the results are most consistent with the view that
return to work contributed to the maintenance of treatment gains.
In a previous study, high levels of posttreatment pain
catastrophizing were shown to predict the failure to maintain
treatment gains following participation in a rehabilitation intervention.  In this study, posttreatment pain catastrophizing was associated with increases in follow-up pain severity in univariate analyses, but did not emerge as a significant unique predictor of the maintenance of treatment gains in multivariate analyses. It is likely that the shared variance between pain catastrophizing and other predictor variables reduced the probability that any one variable would make a significant unique contribution in the regression equation. In support of this explanation, when only pain catastrophizing and return-to-work status were included as independent variables in the regression, both variables emerged as significant unique predictors of the maintenance of treatment gains.
There are several possible pathways by which prolonged work
absence following whiplash injury might contribute to the failure to maintain treatment gains. Individuals who do not return to work might engage in a lower level of physical activity, in turn, compromising their recovery potential.  Prolonged work absence
might also be associated with increases in symptoms of
mental health problems such as depression or anxiety that could
exacerbate pain symptoms. [55, 56] It is also possible that ongoing stresses related to the disability claims process, pressure to prove the basis for ongoing disability, and financial strain might also contribute to failure to maintain treatment gains in individuals who do not return to work. [18, 19] The pathways by which prolonged work absence following whiplash injury leads to failure to maintain treatment gains will need to be clarified by future research.
Return to work did not guarantee the maintenance of treatment
gains. Results revealed that 23% of participants who returned to
work did not maintain treatment gains. Inactivity and stress have been associated with poor recovery outcomes following whiplash injury. [30, 41] It is possible that participants who returned to employment that was sedentary and/or stressful might have been at higher risk for losing the gains they made in rehabilitation. On the basis of the data collected in the present study, it was not possible to identify the determinants of failure to maintain treatment gains in participants who returned to work.
Although return to work was not associated with health
benefits, at least defined as further reduction in pain symptoms, participants who returned to work were more likely than participants who remained work-disabled to report that their condition had “improved” during the follow-up period. It is possible that other symptoms or correlates of whiplash injury
might have continued to improve during the follow-up period.
Research on occupational injury suggests that return to work
can contribute to reductions in emotional distress symptoms,
increased social contact, feelings of accomplishment, or reduced
financial stresses. [26, 27, 35, 58] Similar benefits might be associated with return to work in individuals who have sustained whiplash injuries.
The findings of this study argue strongly for placing return to
work as a priority in the treatment of individuals who have
sustained whiplash injuries. Primary care practice places
emphasis on symptom management and mobilisation. [25, 37] It has been suggested that primary care practitioners do not necessarily consider their role to include involvement in the return-to-work process.  An implicit assumption guiding early intervention is that return to work will occur automatically once symptoms are effectively controlled.
However, research indicates that symptom severity is only a partial determinant of workdisability and symptom reduction is not a prerequisite for successful occupational reintegration. [13, 16] In addition, considering symptom control as a prerequisite of return to work might unnecessarily prolong the work-disability period, ultimately impacting negatively on the likelihood of successful work reintegration. The results of this study suggest that treatment gains such as pain reduction might not be maintained if return to work is not achieved. Neglecting to place return to work as a central treatment objective in the treatment of whiplash injury could be associated with high costs. In addition to the increase in health care costs associated with failing to maintain treatment gains, the resurgence of symptoms might be experienced as a treatment failure that could impact negatively on individuals’ expectations for future treatment outcomes or recovery potential. 
Some degree of caution must be exercised in the interpretation
of the study findings. Participants were recruited from multidisciplinary rehabilitation centres. Only a minority of individuals with whiplash injuries are referred to these centres. In addition, all participants were work-disabled. These sample characteristics necessarily have implications for the generalizability of findings. It is also necessary to consider that a wide range of symptomrelated, treatment-related, psychosocial, and workplace factors that have been shown to be associated with recovery outcomes and return to work were not assessed in this study. Whether the relation between return to work and maintenance of treatment gain is independent of these factors remains to be clarified by future research. It is also important to note that the sample consisted only of individuals who were working full time before the current period of work absence. It is not clear whether the findings are generalizable to individuals who were not gainfully employed before injury.
Despite these limitations, the results of this study suggest that the return to work contributes to the maintenance of treatment gains made over the course of rehabilitation interventions for whiplash injury. If replicated, these findings would have important implications for treatment planning for work-disabled individuals with whiplash injuries. By placing return to work as a central treatment objective of rehabilitation interventions, the probability of maintaining treatment gains might be substantively increased. Considering return to work as part of intervention plan to maintain treatment-related reductions in pain symptoms would also impact positively on the long-term cost-effectiveness of symptomatic treatment of whiplash injury.
Research on the determinants of the maintenance of treatment
gains following rehabilitation of whiplash injury is still in its infancy. To date, only a handful of studies have examined the course of symptom severity and disability after termination of a rehabilitation intervention. Important knowledge gaps still remain concerning the individual, workplace, and system variables that might play a role in whether or not the gains made in the rehabilitation of whiplash injury are maintained. These knowledge gaps will need to be addressed by future research.
Conflict of interest statement
The authors have no conflicts of interest to declare.
Supported by an operating grant from the Canadian Institutes
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