Randomized controlled trial of exercise for chronic whiplash-associated disorders

Effects of a Guided Neck-Specific Exercise Therapy on Recovery After a Whiplash: A Systematic Review and Meta-analysis

OBJECTIVE

To analyze the effects on pain and disability recovery after a whiplash of a guided neck-specific exercise therapy, compared to a different or an unguided neck-specific exercise therapy.

DESIGN

A literature search was conducted from inception to May 31, 2023, in three electronic databases: PubMed, ScienceDirect, and Web of Science. Eleven randomized controlled trials were included. Meta-analyses were performed with Review Manager software. The standardized mean difference with a 95% confidence interval was used to measure the effect sizes and only short-term time points were considered.

RESULTS

Not all studies reported a significant decrease of pain and disability in the neck-specific exercise group compared to controls. However, meta-analyses demonstrated a significantly greater decrease in neck pain (standardized mean difference: -0.25; 95% confidence interval: [-0.38, -0.12]; P = 0.0002) and neck-disability index (standardized mean difference: -0.35; 95% confidence interval: [-0.54, -0.15]; P = 0.0005) in the neck-specific exercise group.

CONCLUSIONS

In addition to the benefits that a guided neck-specific exercise therapy has on motivation and program adherence, it provides greater benefits in pain and disability than a different or unguided neck-specific exercise therapy. Positive results are observed primarily with intervention periods of more than 6 wks and at least two sessions per week.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.

CME OBJECTIVES

Upon completion of this article, the reader should be able to: (1) Determine the impact that whiplash-associated disorders have on a patient's life; (2) Identify and recognize the greater benefits of a supervised exercise therapy on recovery after a whiplash injury; and (3) Differentiate between the different exercise protocols conducted (types of exercises and duration) and incorporate therapy appropriately as part of an effective treatment plan.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The quality of reporting in randomized controlled trials investigating exercise for individuals with whiplash-associated disorders; a systematic review

BACKGROUND

Whiplash-associated disorders are a common sequela of road traffic accidents. Exercise therapy is considered an effective intervention, and it is recommended for the management of such condition. However, the application of research findings to everyday clinical practice is dependent on sufficient details being reported.

OBJECTIVES

To explore the quality of reporting in studies investigating the effectiveness of exercise for whiplash-associated disorders.

METHODS

A literature search was conducted to identify studies testing the effectiveness of exercise for whiplash-associated disorders. Two reporting checklists were used to evaluate reporting completeness. The median positive scores for each study and overall percentage of positive scores for each item were calculated. Percentage agreement and the Cohen's Kappa coefficient were calculated.

RESULTS

Twenty-one studies were included. According to the Template for Intervention Description and Replication checklist, items were reported appropriately with a median of 29% (range 0-95%, IQR 40.5). The median number of adequately reported items per study was 5 (range 1-10, IQR 3). For the Consensus on Exercise Reporting Template checklist, items were reported appropriately with a median of 29% (range 0-57%, IQR 29). The median number of adequately reported items per study was 4 (range 0-16, IQR 8). Percentage agreement ranged from 57% to 100% while Cohen's Kappa from -0.17 to 1.00.

CONCLUSIONS

The study reveals significant gaps in the quality of reporting in studies investigating exercise for whiplash-associated disorders as both checklists showed a median reporting adequacy of only 29%. Overall, the inter-rater agreement for both checklists was acceptable.

Effect of neck-specific exercises with and without internet support on cervical range of motion and neck muscle endurance in chronic whiplash-associated disorders: analysis of functional outcomes of a randomized controlled trial

OBJECTIVE

To compare the effects of a neck-specific exercise programme with internet support and 4 physiotherapist sessions (NSEIT) and the same neck-specific exercises supervised by a physiotherapist (NSE) on neck muscle endurance and cervical range of motion.

DESIGN

Randomized controlled trial.

PATIENTS

A total of 140 participants with chronic whiplash-associated disorders grade II or grade III were randomly assigned to the NSEIT or NSE groups.

METHODS

Outcomes were changes in active cervical range of motion, cranio-cervical flexion test, neck muscle endurance, and neck pain, at 3- and 15-month follow-ups.

RESULTS

There were no significant differences between the NSEIT and NSE groups. There was a significant group-by-time inter-action effect in active cervical range of motion flexion/extension where the NSEIT group improved to 3-month follow-up, but the NSE group did not. Both groups were significantly improved over time in all other outcomes (p < 0.001) at 3- and 15-month follow-ups, with effect size between 0.64 and 1.35 in active cervical range of motion, cranio-cervical flexion test, dorsal neck muscle endurance, and neck pain, and effect size between 0.22 and 0.42 in ventral neck muscle endurance.

CONCLUSION

Both NSE and NSEIT led to improved neck function. Depending on the patients' needs, either NSE or NSEIT could be used as treatment for patients with chronic whiplash-associated disorders.

Results of neck-specific exercise for altered postural sway in individuals with chronic whiplash-associated disorders: a longitudinal case-control study

Postural sway has not been investigated before or after a neck exercise intervention in individuals with chronic whiplash-associated disorders (WAD). The aim of the study was to investigate postural sway in individuals with chronic WAD grades 2 and 3: (a) compared with healthy matched controls at baseline; (b) after three months of neck-specific exercise and (c) to investigate the correlation between postural sway with self-reported dizziness during motion and balance problems/unsteadiness. This is a longitudinal prospective experimental case-control intervention study. Individuals with WAD (n = 30) and age- and gender-matched healthy volunteers (n = 30) participated. Postural sway was assessed using an iPhone application. Measurements were carried out at baseline, and for those with WAD a second measurement was performed at the three-month follow-up when neck-specific exercise intervention ended. The WAD group performed significantly worse than the healthy group in both pathway and ellipse area double stance eyes closed at baseline (main outcome), but not at the three-month follow-up. The WAD group significantly improved after rehabilitation in both pathway double stance eyes closed and pathway single stance eyes open. The correlation between postural sway and self-rated dizziness during motion and balance problems was low to moderate. One may conclude that postural sway was improved after a neck-specific exercise programme. The study results strengthen earlier findings that individuals with WAD have worse balance outcome when they have to rely on neck proprioception (eyes closed). The study results may be important for the development of improved rehabilitation methods for WAD.

Effectiveness of Interventions on Work Outcomes After Road Traffic Crash-Related Musculoskeletal Injuries: A Systematic Review and Meta-analysis

BACKGROUND

Musculoskeletal injuries are common after road traffic crash (RTC) and can lead to poor work-related outcomes. This review evaluated the impact of interventions on work-related (e.g. sick leave), health, and functional outcomes in individuals with a RTC-related musculoskeletal injury, and explored what factors were associated with work-related outcomes.

METHODS

Searches of seven databases were conducted up until 9/03/2023. Eligible interventions included adults with RTC-related musculoskeletal injuries, a comparison group, and a work-related outcome, and were in English. Meta-analyses were conducted using RevMan and meta-regressions in Stata.

RESULTS

Studies (n = 27) were predominantly conducted in countries with third-party liability schemes (n = 26), by physiotherapists (n = 17), and in participants with whiplash injuries (94%). Pooled effects in favour of the intervention group were seen overall (SMD = - 0.14, 95% CI: - 0.29, 0.00), for time to return to work (- 17.84 days, 95% CI: - 24.94, - 10.74), likelihood of returning to full duties vs. partial duties (RR = 1.17, 95% CI: 1.01, 1.36), decreased pain intensity (- 6.17 units, 95% CI: - 11.96, - 0.39, 100-point scale), and neck disability (- 1.77 units, 95% CI: - 3.24, - 0.30, 50-point scale).

DISCUSSION

Interventions after RTC can reduce time to return to work and increase the likelihood of returning to normal duties, but the results for these outcomes were based on a small number of studies with low-quality evidence. Further research is needed to evaluate a broader range of interventions, musculoskeletal injury types, and to include better quality work-related outcomes.

Physical therapist-led interventions based on the biopsychosocial model provide improvement in disability and pain for spinal disorders: A systematic review and meta-analysis

OBJECTIVE

To summarize the effects of physical therapist-led interventions based on the biopsychosocial (BPS) model in spinal disorders compared to interventions with no BPS model through a systematic review and meta-analysis of randomized-controlled trials. TYPE: Systematic review and meta-analysis.

LITERATURE SURVEY

We searched the Web of Science, CENTRAL, MEDLINE, PsycINFO, CINAHL, and PEDro up to October 27, 2022.

METHODOLOGY

Pain intensity and disability were primary outcomes and psychological factors were secondary outcomes in spinal disorders. The included intervention was physical therapist-led interventions based on the BPS model. The control group received no physiotherapy intervention for BPS. Pooled effects were analyzed as standardized mean differences (SMDs) and 95% confidence intervals (CIs), and the random-effects model was used for the meta-analysis. The subgroup analysis was divided into low back pain group and neck pain group. Another subgroup analysis was conducted only of the groups that had received training of the BPS model.

SYNTHESIS

Fifty-seven studies with 5471 participants met the inclusion criteria. For pain intensity, there was a statistically significant effect for the BPS model led by physical therapists in the short, medium, and long terms. The SMDs with 95% CIs were -0.44 (-0.62, -0.27), -0.24 (-0.37, -0.12), and -0.17 (-0.28, -0.06), respectively. Outcomes were clinically significant, except in the long term. For disability, there was a statistically significant effect in the short, medium, and long terms. The SMDs with 95% CIs were -0.48 (-0.69, -0.27), -0.44 (-0.64, -0.25), and -0.37 (-0.58, -0.15), respectively. All periods were clinically significant. The quality of the evidence was low for all of the main outcomes for all of the terms.

CONCLUSION

Physical therapist-led interventions based on the BPS model effectively improve pain intensity and disability in patients with spinal disorders based on low-quality evidence.

The effectiveness of aerobic versus strengthening exercise therapy in individuals with chronic whiplash-associated disorder: a randomised single case experimental design study

PURPOSE

Recent RCTs and meta-analyses compare the effectiveness of different types of exercise for chronic whiplash associated disorder (WAD). This study aimed to verify whether the results of these studies translate to statistically significant and clinically meaningful effects in individual participants.

MATERIALS AND METHODS

A series of replicated randomised single case experimental design studies (SCEDs) with A-B design (A: baseline, B: intervention). Eight participants with chronic WAD (8 female, mean [SD] age 47 [10] years) were randomised into one of four baseline durations (5, 8, 11, and 14 days) and to one of two eight-week exercise interventions (aerobic or strengthening). Daily measures of pain intensity, bothersomeness, and interference were collected during the baseline phase and the intervention phase.

RESULTS

Visual analyses indicated that three participants in the aerobic exercise group meaningfully improved. No improvements were found in the strengthening group. Effect sizes favoured the aerobic exercise group, yet randomisation tests of pooled effects did not show a difference in between-intervention effectiveness.

CONCLUSION

Contrary to our expectations, three out of four participants were nearly pain-free at the end of the aerobic exercise intervention, whereas none of the participants in the strengthening group improved meaningfully. This suggests that aerobic exercise may be favourable for WAD.Implications for RehabilitationOur results suggest that aerobic exercises are favourable over strengthening exercises and may be the preferred option for patients with chronic WAD.We found substantial variability in self-reported outcomes within participants, clinicians should be aware of this in the judgement of treatment effectiveness.

Efficacy of Neck-Specific Exercise With Internet Support Versus Neck-Specific Exercise at a Physiotherapy Clinic in Chronic Whiplash-Associated Disorders: Multicenter Randomized Controlled Noninferiority Trial

BACKGROUND

Neck-specific exercises (NSE) supervised by a physiotherapist twice a week for 12 weeks have shown good results in chronic whiplash-associated disorders (WADs), but the effect of exercise delivered via the internet is unknown.

OBJECTIVE

This study examined whether NSE with internet support (NSEIT) and 4 physiotherapy sessions for 12 weeks were noninferior to the same exercises supervised by a physiotherapist twice a week for 12 weeks (NSE).

METHODS

In this multicenter randomized controlled noninferiority trial with masked assessors, we recruited adults aged 18-63 years with chronic WAD grade II (ie, neck pain and clinical musculoskeletal signs) or III (ie, grade II plus neurological signs). Outcomes were measured at baseline and at 3- and 15-month follow-ups. The primary outcome was change in neck-related disability, measured with the Neck Disability Index (NDI; 0%-100%), with higher percentages indicating greater disability. Secondary outcomes were neck and arm pain intensity (Visual Analog Scale [VAS]), physical function (Whiplash Disability Questionnaire [WDQ] and Patient-Specific Functional Scale [PSFS]), health-related quality of life (EQ-5D-3L and EQ VAS), and self-rated recovery (Global Rating Scale [GRS]). The analyses were conducted on an intention-to-treat basis and with the per-protocol approach as sensitivity analyses.

RESULTS

Between April 6, 2017, and September 15, 2020, 140 participants were randomly assigned to the NSEIT group (n=70) or the NSE group (n=70); 63 (90%) and 64 (91%), respectively, were followed up at 3 months, and 56 (80%) and 58 (83%), respectively, at 15 months. NSEIT demonstrated noninferiority to NSE in the primary outcome NDI, as the 1-sided 95% CI of the mean difference in change did not cross the specified noninferiority margin (7 percentage units). There were no significant between-group differences in change in NDI at the 3- or 15-month follow-up, with a mean difference of 1.4 (95% CI -2.5 to 5.3) and 0.9 (95% CI -3.6 to 5.3), respectively. In both groups, the NDI significantly decreased over time (NSEIT: mean change -10.1, 95% CI -13.7 to -6.5, effect size=1.33; NSE: mean change -9.3, 95% CI -12.8 to -5.7, effect size=1.19 at 15 months; P<.001). NSEIT was noninferior to NSE for most of the secondary outcomes except for neck pain intensity and EQ VAS, but post hoc analyses showed no differences between the groups. Similar results were seen in the per-protocol population. No serious adverse events were reported.

CONCLUSIONS

NSEIT was noninferior to NSE in chronic WAD and required less physiotherapist time. NSEIT could be used as a treatment for patients with chronic WAD grades II and III.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03022812; https://clinicaltrials.gov/ct2/show/NCT03022812.

Cervical facet joint platelet-rich plasma in people with chronic whiplash-associated disorders: A prospective case series of longer term 6- and 12- month outcomes

Objective

To explore the 6- and 12-month effectiveness of a single autologous injection of platelet-rich plasma (PRP) in cervical facet joints of people with chronic WAD and facet-mediated pain.

Design

A prospective case series of people with chronic whiplash-associated disorders and cervical facet joint mediated pain in a community setting.

Interventions

We investigated 44 consecutive people who underwent cervical facet joint PRP ( ​± ​adjunct physiotherapy) between 2019 and 2021, selected for PRP based on 80% relief following single diagnostic medial branch blocks or 50% relief and a significant improvement in performing a previously limited activity of daily living.

Measures

Measures of pain (numerical pain rating scale - NPRS) and disability (Neck Disability Index - NDI) were collected prior to and 3-, 6- and 12- months following cervical facet joint PRP in an electronic registry database. Success was defined as those exceeding the minimal clinically important difference (MCID) for pain (>15%) and disability (>10%). We also calculated the proportion of people with greater than 50% relief of pain. People not reached for follow-up were considered failures for worst-case analysis.

Results

Forty-four people (82% female, mean age ​= ​45.2 (range: 25-71) years) underwent cervical facet joint PRP. Nine people received repeat PRP interventions. Thirty-five people provided 12-month data. There was a significant improvement in pain and disability following PRP (and possibly adjunct physiotherapy) received during this time period. At 12-months, 53% of people exceeded MCID for pain, reporting a mean improvement of 66% (95%CI: 55-77%) on the NPRS. For NDI scores, 69% of people exceeded MCID, reporting a mean improvement of 48% (95%CI: 38-58%). Thirty-seven percent of people reported greater than 50% relief of pain 12-months post-cervical facet joint PRP.

Conclusion

In people with chronic WAD and facet-mediated pain, our long-term data suggests that PRP (and possibly adjunct physiotherapy) is effective. A controlled study is warranted to evaluate the efficacy of PRP.

Comparative Effectiveness and Safety of Concomitant Treatment with Chuna Manual Therapy and Usual Care for Whiplash Injuries: A Multicenter Randomized Controlled Trial

OBJECTIVES

We aimed to compare the effectiveness and safety of Chuna manual therapy combined with usual care to those of usual care alone for treating whiplash injuries.

DESIGN

A two-arm, parallel, assessor-blinded, multicenter pragmatic randomized clinical trial.

SETTING

Three hospitals in Korea.

PARTICIPANTS

Overall, 132 participants between 19 and 70 years of age, involved in traffic accidents and treated at three hospitals in Korea, >2 but <13 weeks prior to enrollment, with neck pain consistent with whiplash-associated disorder grades I and II and a numeric rating scale score ≥5 were included.

INTERVENTIONS

Participants were equally and randomly allocated to the Chuna manual therapy and usual care (n = 66) or usual care (n = 66) groups and underwent corresponding treatment for three weeks.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the number of days to achieve a 50% pain reduction. Secondary outcomes included areas under the 50% numeric rating scale reduction curve: pain, disability, quality of life, and safety.

RESULTS

The Chuna manual therapy + usual care group (23.31 ± 21.36 days; p = 0.01) required significantly fewer days to achieve 50% pain reduction compared to the usual care group (50.41 ± 48.32 days; p = 0.01). Regarding pain severity, functional index, and quality of life index, Chuna manual therapy and usual care were more effective than usual care alone. Safety was acceptable in both groups.

CONCLUSIONS

In patients with subacute whiplash injury, Chuna manual therapy showed a rapid rate of recovery, high effectiveness, and safety.

Effects of clinical pilates exercises in patients with chronic nonspecific neck pain: a randomized clinical trial

BACKGROUND

Neck pain is a common musculoskeletal problem in adults. Clinical pilates exercises can be beneficial managing the pain and improving the risk factors.

AIMS

The aim of this study was to investigate the effects of clinical pilates exercises on pain and disability, deep neck flexor endurance (DNFE), posture, cervical range of motion (CROM), and proprioception in patients with chronic nonspecific neck pain.

METHODS

Fifty patients with chronic nonspecific neck pain were randomized into two groups. The clinical pilates exercise group (CPEG) received clinical pilates exercises for 6 weeks. The control group (CG) received posture education. Pain and disability, DNFE, forward head angle (FHA) and forward shoulder angle (FSA) degrees, CROM, and joint position error (JPE) were measured before and after 6 weeks.

RESULTS

Clinical pilates exercises improved pain, Neck Disability Index (NDI), DNFE, posture, CROM (except extension), and JPE (p < 0.05). We found significant differences between CPEG and CG in the comparisons for the change of pain, NDI, DNFE, FSA, CROM (except extension), and JPE (except left rotation) (p < 0.05). NDI, FSA, and rotational JPE also improved in CG (p < 0.05). However, these improvements were significantly better in CPEG than CG (p < 0.05) except JPE in left rotation (p = 0.118).

CONCLUSION

In patients with chronic nonspecific neck pain, clinical pilates exercise is a safe and effective method to improve pain and disability, DNFE, posture, ROM, and proprioception.

CLINICAL TRIAL REGISTRATION

NCT03782584 retrospectively registered December 20 2018.

Cervical facet joint platelet-rich plasma in people with chronic whiplash-associated disorders: A prospective case series of short-term outcomes

Objective

To explore the safety and feasibility of a single autologous injection of platelet-rich plasma (PRP) in cervical facet joints of people with chronic WAD and facet-mediated pain, and explore the association between pain relief reported with diagnostic medial branch blocks (MBBs) and 3-months post-PRP.

Design

A prospective case series of people with chronic whiplash-associated disorders and cervical facet joint mediated pain in a community setting.

Interventions

A single autologous PRP injection was provided to cervical facet joints under ultrasound and fluoroscopic guidance.

Measures

Adverse events were recorded one-week, and measures of pain (numerical pain rating scale - NPRS) and disability (Neck Disability Index - NDI) were collected prior to and 3-months following cervical facet joint PRP. People not reached for follow-up were considered failures for worst-case analysis. The correlation between percentage response to diagnostic cervical medial branch blocks (MBBs) and percentage pain relief reported at 3-months was also investigated.

Results

Forty-four people (82% female; mean age (SD): 45.2 (10.8) years) underwent cervical facet joint PRP. There was a significant improvement in pain and disability following PRP. Seventy percent of people exceeded MCID for pain. For NDI scores, 80% of people exceeded MCID. Forty-one percent of people reported greater than 50% relief of pain 3-months post-cervical facet joint PRP.There was no significant correlation between percentage relief of pain with cervical MBBs and percentage relief of pain 3-months post-PRP (r ​= ​0.06, p ​= ​0.73).There were no adverse events reported.

Conclusion

In people with chronic WAD and facet-mediated pain, preliminary data suggests that PRP is safe and it is feasible to move forwards with randomized studies to further investigate efficacy and effectiveness.

Evaluation of implementation and effectiveness of neck-specific exercise for persistent disability and pain after whiplash injury: study protocol for a randomized controlled study using a hybrid 2 design

Background

Persistent pain and disability in whiplash-associated disorders (WAD) grades II and III are common. In two randomized controlled trials (RCTs) of neck-specific exercises (NSE), we have seen promising results in chronic WAD, with a sustained clinically important reduction in pain and disability. NSE can also be delivered through internet support (NSEIT) and a few visits to a physiotherapist, saving time and cost for both patients and providers. NSE have been shown to have positive effects in other neck pain disorders and we will evaluate the diffusion of the exercises to other patients. The aims of the proposed study are to evaluate an implementation strategy for NSEIT and NSE in primary health care and to evaluate the effectiveness of NSEIT and NSE in clinical practice.

Methods

The proposed study is a prospective cluster-randomized mixed-design study with hybrid 2 trial design. Reg. physiotherapists working in twenty physiotherapy clinics will be included. The primary implementation outcome is proportion of patients with neck pain receiving neck-specific exercise. Secondary outcomes are; physiotherapists attitudes to implementation of evidence-based practice, their self-efficacy and confidence in performing NSEIT/NSE, number of patients visits, and use of additional or other exercises or treatment. To further evaluate the implementation strategy, two qualitative studies will be performed with a sample of the physiotherapists. The primary outcome in the patient effectiveness evaluation is self-reported neck disability according to the Neck Disability Index (NDI). Secondary outcomes are pain intensity in the neck, arm, and head; dizziness; work- and health-related issues; and patient’s improvement or deterioration over time. All measurements will be conducted at baseline and at 3 and 12 months. Physiotherapists´ self-efficacy and confidence in diagnosing and treating patients with neck pain will also be evaluated directly after their instruction in NSEIT/NSE.

Discussion

This trial will evaluate the implementation strategy in terms of adoption of and adherence to NSEIT and NSE in clinical primary health care, and measure diffusion of the method to other patients. In parallel, the effectiveness of the method will be evaluated. The results may guide physiotherapists and health care providers to sustainable and effective implementation of effective exercise programs.

Trial registration

The randomized trial is registered on ClinicalTrials.gov, NCT05198258, initial release date January 20, 2022.

Exercise therapy for whiplash-associated disorders: a systematic review and meta-analysis

OBJECTIVES

Acute as well as chronic pain syndromes are common after whiplash trauma and exercise therapy is proposed as one possible intervention strategy. The aim of the present systematic review was to evaluate the effect of exercise therapy in patients with Whiplash-Associated Disorders for the improvement of neck pain and neck disability, compared with other therapeutic interventions, placebo interventions, no treatment, or waiting list.

CONTENT

The review was registered in Prospero (CRD42017060356) and conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search in PubMed, Scopus and Cochrane from inception until January 13, 2020 was combined with a hand search to identify eligible randomized controlled studies. Abstract screening, full text assessment and risk of bias assessment (Cochrane RoB 2.0) were conducted by two independent reviewers.

SUMMARY

The search identified 4,103 articles. After removal of duplicates, screening of 2,921 abstracts and full text assessment of 100 articles, 27 articles that reported data for 2,127 patients were included. The included articles evaluated the effect of exercise therapy on neck pain, neck disability or other outcome measures and indicated some positive effects from exercise, but many studies lacked control groups not receiving active treatment. Studies on exercise that could be included in the random-effect meta-analysis showed significant short-term effects on neck pain and medium-term effects on neck disability.

OUTLOOK

Despite a large number of articles published in the area of exercise therapy and Whiplash-Associated Disorders, the current evidence base is weak. The results from the present review with meta-analysis suggests that exercise therapy may provide additional effect for improvement of neck pain and disability in patients with Whiplash-Associated Disorders.

Specific versus Non-Specific Exercises for Chronic Neck or Shoulder Pain: A Systematic Review

The current systematic review aimed to compare the effect of injury-focused (specific) exercises versus more general (non-specific) exercises on pain in patients with chronic neck or shoulder pain. We searched PubMed, EMBASE, and Web of Science. Two reviewers screened and selected studies, extracted outcomes, assessed risk of bias, and rated the quality of evidence. A total of nine eligible studies, represented in 13 articles, were identified, with a considerable risk of bias. One article investigated the acute effect of single bouts of exercise on pain and reported an immediate pain reduction after non-specific exercise. Regarding short-term effects, seven out of the nine studies found no differences in pain between interventions, with inconsistent results among two other studies. Concerning the long-term effects, while pain reduction seems to be favored by specific exercises (two out of four articles), the best format is still unclear. Based on the acute effects, a single bout of non-specific exercise seems to be a better option for pain-relief for patients with chronic neck or shoulder pain. For short-term effects, there are no differences in pain between specific and non-specific exercises. Regarding long-term effects, specific exercises seem to be the best option. Nevertheless, more studies are warranted.

Neck-related function and its connection with disability in chronic whiplash-associated disorders: secondary analysis of a randomized controlled study

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<0.01) in ventral (only males) and dorsal NME, AROM, and pain intensity during testing. We found no significant between-group differences in grip strength and no significant differences between the NSE and NSEB groups. Improvement in disability was seen at the 12-month follow-up of NSE and/or NSEB for individuals both below and above the cut-off reference values for NME and AROM. Individuals in the PPA group below the reference values for NME and AROM reported increasing disability at 12 months compared to baseline.

CONCLUSIONS

The results suggest that neck-specific exercises (i.e., NSE, NSEB) improve clinical function and decrease disability in chronic WAD compared to PPA, but PPA can increase disability for patients with low neck-related function.

CLINICAL REHABILITATION IMPACT

Higher neck-related function seems to be important for reduced disability in persistent WAD grades II and III. Neck-specific exercises could lead to higher neck-related function.

Experiences of responsiveness to exercise in people with chronic whiplash: A qualitative study

Exercise is recommended in clinical guidelines for the treatment of chronic whiplash associated disorders (WAD). However, randomised controlled trials have shown similar effects for comprehensive exercise programs and advice. To date, there is no clear understanding of why some individuals with WAD appear to respond to exercise whilst others do not. The aim of this study was to explore the experiences and self-reported characteristics of people with chronic whiplash identifying as 'responders' and 'non-responders' to exercise. Semi-structured interviews were conducted with 13 people with chronic whiplash (patients) and seven treating physiotherapists. Patients were asked whether they responded to the exercise program, and what contributed to this. Physiotherapists were asked to share their experiences about the characteristics of people that appear to respond to exercise, and those that do not. An interpretive descriptive approach was selected to facilitate the generation of discipline-specific knowledge. Four themes were generated from patient and physiotherapist interviews, including: (1) the therapeutic relationship, (2) exercise experiences and beliefs, (3) self-efficacy and acceptance, (4) physical and psychological determinants of responsiveness. Responsiveness to exercise is complex and multifaceted. Clinicians may seek to identify the presence of discrete physical impairment(s) (e.g., range of motion restriction), and where present, determine whether targeted exercise results in an immediate and positive response. Clinicians may also focus their efforts on developing aspects of the therapeutic relationship identified as important to patients, such as hope, partnership and rapport.

Exercise induced hypoalgesia profile in rats is associated with IL-10 and IL-1 β levels and pain severity following nerve injury

BACKGROUND

Pain may undergo modulation in the central nervous system prior to reaching the primary somatosensory cortex and being perceived as pain. Faulty pain modulation mechanisms have been linked to various chronic pain conditions. Cytokines such as IL-10 and IL-1beta, are known to be involved in initiation and maintenance of neuropathic pain. In this study, we investigated the association between pain modulation profile, pain intensity and cytokines (IL-10 and IL-1beta) levels in a rat model of neuropathic pain.

METHODS

Exercise-Induced Hypoalgesia (EIH) was assessed by evaluating the percentage of responses to a train of 60g mechanical stimuli before and after 180 seconds of exercise on a rotating rod. The differences in the response rates before and after the exercise were used to divide the rats into low and high EIH responders. Rats from low and high EIH groups underwent constriction injury of the left sciatic nerve. Pain behavior (allodynia and hyperalgesia) were assessed by measuring responses to mechanical and thermal stimuli applied to the plantar surface of the foot. Serum, sciatic nerve and the related Dorsal Root Ganglia (DRG) levels of IL-10 and IL-1beta were determined by ELISA. The DRG mRNA levels of IL-10 and IL-1beta measured with PCR. A comparison between the low and high EIH rats of all measured parameters was made.

RESULTS

The low EIH rats developed significantly more severe allodynia and hyperalgesia in the affected paw and allodynia in the contralateral paw compared to the high EIH rats, 7 days following the injury. The low EIH rats had higher IL-1beta protein levels in serum prior to and following injury, higher affected and contralateral sciatic nerve IL-1beta levels following injury and higher IL-1beta levels in the contralateral DRG (protein and mRNA) following injury when compared to high EIH rats. The high EIH rats had higher affected sciatic nerve IL-10 levels following nerve injury and higher IL-10 levels of both protein and mRNA in the affected and contralateral DRG at baseline and following injury.

CONCLUSION

EIH profile was found to be predictive of pain behavior following nerve injury, low EIH rats developed more severe allodynia and hyperalgesia. IL-1beta may be associated with painful neuropathy developed in rats with low EIH while the anti-inflammatory cytokine IL-10 may have a protective role, inhibiting the development of painful.

Usefulness of a global rating change scale for contact lens discomfort evaluation

OBJECTIVES

To evaluate the usefulness of a global rate of change scale (GRCS) to detect variations in contact lens discomfort (CLD).

METHODS

Symptomatic contact lens (CL) wearers were recruited according to the 'Contact Lens Dry Eye Questionnaire-8' (CLDEQ-8). At the baseline visit, subjects scored their comfort following insertion of their habitual CL using a 0-100 visual analogue scale (VAS). After 4-10 h of CL wear, comfort was again self-evaluated with the VAS and with a GRCS (range, -50 to +50). Then, a daily disposable CL (DDCL) was fitted. After one month of DDCL wear, a follow-up visit was conducted where the same evaluations as the baseline visit were performed. Changes in comfort were estimated using a Student's t-test for normal variables and the Friedman test for multiple comparisons of non-parametric variables. Internal responsiveness was measured by calculating the standardised response mean. Agreement between scales was estimated by the intraclass correlation coefficient (ICC).

RESULTS

Twenty-nine (22 females and 7 males) CL wearers with a mean age of 23.4 ± 5.4 years participated in the study. There was a significant decrease in comfort at both visits detected by the GRCS (baseline = -13.58 ± 17.48, p < 0.001; follow up = -6.86 ± 12.69, p = 0.007). However, the VAS did not detect that change, either at baseline (insertion = 64.28 ± 18.72 vs removal = 52.89 ± 17.64, p = 1.000) or follow-up visit (insertion = 81.97 ± 12.91 vs removal = 76.48 ± 16.02, p = 1.000). Comfort at insertion and removal times was significantly higher with the DDCL (p = 0.008 at insertion and p = 0.004 at removal). The standardised response mean was greater with the GRCS than the VAS at baseline (0.78 vs 0.63) and follow-up (0.54 vs 0.37) visits. Agreement between both scales was moderate and significant (p < 0.001) for both visits, ICC: 0.674 (95 % confidence interval (CI):0.411-0.833) (baseline) and 0.652 (95 % CI:0.377-0.821) (follow-up visit).

CONCLUSIONS

The GRCS can detect slight changes in CL wear comfort and shows higher responsiveness than the VAS. This subjective scale can allow detection of changes in comfort in a simple and quick way.

Comparison of the Accuracy of WhipPredict to That of a Modified Version of the Short-Form Örebro Musculoskeletal Pain Screening Questionnaire to Predict Poor Recovery After Whiplash Injury

OBJECTIVE

To compare the accuracy of a whiplash-specific risk screening tool (WhipPredict) with that of the modified generic short-form Örebro Musculoskeletal Pain Screening Questionnaire (SF-ÖMPSQ) for predicting poor recovery in patients following whiplash injury.

STUDY DESIGN

Inception cohort study.

METHODS

Two hundred two participants with acute whiplash completed the WhipPredict and modified SF-ÖMPSQ at baseline. Poor recovery was measured at 6 and 12 months using the Neck Disability Index (greater than 10%), numeric pain-rating scale (greater than 3/10), global perceived recovery (less than +4), and inability to return to preinjury work level. Accuracy statistics were calculated to predict poor recovery.

RESULTS

Seventy-one percent (n = 143) of participants completed the 6-month assessment and 56% (n = 113) completed the 12-month assessment. At baseline, agreement between the WhipPredict and modified SF-ÖMPSQ was fair (prevalence-adjusted and bias-adjusted κ = 0.26; 95% confidence interval: 0.12, 0.39). Depending on the outcome, 20% to 72% of people had not recovered at 6 months and 12% to 71% had not recovered at 12 months. At 6 and 12 months, the WhipPredict tool showed high sensitivity (88%-96%) and low specificity (all outcomes less than 31%) on all 4 separate outcomes. The modified SF-ÖMPSQ showed moderate sensitivity (67%-75%) for the Neck Disability Index, numeric pain-rating scale, and global perceived recovery, high sensitivity for return to work (81%-90%), and moderate specificity (54%-77%) for all 4 outcomes.

CONCLUSION

Both tools showed acceptable accuracy in predicting poor recovery. The WhipPredict tool is recommended to correctly identify patients who will not recover but may falsely classify those who recover well. Using the modified SF-ÖMPSQ will result in fewer patients falsely categorized as being at risk of poor recovery and may result in some people being undertreated. J Orthop Sports Phys Ther 2021;51(5):207-215. Epub 19 Feb 2021. doi:10.2519/jospt.2021.9987.

Predictors for Positive Response to Home Kinematic Training in Chronic Neck Pain

OBJECTIVES

There is strong evidence for exercise therapy in neck pain, but a wide variety of protocols. Predictors for outcome are unknown and current practice is based on trial and error. The objective of this study was to identify predictors for response to home kinematic training (KT) considering improvement in both self-reported and kinematic measures.

METHODS

A continuing analysis of data from the second phase of a randomized controlled trial, which included 4 weeks of KT using laser or virtual reality, with baseline, postintervention, and 3-month follow-up measures. Positive self-reported response was defined as a ≥50% pain reduction, ≥7% reduction in neck disability index (NDI), or a global perceived effect of 3 to 5 of 5. A second model defined improvement by ≥40% increase in cervical velocity.

RESULTS

Data were retrieved from 79 participants with chronic neck pain who completed the postintervention evaluation and 52 who completed the 3-month follow-up. Self-reported response was 71% to 73% and kinematic response was 41% to 46%. Prediction models indicated an immediate increase in self-reported measures in men with NDI ≥ 20% slower (≤65°/s), and less accurate (≥16° error) cervical motion at baseline. In the longer term, older patients with higher NDI seemed to benefit more. In the second model, no factors significantly predicted improvement in kinematic measures at either time point.

CONCLUSION

A high positive response rate to home KT was found by self-reported criteria. Males with poorer clinical and kinematic presentation at baseline, that is greater disability and slower neck motion, were more likely to respond.

Chronic Pain and Premature Aging - The Moderating Role of Physical Exercise

Chronic pain induces a multitude of harmful effects; recently it has been suggested that chronic pain is also associated with premature aging, manifested in shortened telomere length (TL). However, evidence for this hypothesis is scarce and inconsistent. The aim was twofold: 1) Investigate whether chronic pain is associated with premature aging, and 2) Determine whether physical exercise (PE) moderates this association if it exists. Participants were 116 male subjects, with (n = 67) and without chronic pain (n = 49). Blood samples for TL analysis were collected and participants were interviewed and completed questionnaires. As a part of the cohort, we included people with physical disability; this variable was controlled in the analysis. The TL of individuals with chronic pain was significantly shorter than that of pain-free individuals. Regression analysis revealed a significant moderating effect of PE on chronic pain and TL, above and beyond the effects of disability, age, and weight. Whereas chronic pain was associated with shorter telomeres in participants who did not exercise, this association was nonsignificant among participants who did exercise. The results suggest that chronic pain is associated with premature ageing; however, PE may mitigate this association and may protect individuals against the harmful effects of chronic pain. PERSPECTIVE: The study suggests that it is important to monitor signs of premature ageing among chronic pain patients as they are at risk. However, chronic pain patients may benefit from regular PE in this respect as it may moderate premature ageing.

The effectiveness of an aerobic exercise training on patients with neck pain during a short- and long-term follow-up: a prospective double-blind randomized controlled trial

Objective:

To examine the effect of adding aerobic exercise (AE) to neck-specific exercise treatment for patients with neck pain (NP) to reduce pain and disability.

Design:

A prospective multicentre randomized controlled trial.

Setting:

Physiotherapy outpatient clinics.

Subjects:

Patients with nonspecific NP.

Intervention:

Patients with NP were randomly assigned to six weeks of neck-specific exercise with and without the addition of AE.

Measures:

Patients were classified as having a successful or non-successful outcome according to the Global Rating of Change (GROC). Outcome measures included Visual Analogue Scale (VAS), Neck Disability Index (NDI), Fear Avoidance Beliefs Questionnaire (FABQ) and cervicogenic headache. Assessments were performed at six-week, and three- and six-month follow-ups.

Results:

A total of 139 participants (mean age: 54.6 ± 10.5 years) were recruited ( n = 69 AE, n = 70 control). According to GROC, 77.4% of the AE group reported a successful outcome at six months vs. 40% in the control group ( P < 0.001). There was a significant reduction in VAS from baseline to six months in the AE vs. control group 6.73 (±1.69) to 1.89 (±1.37) vs. 6.65 (±1.67) to 3.32 (±1.82), respectively ( P  < 0.001). Significant improvements were also obtained for NDI and FABQ from baseline to six weeks in the AE group: NDI from 16.10 (±4.53) to 7.78 (±4.78) vs. 17.01 (±4.84) to 11.09 (±5.64) in the control group ( P = 0.003); FABQ from 33.53 (±9.31) to 20.94 (±841) in the AE vs. 33.45 (±10.20) to 26.83 (±10.79) in the control group ( P < 0.001). The AE group also demonstrated significant reduction in cervicogenic headache from baseline to six months ( P = 0.003).

Conclusion:

Adding AE to long-term neck-specific exercises is an effective treatment for reducing NP and headache in patients with NP.

Responsiveness of the Lymphedema Functioning, Disability, and Health Questionnaire for Upper Limb Lymphedema in Patients with Breast Cancer-Related Lymphedema

Background: The Lymphedema Functioning, Disability, and Health questionnaire for Upper Limb Lymphedema (Lymph-ICF-UL) is a health-related quality-of-life questionnaire for patients with breast cancer-related lymphedema. Previous testing of this questionnaire showed very good psychometric properties; however, responsiveness has not yet been established. The aim of this study was to determine its internal and external responsiveness. Methods and Results: Ninety-five patients treated with decongestive lymphatic therapy in a longitudinal trial were recruited. Patients completed the Lymph-ICF-UL twice within a time interval of 7 weeks ("intensive group" receiving intensive treatment; n = 73) or 3 months ("stable group" receiving maintenance treatment; n = 22), and once the Global Perceived Effect (GPE) questionnaire at the second time point. The significance of change in scores and standardized response mean (SRM) were determined for the total and domain scores. Correlations between Lymph-ICF-UL and GPE were ascertained. In addition, the minimal clinical important difference (MCID) was determined. The Lymph-ICF-UL total score changed significantly in the intensive group (p < 0.001) and nonsignificantly for those in the stable group (p = 0.25). The SRM represented moderate responsiveness (0.65). Patients who reported a clinical improvement ( = responders) after intensive treatment showed a significant decrease in total score (p < 0.001), this was also the case for nonresponders (p < 0.001). Lymph-ICF-UL total and domain scores showed nonsignificant weak correlations with the GPE (p > 0.05). There was a significant difference in mean total score changes between responders and nonresponders (p < 0.001). MCID for the total score was 9%. Conclusion: The Lymph-ICF-UL is responsive to change after decongestive lymphatic therapy. No correlations were found between Lymph-ICF-UL change scores and GPE. Future studies should be conducted in a clinical setting, with more variability between participants and their treatment responses.

Evaluation of a novel intervention to improve physical activity for adults with whiplash associated disorders: Protocol for a multiple-baseline, single case experimental study

Half of individuals with a whiplash injury experience ongoing pain and disability. Many are insufficiently active for good health, increasing their risk of preventable morbidity and mortality, and compounding the effects of the whiplash injury. This paper describes a protocol for evaluating the efficacy of a physical activity promotion intervention in adults with whiplash associated disorders. A multiple-baseline, single case experimental design will be used to evaluate the effects of a physical activity (PA) intervention that includes evidence-based behaviour change activities and relapse prevention strategies for six adults with chronic whiplash. A structured visual analysis supplemented with statistical analysis will be used to analyse: accelerometer-measured PA, confidence completing PA in the presence of neck pain, and pain interference.

Evidence-based care in high- and low-risk groups following whiplash injury: a multi-centre inception cohort study

BACKGROUND

Studies aimed at improving the provision of evidence-based care (EBC) for the management of acute whiplash injuries have been largely successful. However, whether EBC is broadly provided and whether delivery of EBC varies based on risk of non-recovery, is uncertain. Receiving EBC should improve recovery, though this relationship has yet to be established. Further, mitigating the effect of EBC is the relationship with the practitioner, a phenomenon poorly understood in WAD. This study aimed to determine the proportion of individuals with whiplash, at differing baseline risk levels, receiving EBC. This study also aimed to determine whether receiving EBC and the therapeutic relationship were associated with recovery at 3 months post injury.

METHODS

Participants with acute whiplash were recruited from public hospital emergency departments, private physiotherapy practices, and State Insurance Regulatory Authority (SIRA) databases. Participants completed questionnaires at baseline (demographics, risk of non-recovery) and 3-months (treatment received, risk identification, therapeutic relationship) post injury. Primary health care providers (HCPs) treating these participants also completed questionnaires at 3-months. Recovery was defined as neck disability index ≤4/50 and global perceived effect of ≥4/5.

RESULTS

Two-hundred and twenty-eight people with acute whiplash, and 53 primary care practitioners were recruited. The majority of the cohort reported receiving EBC, with correct application of the Canadian C-spine rule (74%), and provision of active treatments (e.g. 89% receiving advice) high. Non-recommended (passive) treatments were also received by a large proportion of the cohort (e.g. 50% receiving massage). The therapeutic relationship was associated with higher odds of recovery, which was potentially clinically significant (OR 1.34, 95% CI 1.18-1.62). EBC was not significantly associated with recovery.

CONCLUSIONS

Guideline-based knowledge and practice has largely been retained from previous implementation strategies. However, recommendations for routine risk identification and tailored management, and reduction in the provision of passive treatment have not. The therapeutic relationship was identified as one of several important predictors of recovery, suggesting that clinicians must develop rapport and understanding with their patients to improve the likelihood of recovery.

Beneficial Effects of Regular Physical Activity on Exercise-Induced Analgesia in Adolescent Males

PURPOSE

To evaluate exercise-induced analgesia (EIA) effectiveness in healthy adolescent males and to investigate possible associations between EIA and physiological/psychological variables.

METHODS

Twenty-eight healthy adolescent males (14-17 y) participated in this study. EIA was evaluated by comparing perceptions of heat pain stimulations before and after an increasing maximal load test on a cycle ergometer (VO2max).

RESULTS

Pain intensity for mild and strong heat pain stimulations significantly decreased following physical exercise (mild: EIA = 28.6%; 95% confidence interval, 0.9-1.9; P < .001 and strong: EIA = 11.3%; 95% confidence interval, 0.3-1.4; P = .002). The number of physical activity hours per week was positively correlated with the effectiveness of EIA for mild and strong pain intensity (r = .41, P = .03 and r = .43, P = .02, respectively).

CONCLUSIONS

Intense physical exercise decreases perception of intensity of experimental heat pain in healthy adolescent males. The least physically active adolescents have reduced EIA effectiveness to experimental heat pain stimulations compared with physically active ones. Adolescents adopting an active lifestyle have more endogenous pain inhibition and could, therefore, potentially be less disposed to suffer from chronic pain later in life.

Reduced endogenous pain inhibition in adolescent girls with chronic pain

Background and aims Chronic pain is affecting a growing number of individuals including adolescents. Different endogenous pain inhibitory systems could confer protection against development of chronic pain. Decreased pain perception can be observed following intense pain (i.e. conditioned pain modulation - CPM) or after physical exercise (i.e. exercise-induced analgesia - EIA). Reduced effectiveness of pain inhibitory mechanisms have been reported in several chronic pain conditions. However, the extent of these dysfunctions has not been thoroughly investigated in adolescents suffering from chronic pain. Our hypothesis was that adolescents suffering from chronic pain have less effective CPM and EIA than pain-free teenagers. Methods Twenty-five healthy adolescent girls and 16 teenage girls with chronic pain participated in this study. Only girls were included in this investigation, since chronic pain is more prevalent in females. The effectiveness of CPM was assessed by comparing heat pain stimulations (individually adapted to induce mild pain intensity) performed with a thermode before and after a cold pressor test (CPT; 2 min, 10 °C). EIA was evaluated by comparing pain intensity produced by an ice cube placed on the forearm before and after a graded exercise test on a cycle ergometer. Results Pain intensity produced by heat pain stimulations decreased following CPT in healthy (p<0.05), but not in chronic pain adolescent girls (p=0.4). Pain intensity induced by the ice cube was reduced after exercise in healthy (p<0.05), but not in chronic pain adolescents (p=0.9). The effectiveness of CPM and EIA was inferior in teenage girls suffering from chronic pain compared to healthy participants (p<0.05). Conclusions Endogenous pain inhibitory mechanisms triggered by intense pain or by physical exercise are effective in healthy adolescent girls. Teenage girls living with chronic pain do not show diminished pain perception after a CPT or a graded exercise test. These results suggest that pain inhibitory mechanisms such as CPM and EIA are ineffective in adolescent girls suffering from chronic pain. Implications In a wider context, the findings of the present research could help understand better the mechanisms involved in the development of chronic pain. Improved comprehension of this subject might help prevent chronic pain conditions and thus, reduce the negative impacts of this burden.

Neck-specific exercise improves impaired interactions between ventral neck muscles in chronic whiplash: A randomized controlled ultrasound study

Chronic pain and disability is common in whiplash-associated disorders (WAD), leading to personal suffering, sick leave, and social cost. The cervical spine is heavily dependent on muscular support and whiplash injury can cause damage to the neck muscles, but diagnostic tools to measure neck muscle impairment and evaluate exercise interventions are lacking. Therefore, the present study investigated ventral neck muscle interactions in 26 individuals with chronic WAD randomized to neck-specific exercise (NSE) or remaining on a waiting list (WL) in 3 months. We performed real-time, non-invasive ultrasound measurements with speckle tracking analysis and calculated the deformation area and deformation rate in three ventral neck muscles. Multivariate statistics were used to analyse interactions between the muscles. After 3 months of NSE, significant improvements were observed in neck muscle interactions and pain intensity in the NSE group compared to the WL group. Thus, this study demonstrates that non-invasive ultrasound can be a diagnostic tool for muscle impairment and used to evaluate exercise interventions in WAD and stands to make a breakthrough for better management in chronic WAD.

Orofacial pain of cervical origin: A case report

BACKGROUND

The etiopathogenesis of orofacial pain remains complex and a number of pain referral patterns for this region have been reported in the literature. The purpose of this report is to describe the assessment and successful clinical management of orofacial pain possibly attributable to cervical origin.

CASE DESCRIPTION

A 55-year-old male teacher with a 3-year history of pain in the right lower jaw, radiating to the ear, consulted our institute for assessment and management. The patient was unsuccessfully treated for dental pain and trigeminal neuralgia. The patient's functioning was grossly limited and the patient was unable to sleep because of severe pain. Current and previous medical and physical examinations revealed no infection, malignancies, or sinusitis. Palpation revealed no temporomandibular disorder, tenderness or myofascial trigger points. Examination of the cervical range of motion showed a reduction in rotation to the right side. The patient was treated for upper cervical joint dysfunction involving mobilization of the first three cervical vertebrae and motor control exercises. The patient had an almost complete resolution of symptoms and reported significant improvement in the Patient Specific Functional Scale (PSFS) and the Global Rating of Change (GRC) scale.

CONCLUSION

This case study demonstrates the importance of considering, assessing and treating the cervical spine as a possible source of orofacial pain, and the positive role of cervical mobilization on these disorders.

A narrative review on cervical interventions in adults with chronic whiplash-associated disorder

Introduction

Whiplash injuries are common in society, but clinical interventions are inconclusive on the most effective treatment. Research and reviews have been completed with the goal of determining clinical interventions that are effective for whiplash injuries and disorders, but literature has not recently been summarised on best practices for cervical spine interventions for adults with chronic whiplash.

Purpose

The objective of this narrative review is to update and expand on previous works, to provide recommendations for clinical interventions and future research in the area of cervical spine rehabilitation for adults with chronic whiplash-associated disorder.

Method

The Arskey and O'Malley methodology was used for this narrative review. CINHAL, EMBASE, Medline, PsychInfo, Scopus, Web of Science, as well as grey literature, were searched from 2003 to April 2017. Two reviewers screened titles and abstracts for relevance to the review, and content analysis summarised the study findings. A total of 14 citations were included in the final review.

Findings

Exercise-based interventions targeted at the cervical spine appear most beneficial for adults with chronic whiplash-associated disorder (WAD). Invasive interventions still require more rigorous studies to deem their effectiveness for this population.

Conclusion

Further research is required to investigate and determine clinically relevant results for cervical spine intervention in patients with chronic WAD.

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

Background

Globally, neck pain is the fourth most common condition associated with longer periods of living with disability. Annually, approximately 0.3% of the population of Western countries undergo whiplash trauma, and half of those individuals will develop chronic problems with high costs for the individual and society. Evidence for chronic whiplash-associated disorders (WAD) treatment is scarce, though neck-specific training at a physiotherapy clinic twice a week for 12 weeks has demonstrated good results. More efficient, flexible rehabilitation with reduced waiting times and lower costs is needed, ideally replacing lengthy on-site treatment series by healthcare providers. Internet-based care has been shown to be a viable alternative for a variety of diseases and interventions, but studies are lacking on Internet-based interventions for individuals with chronic neck problems. The aim of the trial described here is to compare the effects of an Internet-based neck-specific exercise programme to the same exercises performed at a physiotherapy clinic in regards to self-reported and clinical measures, as well as cost-effectiveness.

Methods

This prospective, randomized controlled trial will involve 140 participants. Measurements will be made at baseline, 3 months (end of treatment), and 15 months (12 months after end of intervention) and will include ratings of pain, disability, satisfaction with care, work ability, quality of life, and cost-effectiveness.

Discussion

The study results may contribute to the development of a more effective rehabilitation, flexible and equal care, shorter waiting times, increased availability, and lower costs for healthcare and society.

Trial registration

ClinicalTrials.gov Protocol ID: NCT03022812, initial release 12/20/2016.

General Exercise Does Not Improve Long-Term Pain and Disability in Individuals With Whiplash-Associated Disorders: A Systematic Review

Study Design Systematic review of randomized controlled trials. Background General exercise, defined as purposeful physical activity involving repetitive exercises and incorporating multiple muscle groups, is frequently used in the management of whiplash-associated disorders (WADs). Evidence supporting its efficacy is not well established. Objectives To determine whether general exercise is effective in reducing pain and disability in people with WAD. Methods Studies published in English in peer-reviewed journals between January 1990 and May 2015 were eligible if they evaluated a general exercise intervention compared with a different intervention or control. Studies were required to evaluate pain and disability at medium-term (6-14 weeks) and long-term (52 weeks) follow-ups. The mean ± SD and sample size were recorded for follow-up scores and for change scores from baseline to follow-up. Results Of the 3 high-quality studies that were eligible for inclusion, none investigated general exercise alone. There were no clinically meaningful differences between comprehensive exercise programs, which included general exercise, and minimal intervention controls in the medium and long term. No studies directly compared general exercise with a no-treatment control. All included studies used different control interventions, preventing meta-analysis. Conclusion A lack of significant long-term improvements from general exercise interventions in individuals with WAD was identified. This finding differs from the positive benefits of general exercise for other musculoskeletal conditions. This may, in part, relate to the complexity of whiplash conditions. This may also reflect the challenge of exercise prescription in this population, where the need for sufficient intensity is balanced against the impact that exercise has on pain. Level of Evidence Therapy, level 1a. J Orthop Sports Phys Ther 2017;47(7):472-480. Epub 16 Jun 2017. doi:10.2519/jospt.2017.7081.

The Role of Exercise and Patient Education in the Noninvasive Management of Whiplash

Synopsis The majority of people with whiplash-associated disorder do not have neurological deficit or fracture and are therefore largely managed with nonsurgical interventions such as exercise, patient education, and behavioral-based interventions. To date, clinical guidelines, systematic reviews, and the results of high-quality randomized controlled trials recommend exercise and patient education as the primary interventions for people in both acute and chronic stages after injury. However, the relatively weak evidence and small effect sizes in individual trials have led authors of some systematic reviews to reach equivocal recommendations for either exercise or patient education, and led policy makers and funders to question whether the more expensive intervention (exercise) should be funded at all. Physical therapists, one of the most commonly consulted professionals treating individuals with whiplash-associated disorder, need to look beyond the evidence for insights as to what role patient education and exercise should play in the future management of whiplash. This clinical commentary therefore will review the evidence for exercise, patient education, and behavioral-based interventions for whiplash and provide clinical insight as to the future role that exercise and patient education should play in the management of this complex condition. Possible subgroups of patients who may best respond to exercise will be explored using stratification based on impairments, treatment response, and risk/prognostic factors. J Orthop Sports Phys Ther 2017;47(7):481-491. Epub 16 Jun 2017. doi:10.2519/jospt.2017.7138.

Interdisciplinary rehabilitation after whiplash injury: An observational prospective 5 years outcome study

Whiplash injury associated disorders (WAD) cause high costs for public health care. Neck pain is number 16 on the global prevalence lists for the 50 most common sequelae. It is of importance to obtain long-term data on disability and working capacity outcomes after rehabilitation. Long-term prospective data of the outcome course of whiplash are sparse. The aim of this study was to quantify improvements of pain, function/role performance, vitality, and working capacity 5 years after whiplash injury and to compare the state of health to normative values at 5 years after rehabilitation.In this naturalistic, observational, prospective cohort study, 115 patients were assessed 5 years (60 months) after a multidisciplinary rehabilitation program. The assessment set consisted of the Short Form 36 (SF-36), parts of the North American Spine Society's cervical spine assessment questionnaire (NASS) and the coping strategies questionnaire (CSQ). The effects were quantified by effect size (ES) and standardized response mean (SRM). Score differences over the course were tested by the Wilcoxon-Mann-Whitney U test for significance.Comparing data between entry and 60 months after rehabilitation 8 of 15 parameters improved with large ES/SRM. Outcome between 6 and 60 months showed small to moderate ES/SRM. Working capacity increased from 0 at entry to rehabilitation to 21 h/wk at 6 months and to 30 h/wk at 60 months follow-up.After large improvements in health and working capacity in the mid-term, further important improvements were observed in the long-term course. It can be hypothesized that part of those can be attributed to the interventions during inpatient rehabilitation, for example, due to better coping strategies.

Does structured patient education improve the recovery and clinical outcomes of patients with neck pain? A systematic review from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

BACKGROUND CONTEXT

In 2008, the Bone and Joint Decade 2000 to 2010 Task Force on Neck Pain and Its Associated Disorders recommended patient education for the management of neck pain. However, the effectiveness of education interventions has recently been challenged.

PURPOSE

To update the findings of the Bone and Joint Decade 2000 to 2010 Task Force on Neck Pain and Its Associated Disorders and evaluate the effectiveness of structured patient education for the management of patients with whiplash-associated disorders (WAD) or neck pain and associated disorders (NAD).

STUDY DESIGN/SETTING

Systematic review of the literature and best-evidence synthesis.

PATIENT SAMPLE

Randomized controlled trials that compared structured patient education with other conservative interventions.

OUTCOME MEASURES

Self-rated recovery, functional recovery (eg, disability, return to activities, work, or school), pain intensity, health-related quality of life, psychological outcomes such as depression or fear, or adverse effects.

METHODS

We systematically searched eight electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Central Register of Controlled Trials, DARE, PubMed, and ICL) from 2000 to 2012. Randomized controlled trials, cohort studies, and case-control studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Scientifically admissible studies were summarized in evidence tables and synthesized following best-evidence synthesis principles.

RESULTS

We retrieved 4,477 articles. Of those, nine were eligible for critical appraisal and six were scientifically admissible. Four admissible articles investigated patients with WAD and two targeted patients with NAD. All structured patient education interventions included advice on activation or exercises delivered orally combined with written information or as written information alone. Overall, as a therapeutic intervention, structured patient education was equal or less effective than other conservative treatments including massage, supervised exercise, and physiotherapy. However, structured patient education may provide small benefits when combined with physiotherapy. Either mode of delivery (ie, oral or written education) provides similar results in patients with recent WAD.

CONCLUSIONS

This review adds to the Bone and Joint Decade 2000 to 2010 Task Force on Neck Pain and Its Associated Disorders by defining more specifically the role of structured patient education in the management of WAD and NAD. Results suggest that structured patient education alone cannot be expected to yield large benefits in clinical effectiveness compared with other conservative interventions for patients with WAD or NAD. Moreover, structured patient education may be of benefit during the recovery of patients with WAD when used as an adjunct therapy to physiotherapy or emergency room care. These benefits are small and short lived.

Is exercise effective for the management of neck pain and associated disorders or whiplash-associated disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

BACKGROUND CONTEXT

In 2008, the Neck Pain Task Force (NPTF) recommended exercise for the management of neck pain and whiplash-associated disorders (WAD). However, no evidence was available on the effectiveness of exercise for Grade III neck pain or WAD. Moreover, limited evidence was available to contrast the effectiveness of various types of exercises.

PURPOSE

To update the findings of the NPTF on the effectiveness of exercise for the management of neck pain and WAD grades I to III.

STUDY DESIGN/SETTING

Systematic review and best evidence synthesis.

SAMPLE

Studies comparing the effectiveness of exercise to other conservative interventions or no intervention.

OUTCOME MEASURES

Outcomes of interest included self-rated recovery, functional recovery, pain intensity, health-related quality of life, psychological outcomes, and/or adverse events.

METHODS

We searched eight electronic databases from 2000 to 2013. Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network criteria. The results of scientifically admissible studies were synthesized following best-evidence synthesis principles.

RESULTS

We retrieved 4,761 articles, and 21 randomized controlled trials (RCTs) were critically appraised. Ten RCTs were scientifically admissible: nine investigated neck pain and one addressed WAD. For the management of recent neck pain Grade I/II, unsupervised range-of-motion exercises, nonsteroidal anti-inflammatory drugs and acetaminophen, or manual therapy lead to similar outcomes. For recent neck pain Grade III, supervised graded strengthening is more effective than advice but leads to similar short-term outcomes as a cervical collar. For persistent neck pain and WAD Grade I/II, supervised qigong and combined strengthening, range-of-motion, and flexibility exercises are more effective than wait list. Additionally, supervised Iyengar yoga is more effective than home exercise. Finally, supervised high-dose strengthening is not superior to home exercises or advice.

CONCLUSIONS

We found evidence that supervised qigong, Iyengar yoga, and combined programs including strengthening, range of motion, and flexibility are effective for the management of persistent neck pain. We did not find evidence that one supervised exercise program is superior to another. Overall, most studies reported small effect sizes suggesting that a small clinical effect can be expected with the use of exercise alone.

Chronic neck pain patients with traumatic or non-traumatic onset: Differences in characteristics. A cross-sectional study

BACKGROUND AND AIMS

Patients with chronic neck pain can present with disability, low quality of life, psychological factors and clinical symptoms. It is unclear whether patients with a traumatic onset differ from those with a non-traumatic onset, by having more complex and severe symptoms. The purpose of this study was to investigate the clinical presentation of chronic neck pain patients with and without traumatic onset by examining cervical mobility, sensorimotor function, cervical muscle performance and pressure pain threshold in addition to the following self-reported characteristics: quality of life, neck pain and function, kinesiophobia, depression, and pain bothersomeness.

METHODS

This cross-sectional study included 200 participants with chronic neck pain: 120 with traumatic onset and 80 with non-traumatic onset. Participants were recruited from physiotherapy clinics in primary and secondary health care. For participants to be included, they were required to be at least 18 years of age, have had neck pain for at least 6 months, and experienced neck-related activity limitation as determined by a score of at least 10 on the Neck Disability Index. We conducted the following clinical tests of cervical range of motion, gaze stability, eye movement, cranio-cervical flexion, cervical extensors, and pressure pain threshold. The participants completed the following questionnaires: physical and mental component summary of the Short Form Health Survey, EuroQol-5D, Neck Disability Index, Patient-Specific Functional Scale, Pain Bothersomeness, Beck Depression Inventory-II, and TAMPA scale of kinesiophobia. The level of significance for all analyses was defined as p<0.01. Differences between groups for the continuous data were determined using either a Student's t-test or Mann Whitney U test.

RESULTS

In both groups, the majority of the participants were female (approximately 75%). Age, educational level, working situation and sleeping patterns were similar in both groups. The traumatic group had symptoms for a shorter duration (88 vs. 138 months p=0.001). Participants in the traumatic group showed worse results on all measures compared with those in the non-traumatic group, significantly on neck muscle function (cervical extension mobility p=0.005, cranio-cervical flexion test p=0.007, cervical extensor test p=0.006) and cervical pressure pain threshold bilateral (p=0.002/0.004), as well on self-reported function (Neck Disability Index p=0.001 and Patient-Specific Functional Scale p=0.007), mental quality of life (mental component summary of the Short Form Health Survey p=0.004 and EuroQol-5D p=0.001) and depression (Beck Depression Inventory-II p=0.001).

CONCLUSIONS

This study showed significant differences between chronic neck pain patients when differentiated into groups based on their onset of pain. However, no specific clinical test or self-reported characteristic could differentiate between the groups at an individual patient level.

IMPLICATIONS

Pressure pain threshold tests, cervical muscle performance tests and patient-reported characteristics about self-perceived function and psychological factors may assist in profiling chronic neck pain patients. The need for more intensive management of those with a traumatic onset compared with those with a non-traumatic onset should be examined further.

MicroRNA 320a Predicts Chronic Axial and Widespread Pain Development Following Motor Vehicle Collision in a Stress-Dependent Manner

Study Design Prospective human cohort study combined with molecular studies. Background A microRNA is a small, noncoding RNA molecule that can play a role in disease onset. Recent studies found that circulating levels of microRNA 320a (miR-320a) are associated with musculoskeletal pain conditions and that miR-320a is stress responsive. Objectives To investigate whether circulating expression levels of miR-320a in the peritraumatic period predict persistent axial musculoskeletal pain 6 months after motor vehicle collision (MVC). Methods We evaluated whether (1) circulating miR-320a and related members of the miR-320a family predict axial musculoskeletal pain and other musculoskeletal pain outcomes 6 months following MVC, and (2) miR-320a regulates stress system and pain-related transcripts in cell culture. Given the wealth of data suggesting that biological mechanisms influencing pain outcomes are often sex and/or stress dependent, interactions between miR-320a, stress, and sex were evaluated. Results In primary analyses (n = 69), a significant crossover interaction was observed between the influence of circulating miR-320a and peritraumatic distress (β = -0.01, P = .002) on post-MVC axial musculoskeletal pain. Reduced peritraumatic miR-320a expression levels predicted axial musculoskeletal pain in distressed individuals (β = -0.12, P = .006) but not nondistressed individuals. In secondary analyses, miR-320a predicted widespread musculoskeletal pain, and related members of the miR-320a family also predicted axial and widespread musculoskeletal pain. In cell culture, miR-320a bound stress and pain-associated 3'UTR transcripts (FKBP5, ADCYAP1, PER2, and NR3C1). Conclusion These data suggest that miR-320a may help mediate regional and widespread changes in pain sensitivity after MVC. J Orthop Sports Phys Ther 2016;46(10):911-919. doi:10.2519/jospt.2016.6944.

Exercises for mechanical neck disorders: A Cochrane review update

BACKGROUND

Neck pain (NP) is disabling and costly.

OBJECTIVES

To assess the effectiveness of exercise on pain, disability, function, patient satisfaction, quality of life (QoL) and global perceived effect (GPE) in adults with NP.

METHODS

We searched computerised databases up to May 2014 for randomized controlled trials (RCTs) comparing exercise to a control in adults with NP with/without cervicogenic headache (CGH) or radiculopathy. Two reviewers independently conducted selection, data abstraction and assessed risk of bias. Meta-analyses were performed to establish pooled standardised mean differences (SMDp). The Grade of Recommendation, Assessment, Development and Evaluation (GRADE) was used to summarise the body of evidence.

MAIN RESULTS

The following exercises (27 trials) were supported by 'Moderate GRADE' evidence: For chronic NP, 1) cervico-scapulothoracic and upper extremity (UE) strengthening for moderate to large pain reduction immediately post treatment (IP) and at short-term (ST) follow-up; 2) scapulothoracic and UE endurance training for a small pain reduction (IP/ST); 3) cervical, shoulder and scapulothoracic strengthening and stretching exercise for a small to large pain reduction in the long-term (LT) (SMDp -0.45 [95%CI: -0.72 to -0.18]) and function improvement; 4) cervico-scapulothoracic strengthening/stabilisation exercises for pain and function at intermediate-term (IT) (SMDp -14.90 [95%CI: -22.40 to -7.39]). 5) mindfulness exercises (Qigong) for minor improved function but not GPE (ST). For chronic CGH, cervico-scapulothoracic strengthening and endurance exercises including pressure biofeedback for small/moderate improvement of pain, function and GPE (IP/LT).

AUTHORS' CONCLUSIONS

Specific strengthening exercises of the neck, scapulothoracic and shoulder for chronic NP and chronic CGH are beneficial. Future research should explore optimal dosage.

Serum C-reactive protein levels predict regional brain responses to noxious cold stimulation of the hand in chronic whiplash associated disorders

BACKGROUND AND AIMS

Whiplash Associated Disorders (WAD) are a costly health burden. The condition is characterised by sensory disturbances such as widespread hyperalgesia likely indicative of central hyperexcitability. Recently elevated levels of pro-inflammatory biomarkers have also found in acute and chronic WAD. The aim of this cross-sectional study was to investigate the relationship between inflammatory biomarkers and pain processing in people with persistent whiplash associated disorders (WAD).

METHODS

Twenty one participants with chronic whiplash (>3 months) were recruited. Venous blood samples were collected and assays performed for C-reactive protein (CRP) and TNF-α. Blood oxygen level-dependent (BOLD) contrast images of the brain were acquired with a Siemens 1.5T MRI scanner during repeated 24s stimulus blocks of innocuous or painful stimuli (thumbnail pressure and cold stimulation of dorsum of hand) separated by 36s inter-stimulus intervals. Stimulus intensities used during scanning were at the level of participants' thresholds for moderate pain. Parameter estimates representing BOLD signal increases during painful events from each participant were tested for associations with inflammatory biomarkers.

RESULTS

Clinically relevant levels of CRP and TNF-α were found in 33% and 38% of participants. Levels of CRP showed a positive correlation with levels of cold pain activation in brain regions including the anterior insula, posterior parietal cortex, caudate and thalamus (p_corrected<0.05). Levels of TNF-α were not related to activation levels during either noxious pressure or cold. Pressure pain activations also did not show a relationship with CRP levels.

CONCLUSIONS

Shared variance between inflammation and increased levels of regional pain-related activation in people with persistent whiplash symptoms is apparent for cold, but not pressure stimuli.

IMPLICATIONS

The results highlight cold pain processing as an important aspect of whiplash chronicity, although the implications of this modality-specific effect are not readily apparent.

Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

PURPOSE

To develop an evidence-based guideline for the management of grades I-III neck pain and associated disorders (NAD).

METHODS

This guideline is based on recent systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences (obtained from qualitative research) when formulating recommendations. Target audience includes clinicians; target population is adults with grades I-III NAD <6 months duration.

RECOMMENDATION 1

Clinicians should rule out major structural or other pathologies as the cause of NAD. Once major pathology has been ruled out, clinicians should classify NAD as grade I, II, or III.

RECOMMENDATION 2

Clinicians should assess prognostic factors for delayed recovery from NAD.

RECOMMENDATION 3

Clinicians should educate and reassure patients about the benign and self-limited nature of the typical course of NAD grades I-III and the importance of maintaining activity and movement. Patients with worsening symptoms and those who develop new physical or psychological symptoms should be referred to a physician for further evaluation at any time during their care.

RECOMMENDATION 4

For NAD grades I-II ≤3 months duration, clinicians may consider structured patient education in combination with: range of motion exercise, multimodal care (range of motion exercise with manipulation or mobilization), or muscle relaxants. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, strain-counterstrain therapy, relaxation massage, cervical collar, electroacupuncture, electrotherapy, or clinic-based heat.

RECOMMENDATION 5

For NAD grades I-II >3 months duration, clinicians may consider structured patient education in combination with: range of motion and strengthening exercises, qigong, yoga, multimodal care (exercise with manipulation or mobilization), clinical massage, low-level laser therapy, or non-steroidal anti-inflammatory drugs. In view of evidence of no effectiveness, clinicians should not offer strengthening exercises alone, strain-counterstrain therapy, relaxation massage, relaxation therapy for pain or disability, electrotherapy, shortwave diathermy, clinic-based heat, electroacupuncture, or botulinum toxin injections.

RECOMMENDATION 6

For NAD grade III ≤3 months duration, clinicians may consider supervised strengthening exercises in addition to structured patient education. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, cervical collar, low-level laser therapy, or traction. RECOMMENDATION 7: For NAD grade III >3 months duration, clinicians should not offer a cervical collar. Patients who continue to experience neurological signs and disability more than 3 months after injury should be referred to a physician for investigation and management. RECOMMENDATION 8: Clinicians should reassess the patient at every visit to determine if additional care is necessary, the condition is worsening, or the patient has recovered. Patients reporting significant recovery should be discharged.

Cervical zygapophysial (facet) joint pain: effectiveness of interventional management strategies

Diagnostic facet joint nerve blocks have been utilized in the diagnosis of cervical facet joint pain in patients without disk herniation or radicular pain due to a lack of reliable noninvasive diagnostic measures. Therapeutic interventions include intra-articular injections, facet joint nerve blocks and radiofrequency neurotomy. The diagnostic accuracy and effectiveness of facet joint interventions have been assessed in multiple diagnostic accuracy studies, randomized controlled trials (RCTs), and systematic reviews in managing chronic neck pain. This assessment shows there is Level II evidence based on a total of 11 controlled diagnostic accuracy studies for diagnosing cervical facet joint pain in patients without disk herniation or radicular pain utilizing controlled diagnostic blocks. Due to significant variability and internal inconsistency regarding prevalence in a heterogenous population; despite 11 studies, evidence is determined as Level II. Prevalence ranged from 36% to 67% with at least 80% pain relief as the criterion standard with a false-positive rate ranging from 27% to 63%. The evidence is Level II for the long-term effectiveness of radiofrequency neurotomy and facet joint nerve blocks in managing cervical facet joint pain. There is Level III evidence for cervical intra-articular injections.

Dry-needling and exercise for chronic whiplash-associated disorders: a randomized single-blind placebo-controlled trial

This randomized controlled trial investigated the effectiveness and cost-effectiveness of dry-needling and exercise compared with sham dry-needling and exercise for chronic whiplash-associated disorders (WAD). The setting was a single university centre and 4 physiotherapy practices in Queensland, Australia. Eighty patients with chronic WAD (>3 months) were enrolled between June 2009 and August 2012 with 1-year follow-up completed in August 2013. The interventions were 6 weeks of dry-needling to posterior neck muscles (n = 40) and exercise or sham dry-needling and exercise (n = 40). The primary outcomes of the Neck Disability Index (NDI) and self-rated recovery were measured at baseline, 6 and 12 weeks, 6 and 12 months by a blinded assessor. Analysis was intention to treat. An economic evaluation was planned but missing data deemed further analysis unwarranted. Seventy-nine patients (99%) were followed up at 6 weeks, 78 (98%) at 12 weeks, 74 (93%) at 6 months, and 73 (91%) at 12 months. The dry-needling and exercise intervention was more effective than sham dry-needling and exercise in reducing disability at 6 and 12 months but not at 6 and 12 weeks. The treatment effects were small and not clinically worthwhile. At 6 weeks, the treatment effect on the 0-100 NDI was -0.3 (95% confidence interval -5.4 to 4.7), 12 weeks -0.3 (-5.2 to 4.9), 6 months -4.4 (-9.6 to -0.74), and 12 months -3.8 (-9.1 to -0.5). There was no effect for self-rated recovery. In patients with chronic WAD, dry-needling and exercise has no clinically worthwhile effects over sham dry-needling and exercise.