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BACKGROUND More than 40% of individuals with whiplash injury experience persistent neck pain and disability years later, called whiplash-associated disorders (WAD). A randomized controlled trial evaluated three exercise interventions in WAD and found that neck-specific exercise (NSE) and NSE with a behavioral approach (NSEB) significantly improve disability compared to prescribed physical activity (PPA). However, the relationship between neck-related function and disability is inconclusive and needs to be further investigated. AIM The present study compares the effect of NSE, NSEB, and PPA on neck muscle endurance (NME), active cervical range of motion (AROM), grip strength, and pain intensity immediately before and after the physical tests, and neck disability in individuals who are below or above the cut-off for normative reference values regarding NME, AROM, and grip strength. DESIGN Follow-up to a multicenter randomized clinical trial. SETTING Primary healthcare centers and hospital outpatient services. POPULATION The selected population of this study included 216 patients with persistent WAD grades II and III. METHODS This is a secondary analysis including 12 months' follow-up. NME, AROM, grip strength, pain, and self-reported disability were recorded at baseline, 3, 6, and 12 months. Linear mixed models were used, and sub-group analyses evaluated by non-parametric tests. RESULTS NSE and NSEB resulted in greater improvements compared to PPA (P

Neck disorders are common in primary health care (PHC) physiotherapy. A neck-specific exercise program based on research findings was implemented among physiotherapists in Swedish PHC. The aim of the study was to evaluate the adoption of the program. We invited PHC physiotherapists to an educational session including theoretical information and practical training. Before the educational session the participants (n = 261) completed a baseline questionnaire. After 3 and 12 months, we distributed surveys to identify changes in practice and in confidence regarding diagnosis and treatment. We compared data from 3-months and 12-months follow-up, respectively, with baseline data. Self-reported frequency of most of the included assessment methods was unchanged after 12 months. Frequency of assessment of neck proprioception had increased significantly. Specific neck muscle exercise for treatment of whiplash associated disorders was applied more frequently after 3 and after 12 months than at baseline. Frequency of other treatment methods remained unchanged. Confidence in diagnosis and treatment increased significantly, particularly among women. The program was not adopted as expected, but resulted in increased confidence regarding diagnosis and treatment. The provision of a short educational session seemed not to be sufficient to obtain a sustained change in practice.

Background: Years after whiplash injury, more than 40 % of people experience persistent neck pain and disability, called whiplash-associated disorders (WAD). The relations between neck related function, neck pain and disability are inconclusive and need to be further investigated. The aims were; a) to compare the effect of three different exercise interventions – neck-specific exercise (NSE), NSE with a behavioral approach (NSEB) and prescribed physical activity (PPA) – on neck-muscle endurance (NME), active cervical range of motion (AROM), grip strength and pain intensity immediately before and after the tests, and b) to compare neck-disability in individuals who are below or above the cut-off for normative reference values of healthy individuals regarding NME, AROM and grip strength.Methods: This is a secondary analysis of a randomized controlled multicenter study including 12 months’ follow-up. A total of 216 individuals with chronic WAD grades II or III were recruited. Data were recorded at baseline, 3, 6, and 12 months. Linear mixed models were used and sub-group analyses were evaluated with non-parametric tests.Results: NSE and NSEB resulted in greater improvements compared to PPA (p < .01) and were maintained at 12 months’ follow-up in ventral (only males) and dorsal NME, AROM and pain intensity during testing. In grip strength, there were no significant between-group differences (p > 0.05). There were no significant differences between the NSE and NSEB groups (p > .05). Sub-group analyses revealed improvement in disability at 12 months follow-up in NSE and/or NSEB for individuals both below and above the cut-off reference value in NME and AROM. More severe disability was seen in individuals below the reference values both at baseline and 12 months’ follow-up. Individuals in the PPA group below the reference values in NME and AROM reported increasing disability at 12 months compared to baseline.Conclusion: The results suggest that neck-specific exercises (NSE, NSEB) improved clinical function and decreased disability in chronic WAD compared to PPA. The results may imply that higher neck-related clinical function can be important for reduced disability. Trial Registration: ClinicalTrials.gov: NCT01528579, date of registration: February 8, 2012, retrospectively registered; https://clinicaltrials.gov/ct2/show/NCT0152857

To explore primary care professionals perceptions of physical activity and other cancer rehabilitation practice in cancer survivors, investigating the preparedness to implement guidelines regarding cancer rehabilitation. We collected qualitative data through seven semi-structured focus group interviews with 48 rehabilitation professionals, with mean 9 years of experience in primary care rehabilitation (32 physiotherapists, 15 occupational therapists, and 1 rehabilitation assistant) in a primary care setting. Data was analyzed using content analysis. Primary care rehabilitation professionals expressed limited experience of cancer survivors, experienced lack of knowledge of cancer-related disability, and had doubts concerning how to treat cancer survivors. They also experienced uncertainty about where to find collaboration and support in the healthcare system outside their own rehabilitation clinic. There is a need to combine different implementation strategies to tackle multiple barriers for effective cancer survivor rehabilitation in primary care, to boost individual rehabilitation professionals knowledge and self-efficacy, to clarify roles and responsibilities for cancer rehabilitation across levels of care, and to develop and strengthen organizational bridges to provide adequate access to rehabilitation for cancer survivors. Funding Agencies|County Council of Ostergotlands funding of research time, Local Research Council of Western County Council of Ostergotland, and Research Council of Southeast Sweden

Up to 90% of people with neurological deficits following whiplash injury report chronic symptoms. A recent unique study of neck-specific exercise showed positive results (post-intervention at 12 weeks), regarding arm pain and neurological deficits in people with chronic whiplash associated disorders (WAD). This 1-year follow-up of that randomised controlled study with assessor blinding aimed to examine whether neck-specific exercise with (NSEB) or without (NSE) a behavioural approach has long-term benefits over physical activity prescription (PPA) regarding arm pain and neurological deficits (n=171). Interventions were: NSE, NSEB, or PPA. Follow-up of arm pain, paraesthesia bothersomeness (questionnaires) and clinical neurological tests were performed after 3, 6 and 12 months and analysed with Linear Mixed Models and General Estimating Equations. The NSE and/or NSEB groups reported significantly less pain and paraesthesia bothersomeness as well as higher odds of normal key muscle arm strength and of normal upper limb neural tension over the year (all pFunding Agencies|Swedish government through the REHSAM Foundation [RS2010/009]; Swedish Research CouncilSwedish Research Council [521-2014-2982]; County Council of ostergotland [LIO-533041, LIO-439541, LIO-197631, LIO-276151, LIO-354241]; Centre for Clinical Research Sormland at Uppsala University [DLL-553281, DLL-465071, DLL-221851, DLL-112241, DLL-376711]; Medical Research Council of Southeast Sweden [FORSS-472691, FORSS-302601, FORSS-384421]; Uppsala-orebro Regional Research Council [RFR-384651, RFR-150591, RFR-297301, RFR-215571]; Linkoping University, Sweden; Linkoping University; regional Centre for Clinical Research [LIO-533041, LIO-439541, LIO-197631, LIO-276151, LIO-354241]

Patient enablement reflects patient's understanding of and coping with illness. The aim of this study was to investigate the content validity, construct validity, internal consistency and self-rated change (SRC) of the Patient Enablement Instrument (PEI) in patients with whiplash-associated disorders, cervical radiculopathy and mixed chronic pain treated in different settings.Psychometric analyses.Patients with disabling non-malignant chronic musculoskeletal pain.Participants answered questionnaires on disability (Neck Disability Index (NDI) or Functional Rating Index (FRI)), anxiety/depression (Hospital Anxiety and Depression Scale; HADS) and general health (EuroQol; EQ-5D). Content validity, construct validity (confirmatory factor analysis), internal consistency and cut-off for SRC were investigated for the PEI after treatment. The SRC value was the receiver operating characteristic (ROC) curve optimal cut-off point.After treatment all items were completed by 516 patients (mean standard deviation (SD) age 45.1 years (SD 10.1), women 75% (n = 385)). The 1-factor PEI model had approximate fit to the data. The internal consistency Cronbach's alpha was between 0.878 and 0.929 for the 3 groups. Correlations between the PEI and the NDI/FRI, HADS and EQ-5D were fair to good. The SRCROC for whiplash-associated disorders, cervical radiculopathy and mixed chronic pain groups was 5, 6 and 4 points in the PEI, respectively.The PEI showed fair content validity, construct validity and internal consistency. However, the scale needs further development to improve measurement of change.

Objectives: The present studys objective was to understand the causal mechanisms underpinning the recovery of individuals with whiplash-associated disorders (WAD). We applied Bayesian Networks (BN) to answer 2 study aims: (1) to identify the causal mechanism(s) of recovery underpinning neck-specific exercise (NSE), and (2) quantify if the cyclical pathway of the fear-avoidance model (FAM) is supported by the present data. Materials and Methods: We analyzed a prospective cohort data set of 216 individuals with chronic WAD. Fifteen variables were used to build a BN model: treatment group (NSE with or without a behavioral approach, or general physical activity), muscle endurance, range of motion, hand strength, neck proprioception, pain catastrophizing, fear, anxiety, depression, self-efficacy, perceived work ability, disability, pain intensity, sex, and follow-up time. Results: The BN model showed that neck pain reduction rate was greater after NSE compared with physical activity prescription (beta=0.59 points per month [Pamp;lt;0.001]) only in the presence of 2 mediators: global neck muscle endurance and perceived work ability. We also found the following pathway of variables that constituted the FAM: anxiety, followed by depressive symptoms, fear, catastrophizing, self-efficacy, and consequently pain. Conclusions: We uncovered 2 mediators that explained the mechanisms of effect behind NSE, and proposed an alternative FAM pathway. The present study is the first to apply BN modelling to understand the causal mechanisms of recovery in WAD. In doing so, it is anticipated that such analytical methods could increase the precision of treatment of individuals with chronic WAD. Funding Agencies|Swedish government through the REHSAM Foundation; Swedish Research Council; regional Center for Clinical Research; County Council of Ostergotland; Centre for Clinical Research Sormland at Uppsala University; Medical Research Council of Southeast Sweden; Uppsala-Orebro Regional Research Council, Sweden

Study Design Secondary analysis of a randomized clinical trial. Background Patient perception of the benefits gained from treatment is important, yet satisfaction with the outcome of treatment for chronic whiplash-associated disorders (WADs) has not been investigated. Objectives To investigate whether satisfaction with the outcome of treatment for chronic WAD changed over time, and whether there were group differences. Methods Two hundred sixteen people with chronic WAD (66% women; mean age, 40.4 years) participated in a 3-month program of physical therapist-led neck-specific exercises with or without a behavioral approach, or received a prescription of general physical activity. The main outcome was satisfaction with the outcome of treatment, assessed at baseline and 3, 6, and 12 months later. Additional outcomes were enablement and expectation fulfillment. Results Satisfaction improved over time in the 3 groups (odds ratio = 1.15; 95% confidence interval: 1.10, 1.20; P

Introduction Patients suffering from remaining disability after anterior cervical decompression and fusion (ACDF) surgery for cervical disc disease may be prescribed physical activity (PPA) or neck-specific exercises (NSEs). Currently, we lack data for the success of either approach. There is also a knowledge gap concerning the use of internet-based care for cervical disc disease. The scarcity of these data, and the high proportion of patients with various degrees of incapacity following ACDF, warrant increased efforts to investigate and improve cost-effective rehabilitation. The objective is to compare the effectiveness of a structured, internet-based NSE programme, versus PPA following ACDF surgery. Methods and analysis This is a prospective, randomised, multicentre study that includes 140 patients with remaining disability (≥30% on the Neck Disability Index, NDI) following ACDF for radiculopathy due to cervical disc disease. Patient recruitment occurs following attendance at routine clinical appointments, scheduled at 3 months postsurgery. Patients are then randomised to one of two groups (70 patients/group) for a 3-month treatment programme/period of either internet-based NSE or PPA. Questionnaires on background data, pain and discomfort, physical and mental capacity, satisfaction with care, and health and workplace factors are completed, along with physical measures of neck-related function conducted by independent test leaders blinded to randomisation. Measures are collected at inclusion, after the 3-month treatments (end of treatment) and at a 2-year follow-up. Radiography will be completed at the 2-year follow-up. Preoperative data will be collected from the Swedish Spine Registry. Data on healthcare consumption, drug use and sick leave will be requested from the relevant national registers. Ethical considerations This study was approved by the Regional Ethical Review Board in Linköping Ref. 2016/283–31 and 2017/91– 32. The scientists are independent with no commercial ties. Patients are recruited after providing written informed consent. Patient data are presented at group level such that no connection to any individual can be made. All data are anonymised when reported, and subject to the Swedish Official Secrets Health Acts. The test leaders are independent and blinded for randomisation. Exercises, both general and neck-specific, have been used extensively in clinical practice and we anticipate no harm from their implementation other than a risk of muscle soreness. Both randomisation groups will receive care that is expected to relieve pain, although the group receiving NSE is expected to demonstrate a greater and more cost-effective improvement versu s the PPA group. Any significant harm or unintended effects in each group will be collected by the test leaders. All questionnaires and test materials are coded by the research group, with code lists stored in locked, fireproof file cabinets, housed at the university in a room with controlled (card-based) access. Only individuals in receipt of a unique website address posted by the researchers can access the programme; patients can neither communicate with each other nor with caregivers via the programme. Study participation might lead to improved rehabilitation versus non-participation, and might therefore be of benefit. The results of this study should also contribute to more effective and flexible rehabilitation, shorter waiting times, lower costs and the possibility to implement our findings on a wider level. Dissemination If effective, the protocols used in this study can be implemented in existing healthcare structures. The results of the study will be presented in scientific journals and popular science magazines of relevance to health. The findings will also be presented at local, regional, national and international conferences and meetings, as well as in the education of university students and at public lectures. Information about the results will be communicated to the general population in cooperation with patient organisations and the media. Trial registration NCT03036007.

Purpose The aim was to evaluate whether neck-specific exercise, with (NSEB) or without (NSE) a behavioural approach, improves health-related quality of life (HRQoL) compared to physical activity prescription (PPA) in chronic whiplash-associated disorders (WAD) grades 2 and 3. A secondary aim was to identify factors associated with HRQoL and HRQoL improvement following exercise interventions. Methods This is a secondary analysis of a multicentre randomized clinical trial. Participants (n = 216) with chronic WAD grades 2 and 3 were randomized to 12 weeks of PPA or physiotherapist-led NSE or NSEB. The EQ-5D 3L/EQ-VAS and SF-36v2 physical (PCS) and mental (MCS) component summaries were collected together with several neck-related and psychosocial outcomes at baseline, after 3, 6 and 12 months, and were analysed with linear mixed models (all time points) and multivariate linear regressions (baseline, 6 months). Results NSE/NSEB resulted in better outcomes than PPA (EQ-VAS and SF-36 PCS, both groups, p p p R2 = 0.38–0.59) were both neck-related and psychosocial (e.g. depression, work ability). Conclusion Neck-specific exercise, particularly with a behavioural approach, may have a more positive impact on HRQoL than physical activity prescription in chronic WAD grades 2 and 3. HRQoL is however complex, and other factors also need to be considered. Factors associated with HRQL and improvements in HRQoL following exercise are multidimensional. Trial registration number: ClinicalTrials.gov, No. NCT01528579.

To investigate the efficacy of exercise interventions and factors associated with changes in work ability for people with chronic whiplash-associated disorders.Secondary analysis of a single-blind, randomized multi-centre controlled trial.Interventions were conducted in Swedish primary care settings.A total of 165 individuals with chronic whiplash-associated disorders grade II-III.Participants were randomly allocated to neck-specific exercise, neck-specific exercise with a behavioural approach, or prescribed physical activity interventions. Work ability was evaluated with the Work Ability Index at baseline, 3, 6 and 12 months.The neck-specific exercise with a behavioural approach intervention significantly improved work ability compared with the prescribed physical activity intervention (3 months, p = 0.03; 6 months, p = 0.01; 12 months, p = 0.01), and neck-specific exercise at 12 months (p = 0.01). Neck-specific exercise was better than the prescribed physical activity intervention at 6 months (p = 0.05). An increase in work ability from baseline to one year for the neck-specific exercise with a behavioural approach group (p 0.01) was the only significant within-group difference. Higher self-rated physical demands at work, greater disability, greater depression and poorer financial situation were associated with poorer work ability (p0.01).This study found that neck-specific exercise with a behavioural approach intervention was better at improving self-reported work ability than neck-specific exercise or prescribed physical activity. Improvement in work ability is associated with a variety of factors.

Approximately 50% of people with Whiplash Associated Disorders (WAD) report longstanding symptoms. The upper trapezius is commonly painful yet its mechanical properties are not fully understood.This study examined the deformation of different depths of the upper trapezius muscle during a scapular elevation task (shoulder shrugging) before and following loaded arm abduction.A cross-sectional case-control study of 36 people (26 female and 10 male, mean age 38 (SD 11)) with chronic WAD and 36 controls, matched for age and gender. Real-time ultrasound recordings of upper trapezius were taken during both scapular elevation tasks. Post-process speckle tracking analysis was undertaken of three different sections of the upper trapezius muscle (superficial, middle, deep).The WAD group had lower deformation of the superficial section of the upper trapezius compared to the control group in both concentric and eccentric phases of scapular elevation (p 0.05) especially before the loaded arm abduction. After arm abduction, the deformation of the trapezius was reduced in both groups but only significantly in the WAD-group (p = 0.03). Within-group analysis revealed that the control group least engaged the deep section of upper trapezius during the task (p 0.01).This study, measuring mechanical deformation of the upper trapezius during a scapular elevation task indicates that persons with WAD may display different patterns in engagement of the muscle sections than those in the control group. Further research is needed to replicate and understand the reasons for and implications of this possible change in motor strategy within upper trapezius. Clinical Trials.gov, Number: NCT01547624.

BackgroundSome studies support the prescription of exercise for people with whiplash-associated disorders (WAD); however, the response is highly variable. Further research is necessary to identify factors which predict response. MethodsThis is a secondary analysis of a randomized, multicentre controlled clinical trial of 202 volunteers with chronic WAD (grades 2 and 3). They received either neck-specific exercise with, or without a behavioural approach, or prescription of physical activity for 12weeks. Treatment response, defined as a clinical important reduction in pain or disability, was registered after 3 and 12months, and factors associated with treatment response were explored using logistic regression. ResultsParticipation in the neck-specific exercise group was the only significant factor associated with both neck pain and neck disability reduction both at 3 and 12months. Patients in this group had up to 5.3 times higher odds of disability reduction and 3.9 times higher odds of pain reduction compared to those in the physical activity group. Different baseline features were identified as predictors of response depending on the time point examined and the outcome measure selected (pain vs. disability). ConclusionFactors associated with treatment response after exercise interventions differ in the short and long term and differ depending on whether neck pain or disability is considered as the primary outcome. Participation in a neck-specific exercise intervention, in contrast to general physical activity, was the only factor that consistently indicated higher odds of treatment success. These results support the prescription of neck-specific exercise for individuals with chronic WAD. Funding Agencies|Swedish government through the REH-SAM Foundation; Clinical Research of Ostergotland Council; Clinical Research of Sormland County Council; Medical Research Council of Southeast Sweden; Uppsala-O rebro Regional Research Council Sweden; Swedish Research Council

Background: Fifty percent of people injured by whiplash still report neck pain after 1 year and costs associated with whiplash associated disorders (WAD) are mostly attributed to health service and sick-leave costs in chronic conditions. With increasing health care expenditures the economic impact of interventions needs to be considered. Objective: To analyze the cost-effectiveness of physiotherapist-led neck-specific exercise without (NSE) or with a behavioral approach (NSEB), or prescription of physical activity (PPA) in chronic WAD, grade 2 to 3. Methods: This is a secondary cost-effectiveness analysis of a multicenter randomized clinical trial of 216 participants with chronic WAD grade 2 to 3. The interventions were physiotherapist-led neck-specific exercise without or with a behavioral approach, or prescription of physical activity for 12 weeks. Incremental cost-effectiveness ratios (ICERs) were determined after 1 year and bootstrapped cost-effectiveness planes and sensitivity analyses of physiotherapy visits were performed. Health care and production loss costs were included and quality-adjusted life years (QALYs) were estimated, using the Euroqol-5D questionnaire. Comparisons with the Short Form-6D, and neck disability index (NDI) were also made. Results: The 1-year follow-up was completed by 170 participants (79%). Both physiotherapist-led groups improved in health related quality of life. The intervention cost alone, per quality-adjusted life year (QALY) gain in the NSE group was US$ 12,067. A trend for higher QALY gains were observed in the NSEB group but the costs were also higher. The ICERs varied depending on questionnaire used, but the addition of a behavioral approach to neck-specific exercise alone was not cost-effective from a societal perspective (ICER primary outcome $127,800 [95% confidence interval [CI], 37,816–711,302]). The sensitivity analyses confirmed the results. The prescription of physical activity did not result in any QALY gain and the societal costs were not lower. Conclusion: Neck-specific exercise was cost-effective from a societal perspective in the treatment of chronic WAD compared with the other exercise interventions. ICERS varied depending on health-related quality of life questionnaires used, but the addition of a behavioral approach was not cost-effective from a societal perspective. The prescription of physical activity did not result in any QALY gain and was thus not considered a relevant option.

Objective The purposes of this study were to examine whether any differences in function and health exist between patients with cervical radiculopathy (CR) due to disk disease scheduled for surgery and patients with chronic whiplash-associated disorders (WADs) and to compare measures of patients' physical function with those obtained from healthy volunteers. Methods This is a cross-sectional study of patients with CR (n = 198) and patients with chronic WAD (n = 215). Patient data were compared with raw data previously obtained from healthy people. Physical measures included cervical active range of motion, neck muscle endurance, and hand grip strength. Self-rated measures included pain intensity (visual analog scale), neck disability (Neck Disability Index), self-efficacy (Self-Efficacy Scale), and health-related quality of life (EuroQol 5-dimensional self-classifier). Results Patient groups exhibited significantly lower performance than the healthy group in all physical measures (P < .0005) except for neck muscle endurance in flexion for women (P > .09). There was a general trend toward worse results in the CR group than the WAD group, with significant differences in neck active range of motion, left hand strength for women, pain intensity, Neck Disability Index, EuroQol 5-dimensional self-classifier, and Self-Efficacy Scale (P < .0001). Conclusions Patients had worse values than healthy individuals in almost all physical measures. There was a trend toward worse results for CR than WAD patients.

Background: Although 50% of those who suffer a whiplash injury still report neck pain after one year, there is a lack of knowledge about effective treatment for chronic whiplash associated disorder ...

Objectives To evaluate primary physiotherapist assessment and management of patients with musculoskeletal disorders in primary care, and to compare patient satisfaction with primary assessment by a physiotherapist or a general practitioner (GP). less thanbrgreater than less thanbrgreater thanDesign An observational, retrospective cohort study reviewing medical records, and a separate consecutive non-randomised study of patient satisfaction. less thanbrgreater than less thanbrgreater thanSetting Primary healthcare centre. less thanbrgreater than less thanbrgreater thanParticipants Four hundred and thirty-two patients with musculoskeletal disorders, primarily assessed by a physiotherapist. Fifty-one of these patients primarily assessed by a physiotherapist and 42 patients assessed by a GP answered a patient satisfaction questionnaire. less thanbrgreater than less thanbrgreater thanInterventions Primary assessment and management of patients with musculoskeletal disorders. less thanbrgreater than less thanbrgreater thanMain outcome measures Data from medical records within 3-month after the visit, and patient satisfaction questionnaire. less thanbrgreater than less thanbrgreater thanResults Eighty-five percent (367/432) of patients did not need to see a GP. Serious pathologies were found among the 6% (26/432) of patients who were referred to a GP by a physiotherapist, but no serious pathologies were found among the 9% (39/432) of patients who subsequently returned for a GP appointment for the same disorder. Patients assessed by a physiotherapist were more satisfied with the information received about their disorder and self-care than patients assessed by a GP. Patients also had higher confidence in the ability of physiotherapists to assess their disorder (P andlt; 0.002). less thanbrgreater than less thanbrgreater thanConclusion Physiotherapists can be considered primary assessors of patients with musculoskeletal disorders in primary care as few patients needed additional assessment by a GP, patients with confirmed serious pathologies were identified by the physiotherapists, and patients were satisfied with assessment by a physiotherapist. Funding Agencies|County Council of Ostergotland, Sweden

BackgroundCompletion of a pain drawing is a familiar task in those presenting with whiplash-associated disorders (WAD). Some people report pain almost over their entire body. Yet the reasons for larger pain extent have not been fully explored. MethodsA novel method was applied to quantify pain extent from the pain drawings of 205 individuals with chronic WAD. Pain extent was evaluated in relation to sex, age, educational level, insurance status and financial status. Multiple linear regression analysis was used to verify whether pain extent was associated with other health indicators including perceived pain and disability, health-related quality of life, pain catastrophizing, anxiety, depression and self-efficacy. ResultsPain extent was influenced by sex ((2):10.392, pamp;lt;0.001) with larger pain extent in women compared to men (7.887.66% vs. 5.406.44%). People with unsettled insurance claims ((2): 7.500, pamp;lt;0.05) and those with a worse financial situation ((2):12.223, pamp;lt;0.01) also had larger pain extent. Multiple linear regression models revealed that, when accounting for age, sex, education, insurance status, financial status and neck pain intensity, pain extent remained associated with perceived disability (pamp;lt;0.01), depression (pamp;lt;0.05) and self-efficacy (pamp;lt;0.001). ConclusionBy utilizing a novel method for pain extent quantification, this study shows that widespread pain is associated with a number of factors including perceived disability, depression and self-efficacy in individuals with chronic WAD. Widespread pain should alert the clinician to consider more specific psychological screening, particularly for depression and self-efficacy, in patients with WAD. What does this study add?Women with chronic WAD, those with unsettled insurance claims and those with poorer financial status perceive more widespread pain. When controlling for these factors, larger pain areas remain associated with perceived pain and disability, depression and self-efficacy. The pain drawing is useful to support psychological screening in people with chronic WAD.

Gabriella Bernhoff,1 Maria Landén Ludvigsson,1,2 Gunnel Peterson,1,3 Bo Christer Bertilson,4,5 Madeleine Elf,6 Anneli Peolsson1 1Division of Physiotherapy, Department of Medical and Health Sciences, Linköping University, Linköping, 2Rehab Väst, County Council of Östergötland, Östergötland, 3Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, 4Musculoskeletal Functions and Pain, Division of Family Medicine, NVS, Karolinska Institutet, 5Academic Primary Health Care Center, Stockholm County Council, 6Kista Rygg and Idrottsklinik, Kista, Sweden Objective: The aim of the study was to investigate the psychometric properties of a standardized assessment of pain drawing with regard to clinical signs of cervical spine nerve root involvement.Design: This cross-sectional study included data collected in a randomized controlled study.Patients: Two hundred and sixteen patients with chronic (≥6months) whiplash-associated disorders, grade 2 or 3, were included in this study.Methods: The validity, sensitivity, and specificity of a standardized pain drawing assessment for determining nerve root involvement were analyzed, compared to the clinical assessment. In addition, we analyzed the interrater reliability with 50 pain drawings.Results: Agreement was poor between the standardized pain drawing assessment and the clinical assessment (kappa =0.11, 95% CI: −0.03 to 0.20). Sensitivity was high (93%), but specificity was low (19%). Interrater reliability was good (kappa =0.64, 95% CI: 0.53 to 0.76).Conclusion: The standardized pain drawing assessment of nerve root involvement in chronic whiplash-associated disorders was not in agreement with the clinical assessment. Further research is warranted to optimize the utilization of a pain/discomfort drawing as a supportive instrument for identifying nerve involvement in cervical spinal injuries. Keywords: pain drawing, cervical vertebrae, diagnostic self-evaluation, radiculopathy, reproducibility of results, whiplash injuries

Background: Dizziness and unsteadiness are common symptoms following a whiplash injury. Objective: To compare the effect of 3 exercise programs on balance, dizziness, proprioception and pain in patients with chronic whiplash complaining of dizziness. Design: A sub-analysis of a randomized study. Methods: One hundred and forty subjects were randomized to either a physiotherapist-guided neck-specific exercise (NSE), physiotherapist-guided neck-specific exercise, with a behavioural approach (NSEB) or prescription of general physical activity (PPA) group. Pre intervention, 3, 6 and 12 months post baseline they completed the University of California Los Angeles Dizziness Questionnaire (UCLA-DQ), Visual Analogue Scales (VAS) for, dizziness at rest and during activity and physical measures (static and dynamic clinical balance tests and head repositioning accuracy (HRA)). Results: There were significant time by group differences with respect to dizziness during activity and UCLA-Q favouring the physiotherapy led neck specific exercise group with a behavioural approach. Within group analysis of changes over time also revealed significant changes in most variables apart from static balance. Conclusion: Between and within group comparisons suggest that physiotherapist led neck exercise groups including a behavioural approach had advantages in improving measures of dizziness compared with the general physical activity group, although many still complained of dizziness and balance impairment. Future studies should consider exercises specifically designed to address balance, dizziness and cervical proprioception in those with persistent whiplash. Crown Copyright (C) 2015 Published by Elsevier Ltd. All rights reserved. Funding Agencies|Swedish government through the REHSAM foundation; regional Centres for Clinical Research of Ostergotland and Sormland County Councils; Medical Research Council of Southeast Sweden; Swedish government; Swedish Social Insurance Agency through the REHSAM foundation; Centre for Clinical Research Sormland at Uppsala University Sweden; Uppsala-Orebro Regional Research Council Sweden; Swedish Research Council; County Council of Ostergotland; County Council of Jonkoping

Objective: To explore whether neck-specific exercise, with or without a behavioural approach, has benefits after 1 and 2 years compared with prescribed physical activity regarding pain, self-rated functioning/disability, and self-efficacy in management of chronic whiplash. Design: Follow-up of a randomized, assessor blinded, clinical trial. Patients: A total of 216 volunteers with chronic whiplash associated disorders, grades 2 or 3. Methods: Participants were randomized to 1 of 3 exercise interventions: neck-specific exercise with or without a behavioural approach, or physical activity prescription. Self-rated pain (visual analogue scale), disability/functioning (Neck Disability Index/Patient Specific Functional Scale) and self-efficacy (Self-Efficacy Scale) were evaluated after 1 and 2 years. Results: Both neck-specific exercise groups maintained more improvement regarding disability/functioning than the prescribed physical activity group at both time-points (p Funding Agencies|Swedish government through the REHSAM Foundation; Swedish Research Council; regional Center for Clinical Research; County Council of Ostergotland; Centre for Clinical Research Sormland at Uppsala University; Medical Research Council of Southeast Sweden; Uppsala-Orebro Regional Research Council, Sweden

Objective: To determine whether 3 months of neck-specific exercises (NSEs) could benefit individuals with chronic whiplash-associated disorder (WAD) who were on a waiting list (WL) for treatment. Design: A prospective, randomized controlled study. Setting: Primary health care. Participants: Individuals (N=41; 31 women, 10 men; mean age +/- SD, 38 +/- 11.2y) with chronic (6-36mo) WAD, grades 2 and 3, were analyzed. Interventions: Patients were randomly assigned to NSEs or no treatment for 3 months. Main Outcome Measures: Neck-specific disability (Neck Disability Index [NDI]), neck pain (visual analog scale), general pain-related disability (Pain Disability Index [PDI]), self-perceived performance ability (Self-Efficacy Scale [SES]), and health-related quality of life (EuroQol 5 dimensions [EQ-5D]) were measured. Results: NSEs significantly improved the NDI, SES, and EQ-5D compared with WL (P

Description of neck specific exercise program as used by Maria Landén Ludvigsson, Anneli Peolsson, Gunnel Peterson in a randomized study comparing exercise approaches in chronic whiplash “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” See also: Peolsson A, Landen Ludvigsson M, Overmeer T, Dedering A, Bernfort L, Johansson G, Kammerlind AS, Peterson G. 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 Musculoskelet Disord 2013;14:311. http://dx.doi.org/ 10.1186/1471-2474-14-311

Objective: To investigate the factors related to self-perceived work ability in patients with chronic whiplash-associated disorder grades II-III. Design: Cross-sectional analysis. Patients: A total of 166 working age patients with chronic whiplash-associated disorder. Methods: A comprehensive survey collected data on work ability (using the Work Ability Index); demographic, psychosocial, personal, work- and condition-related factors. Forward, stepwise regression modelling was used to assess the factors related to work ability. Results: The proportion of patients in each work ability category were as follows: poor (12.7%); moderate (39.8%); good (38.5%); excellent (9%). Seven factors explained 65% (adjusted R-2 = 0.65, p less than 0.01) of the variance in work ability. In descending order of strength of association, these factors are: greater neck disability due to pain; reduced self-rated health status and health-related quality of life; increased frequency of concentration problems; poor workplace satisfaction; lower self-efficacy for performing daily tasks; and greater work-related stress. Conclusion: Condition-specific and psychosocial factors are associated with self-perceived work ability of individuals with chronic whiplash-associated disorder. Funding Agencies|Swedish government; Swedish Social Insurance Agency through the REHSAM Foundation

OBJECTIVES:: The aim of this study was to compare the effect on self-rated pain, disability and self-efficacy of three interventions for the management of chronic Whiplash Associated Disorders (WAD): physiotherapist-led neck-specific exercise, physiotherapist-led neck-specific exercise with the addition of a behavioral approach, or prescription of physical activity. METHODS:: Two hundred and sixteen volunteers with chronic WAD participated in this randomized, assessor blinded, clinical trial of three exercise interventions. Self-rated pain/pain bothersomeness (Visual Analogue Scale), disability (Neck Disability Index) and self-efficacy (Self-Efficacy Scale) were evaluated at baseline and at three and six months. RESULTS:: The proportion of patients reaching substantial reduction in pain bothersomness (at least 50% reduction) was more evident (PThis is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivitives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. http://creativecommons.org/licenses/by-nc-nd/3.0.

Background: Up to 50% of chronic whiplash associated disorders (WAD) patients experience considerable pain and disability and remain on sick-leave. No evidence supports the use of physiotherapy treatment of chronic WAD, although exercise is recommended. Previous randomised controlled studies did not evaluate the value of adding a behavioural therapy intervention to neck-specific exercises, nor did they compare these treatments to prescription of general physical activity. Few exercise studies focus on patients with chronic WAD, and few have looked at patients ability to return to work and the cost-effectiveness of treatments. Thus, there is a great need to develop successful evidence-based rehabilitation models. The study aim is to investigate whether neck-specific exercise with or without a behavioural approach (facilitated by a single caregiver per patient) improves functioning compared to prescription of general physical activity for individuals with chronic WAD. less thanbrgreater than less thanbrgreater thanMethods/Design: The study is a prospective, randomised, controlled, multi-centre study with a 2-year follow-up that includes 216 patients with chronic WAD (andgt;6 months and andlt;3 years). The patients (aged 18 to 63) must be classified as WAD grade 2 or 3. Eligibility will be determined with a questionnaire, telephone interview and clinical examination. The participants will be randomised into one of three treatments: (A) neck-specific exercise followed by prescription of physical activity; (B) neck-specific exercise with a behavioural approach followed by prescription of physical activity; or (C) prescription of physical activity alone without neck-specific exercises. Treatments will be performed for 3 months. We will examine physical and psychological function, pain intensity, health care consumption, the ability to resume work and economic health benefits. An independent, blinded investigator will perform the measurements at baseline and 3, 6, 12 and 24 months after inclusion. The main study outcome will be improvement in neck-specific disability as measured with the Neck Disability Index. All treatments will be recorded in treatment diaries and medical records. less thanbrgreater than less thanbrgreater thanDiscussion: The study findings will help improve the treatment of patients with chronic WAD. Funding Agencies|Swedish government||Swedish Social Insurance Agency through the REHSAM foundation||Research Council of Southeast Sweden||Uppsala-Orebro Regional Research Council, Sweden||Centre for Clinical Research Sormland: Uppsala University, Sweden||County Council of Ostergotland, Sweden

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

Objective: The purpose of this study was to compare the effects of 3 different exercise approaches on neck muscle endurance (NME), kinesiophobia, exercise compliance, and patient satisfaction in patients with chronic whiplash. Methods: This prospective randomized clinical trial included 216 individuals with chronic whiplash. Participants were randomized to 1 of 3 exercise interventions: neck-specific exercise (NSE), NSE combined with a behavioral approach (NSEB), or prescribed physical activity (PPA). Measures of ventral and dorsal NME (endurance time in seconds), perceived pain after NME testing, kinesiophobia, exercise compliance, and patient satisfaction were recorded at baseline and at the 3- and 6-month follow-ups. Results: Compared with individuals in the prescribed physical activity group, participants in the NSE and NSEB groups exhibited greater gains in dorsal NME (P = .003), greater reductions in pain after NME testing (P = .03), and more satisfaction with treatment (P less than .001). Kinesiophobia and exercise compliance did not significantly differ between groups (P greater than .07). Conclusion: Among patients with chronic whiplash, a neck-specific exercise intervention (with or without a behavioral approach) appears to improve NME. Participants were more satisfied with intervention including neck-specific exercises than with the prescription of general exercise. Funding Agencies|Swedish government; Swedish Social Insurance Agency through the REHSAM Foundation [RS2010/009]; Centre for Clinical Research Sormland at Uppsala University Sweden; Medical Research Council of Southeast Sweden; Center for Clinical Research of Ostergotland; Uppsala-Orebro Regional Research Council Sweden; Health Practitioner Research Fellowship from Queensland Health; University of Queensland (NHMRC CCRE Spinal Pain, Injury, and Health); Swedish Research Council; Wennergren Foundation