BMC Public Health 2021 (Apr 23); 21 (1): 785 ~ FULL TEXT
A Peolsson, A Hermansen, G Peterson, E Nilsing Strid
Department of Health, Medicine and Caring Sciences,
Unit of Physiotherapy,
Background: Work resumption is a big challenge in the rehabilitation process for individuals with whiplash-associated disorders (WAD). To better meet the needs of individuals with WAD in their return to work process, more knowledge on their experiences and perspectives is needed. The aim of this study was to explore the experiences of work ability and the work situation of individuals who participated in a neck-specific exercise programme for chronic WAD.
Methods: This qualitative study has an exploratory and descriptive design based on data collected through open-ended interviews with 17 individuals with chronic WAD. Data were analysed inductively using conventional content analysis.
Results: Analysis of the data yielded the following five categories related to the participants' narratives on their experiences of work ability and their work situation: Return to work - a process of setbacks and bureaucracy; The need to be understood by health care professionals, and to receive a treatment plan; Individual resources are important for work ability; The consequences of reduced work ability; and Working conditions are important for work ability.
Conclusion: Individuals with chronic WAD often struggle to return to work. Emotional and practical support from stakeholders is imperative and needs to be strengthened. Participating in a neck-specific exercise programme, including being acknowledged and receiving information about WAD, could positively affect the work ability of WAD sufferers. This study has provided management strategies to improve the ability to work for individuals with chronic WAD, and highlights the need to incorporate a healthy and sustainable return to work in the rehabilitation of individuals with WAD, thereby making their return to work a success.
Keywords: Neck pain; Occupational health; Qualitative research; Return to work; Whiplash injuries.
The FULL TEXT Article:
Individuals with chronic whiplash-associated disorders (WAD) experience a variety of symptoms, including pain and disability, leading to financial consequences for themselves, their employer, and society. [1–3] These individuals return to work more slowly, and their return to work rate is lower, compared with individuals sick-listed with other musculoskeletal disorders. [3, 4] Approximately 50% of those with WAD who return to work experience ongoing pain and disability , which may affect their work ability.  Poor work ability is related to the personal factors higher age, neck pain, multiple pain locations, cognitive dysfunction, low health-related quality of life, and pessimistic illness perceptions [7–10] as well as work-related stress and work dissatisfaction.  Circularly associations have been found between pain relief, functional improvement, and improvement in work capacity (measured as working hours/week) ; however, there are few studies evaluating the effect of rehabilitation on work ability for individuals with chronic WAD, and thus far the effect is inconclusive. [12–14] Adams et al. reported only marginal improvement in work ability despite rehabilitation.  Work ability was, however, improved after a multi-professional rehabilitation programme with cognitive behavioural therapy  and after neck-specific exercises with and without a behavioural approach. 
Previous qualitative studies have explored the experience of living with WAD [15–18], including challenges in returning to work. [18–20 ] Work resumption was identified as the biggest challenge in the rehabilitation process  and in one study, participants expressed sadness over being unable to work.  There are however no previous studies focusing on work ability and work situation from the perspective of individuals with chronic WAD. Since the effect of rehabilitation on work ability is inconclusive [12–14], more knowledge of the individuals’ experiences is needed. This knowledge could be used to better meet the needs of individuals with WAD in their return to work process. The aim of this study was to explore the experiences of work ability and the work situation of individuals who participated in a neck-specific exercise programme for chronic WAD. In this study, we use the definition of work ability as the balance between an individual’s resources and work demands. 
Methods and materials
This qualitative study has an exploratory and descriptive design based on data collected through open-ended interviews.  Data were analysed inductively using conventional content analysis according to Hsieh & Shannon. 
Setting and participants
Participants were recruited from an ongoing randomized controlled trial (RCT)  evaluating two different ways of distributing neck-specific exercises to individuals with chronic WAD Grade II and III  in primary health care in Sweden. Both groups performed neck-specific exercises for 12 weeks: Arm A received internet-based support exercises in combination with four visits to the physiotherapist and arm B received exercises at a physiotherapy clinic 2 times/week. Those who had completed at least half of the training sessions and the 1-year follow-up were eligible to participate in the present study. A purposeful sampling strategy was used to achieve a heterogeneous sample of participants from both RCT arms based on age, gender and geographical area, in order to obtain the richest possible data.  Out of 72 eligible individuals, 44 were purposefully approached, ten at a time according to the purposeful sampling strategy, and received brief written information about the study and an interest request through a text message by one of the researchers. Twenty-one responded and received extended oral and written information as well as a consent form. Interviews were continuously held with those who returned informed consent until informational power  was deemed to have been achieved. In total, 17 individuals were included, comprising 13 women and four men. The participants were between the ages of 25 and 61 years and came from eight different geographical areas. Details of the participants are provided in Table 1.
At the time of the interviews, the majority of the participants (16 out of 17) had returned to ordinary or modified work full or part-time. Since the time of the car accident, a few had been requested to re-train for a new job, had changed jobs by themselves or had been entitled to benefits from the Social Insurance Agency (SIA). One person was waiting for work capacity evaluation. In Sweden, decisions on entitlement to sickness benefits is made by the SIA primarily based on information provided by physicians in a sickness certificate.
A semi-structured interview guide with open-ended questions was developed by the authors concerning the participants’ experiences and perceptions of their work ability and work situation, from the accident until the time of the interview, and anything they had experienced as facilitating or hindering their ability to work. To deepen the discussion, probing questions related to the participants’ narratives were posed, such as “Could you elaborate that?” The interview guide was pilot-tested in one interview with a patient with WAD but not participating in the RCT. The interview was not analysed, but only minor revisions were made. An English version of the interview guide is provided as supplementary information (Additional file 1).
As the participants were spread over a large geographical area, the interviews were conducted by phone. The interviews were conducted in October–December 2019 by one of the authors (E.N.S.), who was not involved in the design of the ongoing RCT. The interviews were digitally recorded. Each interview lasted between 45 and 60 min. The interviewees were pseudonymised and each assigned a number. A professional transcriber transcribed the interviews verbatim. The transcripts were not returned to participants for comments.
Data were analysed using qualitative conventional content analysis.  The analysis was data-driven  and based on the participants’ unique experiences. Two of the authors (E.N.S. and A.P.) were responsible for the analysis and held continuous discussions throughout the analytical steps. The interview text was thoroughly read twice to gain an understanding of the whole.  Initial impressions were written down, and then discussions were held and comparisons made of the understanding of the text.  The transcribed interview text was imported into NVivo 12 (QSR International, Melbourne, Australia), which was used to manage and code data. Meaning units related to the aim of the study were identified and coded for their content by A.P. The two main authors (E.N.S and A.P) discussed the codes and worked together to sort related codes into meaningful clusters forming the basis for developing subcategories, which were finally grouped into a smaller number of categories. 
The subcategories and categories were compared for differences and similarities, striving to be internally homogeneous and externally heterogeneous, which means that no data should fall between two groups nor fit into more than one group.  The process was iterative, going back and forth between the main text and the codes. The consistency and adequacy of the subcategories and categories was checked by a third author (A.H.) and finally discussed among all four authors. Quotations capturing the essence of what had been said were selected to illustrate the different subcategories. The selected quotations were translated into English by a professional language translator and then retranslated into Swedish, to ensure that the meaning was retained. Finally, all authors discussed the categorization and the selected quotations and reached consensus. The coding tree is described in Table 2.
Participation in the current interview study was voluntary. Participants were interviewed after giving oral and written informed consent. All data were decoded and handled with confidentiality as they contained information about the participants’ health. Only the research team had access to the interview files, transcripts and consent forms. Participants were assured that no individual would be identifiable from the quotations or results. In order to maintain confidentiality, no information on age, gender or other participant characteristics were ascribed to the quotations. The interviewer had had no previous contact with the participants. The study followed the ethical principles of the Helsinki Declaration (World Medical Association 2019) and was approved by the Regional Ethics Review Board in Linköping, Sweden (Peolsson, Dnr 2016/135–31 and 2018/462–32).
This study highlights how individuals with chronic with whiplash-associated disorders (WAD) struggle to return to work, and reflects some of the sadness the participants expressed over a changed self-image and work role. The participants were motivated to work and had developed a range of strategies to handle work demands. They related that having emotional and practical support from managers, co-workers, family, health care professionals and others was important; however, their experiences of support varied. Participating in a neck-specific exercise programme, and thus being acknowledged and receiving information about WAD, positively impacted their work ability. These findings will be further discussed in relation to the developmental and dynamic process of return to work  and the holistic model of work ability. 
The focus of this study was on work ability and the work situation from the perspective of individuals with chronic WAD. As suggested in the developmental process of return to work, workers pass through a series of phases when returning to work, including the experience of injury or chronic illness, being off work, and re-entering work, as well as maintenance of work ability and advancement at work.  The participants in this study described a bumpy and uphill road to return to work, which included setbacks and going on-and-off work. This supports the developmental and dynamic process of return to work described by Young and colleagues,  that workers move non-linearly between the mentioned phases. The findings underscore that individuals with chronic WAD need to feel understood and acknowledged by their managers, colleagues, family, health care providers and other stakeholders during this process. According to previous studies, this bumpy road may be explained by different strategies to cope with fluctuations in symptoms, but also by poor self-efficacy , a mismatch between stakeholder expectations [29, 30] and/or insufficient support from health care [17, 19, 31], the SIA [17, 19] or employer. [32, 33] Our findings show how the support for return to work for individuals with chronic WAD can be strengthened.
As anticipated from the holistic work ability model , a balance between the human resources (the individual’s health and functional capacities, competence, values, attitudes, and motivation) and work (demands and content of work, work environment, community, and management) is crucial. A poor balance between human resources and work decreases the person’s work ability. In addition, the balance is also affected by the environment outside of work, such as family and the close community.  The narratives from the participants in this study support that health and functional capacity are an important dimension affecting (though not altogether determining) work ability. Participating in a neck-specific exercise programme could mean receiving a tool for managing symptoms at work, being able to perform work tasks more efficiently and working more hours.
These results are in line with previous findings from quantitative data on symptom reduction  and improved work ability  after neck-specific exercises. In contrast to previous experiences with health care providers, the participants in our study also described feeling understood and acknowledged by the physiotherapists involved in the study. This meant that their injury was “legitimized”; they received information and a treatment plan; and the exercises reduced their symptoms. This type of acknowledgement may be related to the term “validation”. As suggested by Linton , validation in pain communication functions to soothe negative affect by acknowledging the patient’s experience and thereby increasing disclosure to promote problem solving and shared decision making. The importance of being understood by health care professionals , and of receiving information and support to understand and cope with one’s situation, has previously been highlighted in qualitative studies in individuals with WAD. [13, 16, 17, 19] Feeling believed and getting validation of the whiplash injury is considered a necessary step in the recovery process , with implications for return to work as suggested by the findings in this study. According to a previous meta-analysis, better management strategies to support return to work and daily life in general are needed for individuals with WAD. 
Human resources as described previously [21, 36] consist also of a person’s inner values and attitudes as well as factors that motivate them in their working life. A wish to participate in working life has previously been described by individuals with WAD. [19, 31] In this study, the participants all expressed a strong motivation to work. Work was an important part of their identity and they put a lot of effort into maintaining their working life. They described balancing between different strategies to handle work demands using active and passive coping strategies to handle their symptoms. This pattern is in accordance with other studies on patients with WAD , emphasizing the need to unravel self-efficacy beliefs, emotions, coping strategies, as well as expectations to better support individuals with WAD in the process of returning to work.  The aforementioned holistic model of work ability suggests that, within the dimensions of work, management and leadership have the strongest effect on work ability. Managers are suggested to play a key role in influencing the balance between the resources of the individual and work by organizing the work according to the requirements and capabilities of the individual. 
Sustainable return to work after musculoskeletal disorders and common mental disorders is influenced by an interplay of multiple factors, among which the most consistent evidence was found for support from leaders and co-workers.  The importance of emotional and practical support, in terms of timely work adjustments and ergonomics, from the manager was highly emphasized in the interviews as contributing to participants’ ability to work, as was also the importance of being part of a working environment with occupational health services, a good psychosocial climate, and co-worker support. However, not everyone was given this support. These findings highlight the importance of strengthening a supportive communication between the manager, co-workers and the individual during the return to work process.
Our findings suggest that, with better health care support, including validation, information, and an individually tailored, neck-specific exercise programme and treatment plan, individuals with WAD can be empowered and their return to work can be less difficult. This means, to be listen to and believed by the stakeholders involved, and to receive evidence-based rehabilitation. The rehabilitation of individuals with WAD could be improved by implementation of the neck-specific exercise programme in primary health care, education of physiotherapists, physicians and other health care professionals along with information about WAD to media and various stakeholders such as head of health care departments, patients, SIA, workplaces and HRMD departments. Setting return to work as a priority in the rehabilitation of individuals with WAD is strongly recommended in the literature. 
As acknowledged in the model of work ability , in previous research [10, 37, 38] as well as in this study, symptom reduction is important but it is not a prerequisite for work ability and successful work integration. Rather, work ability is affected by the balance between the individual’s resources and work as well as the environment outside of work. This study has provided management strategies to support the ability to work for individuals with chronic WAD, and suggestions on how to incorporate a healthy and sustainable return to work in the rehabilitation of individuals with WAD, thereby helping to make the process smoother.
This study has some strengths and limitations, which need to be considered when interpreting the results. Credibility was demonstrated by the fact that the research team had good scientific knowledge and clinical experience of treating patients with WAD, and of sick leave and return to work, as well as previous experience in conducting qualitative studies. The interview guide was pilot-tested, which further strengthens credibility. The sample size was guided by information power.  A recruitment of 15–20 participants was planned, and during the research process a sample of 17 participants were deemed to be sufficiently large and varied to elucidate the aim of the study and contribute to new knowledge. We included more women than men, which is consistent with the gender distribution in chronic WAD.  In contrast to the 1:1 ratio in the RCT, slightly more participants from treatment arm A were included. Considering other background data such as age, gender and duration since whiplash injury the current cohort was deemed to be representative to the RCT (unpublished data).
The interviews were held over the phone, allowing recruitment of participants from different geographical areas in Sweden. Telephone interviews may allow participants to feel relaxed and speak freely, but to not see and respond to the informants’ facial expressions could hamper the data quality by for an example less in-depth interviews. The data were systematically analysed using conventional content analysis and keeping the analysis close to the text.  To strengthen confirmability, the entire research team held consensus discussions throughout the analysis process, and the findings, including supporting quotations, were approved by the research team. No member check was however performed. The researchers are all physiotherapists and all are women. We have been aware of our perspectives during the data collection and analysis, and have strived to correctly convey the participants’ perspectives in the results. The checklist for reporting of qualitative studies  was used to improve transferability. The findings from this study may serve as a starting point for further research on strategies to support the return to work process among individuals with WAD from the perspective of the individual, workplace and health care provider.
Individuals with chronic whiplash-associated disorders (WAD) often struggle to return to work. Emotional and practical support from stakeholders is imperative to the success of return to work and needs to be strengthened. Participation in a neck-specific exercise programme, including acknowledgement and information about WAD, could positively affect the work ability of WAD sufferers. This study has suggested management strategies to support the ability to work for individuals with chronic WAD and highlights the need to incorporate a healthy and sustainable return to work in the rehabilitation of individuals with WAD, thereby making the return to work a success.
Additional File 1
We would like to acknowledge all participants in the study sharing their experiences.
All authors equally contributed to creation of the study design, data analysis, interpretation of findings and writing of the manuscript. E.N.S interviewed all the participants and had together with A. P the main responsibility for performing the analysis and drafting the manuscript. A. H contributed substantially in the data analysis and both A. H and G. P contributed substantially in interpretation of data. All authors have approved the final version of the manuscript for submission. All authors have agreed both to be personally accountable for their own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.
The study was financially supported by Linköping University, Region Sörmland and Region Örebro County, Sweden. No external funding or benefits were received. Open Access funding provided by Örebro University.
Ethics approval and consent to participate
The study was approved by the Regional Ethics Review Board in Linköping, Sweden (Peolsson, Dnr 2016/135–31 and 2018/462–32). Participants provided written informed consent, and were informed that participation was on voluntary basis and that they could withdraw from the study at any time. Confidentiality was guaranteed.
The authors have no competing interests to declare.
Ferrari R, Russell AS, Carroll LJ, Cassidy JD.
A re-examination of the whiplash associated disorders (WAD)
as a systemic illness.
Ann Rheum Dis. 2005;64(9):1337–1342.
Holm, LW, Carroll, LJ, Cassidy, JD et al.
The Burden and Determinants of Neck Pain in Whiplash-associated Disorders
after Traffic Collisions: 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): S52-59
Leth-Petersen S, Rotger GP.
Long-term labour-market performance of whiplash claimants.
J Health Econ. 2009;28(5):996–1011.
Biering-Sorensen S, Moller A, Stoltenberg CD, Holm JW, Skov PG.
The return-to-work process of individuals sick-listed because of
whiplash-associated disorder: a three-year follow-up study in a
Danish cohort of long-term sickness absentees.
BMC Public Health. 2014;14(1):113.
Kamper SJ, Rebbeck TJ, Maher CG, McAuley JH, Sterling M.
Course and prognostic factors of whiplash:
a systematic review and meta-analysis.
Styrke J, Sojka P, Bjornstig U, Stalnacke BM.
Symptoms, disabilities, and life satisfaction five years after whiplash injuries.
Scand J Pain. 2014;5(4):229–236.
Agnew L, Johnston V, Landen Ludvigsson M, Peterson G, Overmeer T, Johansson G.
Factors associated with work ability in patients with chronic
whiplash-associated disorder grade II-III:
a cross-sectional analysis.
J Rehabil Med. 2015;47(6):546–551.
Gehrt TB, Wisbech Carstensen TB, Ornbol E, Fink PK, Kasch H, Frostholm L.
The role of illness perceptions in predicting outcome after acute
whiplash trauma: a multicenter 12-month follow-up study.
Clin J Pain. 2015;31(1):14–20.
Mankovsky-Arnold T, Wideman TH, Thibault P, Lariviere C, Rainville P.
Sensitivity to movement-evoked pain and multi-site pain are associated
with work-disability following whiplash injury: a cross-sectional study.
J Occup Rehabil. 2017;27(3):413–421.
Buitenhuis J, de Jong PJ, Jaspers JP, Groothoff JW.
Work disability after whiplash: a prospective cohort study.
Angst F, Gantenbein AR, Lehmann S, Gysi-Klaus F, Aeschlimann A, Michel BA.
Multidimensional associative factors for improvement in pain,
function, and working capacity after rehabilitation of whiplash
associated disorder: a prognostic, prospective outcome study.
BMC Musculoskelet Disord. 2014;15(1):130.
Adams H, Ellis T, Stanish WD, Sullivan MJ.
Psychosocial factors related to return to work following
rehabilitation of whiplash injuries.
J Occup Rehabil. 2007;17(2):305–315.
Ehrenborg C, Gustafsson S, Archenholtz B.
Long-term effect in ADL after an interdisciplinary rehabilitation
programme for WAD patients: a mixed-method study for deeper
understanding of participants’ programme experiences.
Disabil Rehabil. 2014;36(12):1006–1013.
Lo HK, Johnston V, Landen Ludvigsson M, Peterson G, Overmeer T, David M, Peolsson A.
Factors associated with work ability following exercise
interventions for people with chronic whiplash-associated
disorders: secondary analysis of a randomized controlled trial.
J Rehabil Med. 2018;50(9):828–836.
Russell G, Nicol P.
I’ve broken my neck or something!’ The general practice experience of whiplash.
Fam Pract. 2009;26(2):115–120.
Williamson E, Nichols V, Lamb SE.
“If I can get over that, I can get over anything”--understanding
how individuals with acute whiplash disorders form beliefs
about pain and recovery: a qualitative study.
Ritchie C, Ehrlich C, Sterling M.
Living with ongoing whiplash associated disorders: a qualitative
study of individual perceptions and experiences.
BMC Musculoskelet Disord. 2017;18(1):531.
Soderlund A, Nordgren L, Sterling M, Stalnacke BM.
Exploring patients’ experiences of the whiplash injury-recovery process - a meta-synthesis.
J Pain Res. 2018;11:1263–1271.
Rydstad M, Schult ML, Lofgren M.
Whiplash patients’ experience of a multimodal rehabilitation
programme and its usefulness one year later.
Disabil Rehabil. 2010;32(22):1810–1818.
Juuso P, Skar L, Soderberg S.
Recovery despite everyday pain: women’s experiences of
living with whiplash-associated disorder.
Musculoskelet Care. 2020;18(1):20–28.
From work ability research to implementation.
Int J Environ Res Public Health. 2019;16(16):7.
Qualitative research & evaluation methods. 4.
London: Sage Publications; 2015.
Hsieh HF, Shannon SE.
Three approaches to qualitative content analysis.
Qual Health Res. 2005;15(9):1277–1288.
Peolsson A, Landen Ludvigsson M, Peterson G.
Neck-specific exercises with internet-based support compared to
neck-specific exercises at a physiotherapy clinic for chronic
whiplash-associated disorders: study protocol of a
randomized controlled multicentre trial.
BMC Musculoskelet Disord. 2017;18(1):524.
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
Malterud K, Siersma VD, Guassora AD.
Sample size in qualitative interview studies: guided by information power.
Qual Health Res. 2016;26(13):1753–1760.
Young AE, Roessler RT, Wasiak R, McPherson KM, van Poppel MNM, Anema JR.
A developmental conceptualization of return to work.
J Occup Rehabil. 2005;15(4):557–568.
Black O, Keegel T, Sim MR, Collie A, Smith P.
The effect of self-efficacy on return-to-work outcomes for
workers with psychological or upper-body musculoskeletal
injuries: a review of the literature.
J Occup Rehabil. 2018;28(1):16–27.
Young AE, Besen E, Choi Y.
The importance, measurement and practical implications
of worker’s expectations for return to work.
Disabil Rehabil. 2015;37(20):1808–1816.
Carriere JS, Thibault P, Adams H, Milioto M, Ditto B, Sullivan MJL.
Expectancies mediate the relationship between perceived injustice and
return to work following whiplash injury: a 1-year prospective study.
Eur J Pain. 2017;21(7):1234–1242.
Krohne K, Ihlebaek C.
Maintaining a balance: a focus group study on living and
coping with chronic whiplash-associated disorder.
BMC Musculoskelet Disord. 2010;11(1):158.
Grant M, J OB-E. Froud R, Underwood M, Seers K.
The work of return to work. Challenges of returning to work
when you have chronic pain: a meta-ethnography.
BMJ Open. 2019;9(6):e025743.
Etuknwa A, Daniels K, Eib C
Sustainable return to work: a systematic review focusing
on personal and social factors.
J Occup Rehabil. 2019;29(4):679–700.
Ludvigsson ML, Peterson G, Dedering A, Peolsson A.
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
J Rehabil Med 2016 (Jan); 48 (1): 56–64
Intricacies of good communication in the context of pain:
does validation reinforce disclosure?
Gould RI, Järvisalo J, Koskinen S.
Dimensions of Work Ability Helsinki 2008
Results of the Health 2000 Survey
Helsinki, Finland: Finnish Centre of Pensions;
The Social Insurance Institution;
National Public Health Institute;
Finnish Institute of Occupational Health; 2008.
Sullivan M, Adams H, Thibault P, Moore E, Carriere JS, Lariviere C.
Return to Work Helps Maintain Treatment Gains
in the Rehabilitation of Whiplash Injury
Pain 2017 (May); 158 (5): 980–987
Carriere JS, Thibault P, Milioto M, Sullivan MJL.
Expectancies mediate the relations among pain catastrophizing, fear
of movement, and return to work outcomes after whiplash injury.
J Pain. 2015;16(12):1280–1287.
Tong A, Sainsbury P, Craig J.
Consolidated criteria for reporting qualitative research (COREQ):
a 32-item checklist for interviews and focus groups.
Int J Qual Health Care. 2007;19(6):349–357.
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