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The Effect of Neck-specific Exercise With, or Without a Behavioral Approach, on Pain, Disability, and Self-Efficacy in Chronic Whiplash-associated Disorders: A Randomized Clinical Trial

Ludvigsson, Maria L. MSc, PT*,†; Peterson, Gunnel MSc, PT*,‡; O’Leary, Shaun PhD, PT§,∥; Dedering, Åsa PhD, PT¶,#; Peolsson, Anneli PhD, PT*,§

doi: 10.1097/AJP.0000000000000123
Original Articles

Objectives: The aim of this study was to compare the effect on self-rated pain, disability, and self-efficacy of 3 interventions for the management of chronic whiplash-associated disorders: physiotherapist-led neck-specific exercise (NSE), physiotherapist-led NSE with the addition of a behavioral approach, or Prescription of Physical Activity (PPA).

Materials and Methods: A total of 216 volunteers with chronic whiplash-associated disorders participated in this randomized, assessor blinded, clinical trial of 3 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 3 and 6 months.

Results: The proportion of patients reaching substantial reduction in pain bothersomness (at least 50% reduction) was more evident (P<0.01) in the 2 NSE groups (29% to 48%) compared with the PPA group (5%) at 3 months. At 6 months 39% to 44% of the patients in the 2 neck-specific groups and 28% in the PPA group reported substantial pain reduction. Reduction of disability was also larger in the 2 neck-specific exercise groups at both 3 and 6 months (P<0.02). Self-efficacy was only improved in the NSE group without a behavioral approach (P=0.02). However, there were no significant differences in any outcomes between the 2 physiotherapist-led NSE groups.

Discussion: NSE resulted in superior outcomes compared with PPA in this study, but the observed benefits of adding a behavioral approach to the implementation of exercise in this study were inconclusive.

*Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping

Rehab Väst, County Council of Östergötland, Östergötland

Centre for Clinical Research Sörmland, Uppsala University, Uppsala

Department of Neurobiology, Division of Physiotherapy, Care Sciences and Society, Karolinska Institutet, Solna

#Department of Physical Therapy, Karolinska University Hospital, Stockholm, Sweden

§NHMRC CCRE (Spinal Pain, Injury and Health), The University of Queensland

Physiotherapy Department, Royal Brisbane and Women’s Hospital, Queensland Health, Brisbane, Qld, Australia

Supported by funding from the Swedish government through the Swedish Research Council in cooperation with the Swedish Social Insurance Agency through the REHSAM foundation Stockholm, Sweden, and the regional Centers for Clinical Research of Östergötland, Linköping, Sweden and Sörmland, Uppsala, Sweden County Councils. A.P. is supported by the Swedish Research Council, Stockholm, Sweden. S.O.L. is supported by a Health Practitioner Research Fellowship (Queensland Health and the University of Queensland, Brisbane, Australia [NHMRC CCRE Spinal Pain, Injury and Health]). The authors declare no conflict of interest.

Reprints: Maria L. Ludvigsson, MSc, PT, Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping SE-581 83, Sweden (e-mail:

This 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.

Received October 21, 2013

Received in revised form July 7, 2014

Accepted May 30, 2014

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