Neck exercises, physical and cognitive behavioural-graded activity as a treatment for adult whiplash patients with chronic neck pain: Design of a randomised controlled trial Pain neurophysiology education improves cognitions, pain thresholds, and movement performance in people with chronic whiplash: a pilot study. Coping and Recovery in Whiplash-associated Disorders: Early use of Passive Coping Strategies is Associated With Slower Recovery of Neck Pain and Pain-related Disability Neither the WAD-classification nor the Quebec Task Force follow-up regimen seems to be important for the outcome after a whiplash injury. A prospective study on 186 consecutive patients A Combination of Gestalt Therapy, Rosen Body Work, and Cranio Sacral Therapy did not help in Chronic Whiplash-Associated Disorders (WAD) - Results of a Randomized Clinical Trial Multidimensional associative factors for improvement in pain, function, and working capacity after rehabilitation of whiplash associated disorder: a prognostic, prospective outcome study Acute whiplash-associated disorders (WAD): the effects of early mobilization and prognostic factors in long-term symptomatology Neck Collar, “Act-as-Usual” or Active Mobilization for Whiplash Injury?: A Randomized Parallel-Group Trial A Randomized Controlled Trial of an Educational Intervention to Prevent the Chronic Pain of Whiplash Associated Disorders Following Rear-End Motor Vehicle Collisions Testing the feasibility of a knowledge translation intervention designed to improve chiropractic care for adults with neck pain disorders: study protocol for a pilot cluster-randomized controlled trial Implementation of a guideline-based clinical pathway of care to improve health outcomes following whiplash injury (Whiplash ImPaCT): protocol of a randomised, controlled trial. Can Exposure and Acceptance Strategies Improve Functioning and Life Satisfaction in People with Chronic Pain and Whiplash‐Associated Disorders (WAD)? A Randomized Controlled Trial Psychological determinants of quality of life in patients with whiplash associated disorders-a prospective study. The Effect of Neck-specific Exercise With, or Without a Behavioral Approach, on Pain, Disability, and Self-Efficacy in Chronic Whiplash-associated Disorders A three-group study, internet-based, face-to-face based and standard- management after acute whiplash associated disorders (WAD) – choosing the most efficient and cost-effective treatment: study protocol of a randomized controlled trial The ability to change of three questionnaires for neck pain. Does a combination of physical training, specific exercises and pain education improve health-related quality of life in patients with chronic neck pain? A randomised control trial with a 4-month follow up.
Background Many patients suffer from chronic neck pain following a whiplash injury . A combination of cognitive , behavioural therapy with physiotherapy interventions has been indicated to be effective in the management of patients with chronic whiplash-associated disorders . The objective is to present the design of a r and omised controlled trial ( RCT ) aim ed at evaluating the effectiveness of a combined individual physical and cognitive behavioural- grade d activity program on self-reported general physical function , in addition to neck function , pain , disability and quality of life in patients with chronic neck pain following whiplash injury compared with a matched control group measured at baseline and 4 and 12 months after baseline . Methods / Design The design is a two-centre , RCT - study with a parallel group design . Included are whiplash patients with chronic neck pain for more than 6 months , recruited from physiotherapy clinics and an out-patient hospital department in Denmark . Patients will be r and omised to either a pain management ( control ) group or a combined pain management and training (intervention)group . The control group will receive four educational sessions on pain management , whereas the intervention group will receive the same educational sessions on pain management plus 8 individual training sessions for 4 months , including guidance in specific neck exercises and an aerobic training programme . Patients and physiotherapists are aware of the allocation and the treatment , while outcome assessors and data analysts are blinded . The primary outcome measures will be Medical Outcomes Study Short Form 36 ( SF36 ) , Physical Component Summary ( PCS ) . Secondary outcomes will be Global Perceived Effect ( -5 to + 5 ) , Neck Disability Index ( 0 - 50 ) , Patient Specific Functioning Scale ( 0 - 10 ) , numeric rating scale for pain bothersomeness ( 0 - 10 ) , SF-36 Mental Component Summary ( MCS ) , TAMPA scale of Kinesiophobia ( 17 - 68 ) , Impact of Event Scale ( 0 - 45 ) , EuroQol ( 0 - 1 ) , craniocervical flexion test ( 22 mmHg - 30 mmHg ) , joint position error test and cervical range of movement . The SF36 scales are scored using norm-based methods with PCS and MCS having a mean score of 50 with a st and ard deviation of 10 . Discussion The perspectives of this study are discussed , in addition to the strengths and weaknesses . Trial registration The study is registered in http://www . Clinical Trials.gov identifier NCT01431261 Chronic whiplash is a debilitating condition characterized by increased sensitivity to painful stimuli , maladaptive illness beliefs , inappropriate attitudes , and movement dysfunctions . Previous work in people with chronic low back pain and chronic fatigue syndrome indicates that pain neurophysiology education is able to improve illness beliefs and attitudes as well as movement performance . This single-case study ( A-B-C design ) with six patients with chronic whiplash associated disorders ( WAD ) was aim ed at examining whether education about the neurophysiology of pain is accompanied by changes in symptoms , daily functioning , pain beliefs , and behavior . Periods A and C represented assessment periods , while period B consisted of the intervention ( pain neurophysiology education ) . Results showed a significant decrease in kinesiophobia ( Tampa Scale for Kinesiophobia ) , the passive coping strategy of resting ( Pain Coping Inventory ) , self-rated disability ( Neck Disability Index ) , and photophobia ( WAD Symptom List ) . At the same time , significantly increased pain pressure thresholds and improved pain-free movement performance ( visual analog scale on Neck Extension Test and Brachial Plexus Provocation Test ) were established . Although the current results need to be verified in a r and omized , controlled trial , they suggest that education about the physiology of pain is able to increase pain thresholds and improve pain behavior and pain-free movement performance in patients with chronic WAD Objective : Coping is shown to affect outcomes in chronic pain patients ; however , few studies have examined the role of coping in the course of recovery in whiplash-associated disorders ( WAD ) . The purpose of this study was to determine the predictive value of coping style for 2 key aspects of WAD recovery , reductions in neck pain , and in disability . Methods : A population -based prospect i ve cohort study design was used to study 2986 adults with traffic-related WAD . Participants were assessed at baseline , 6 weeks , and 4 , 8 , and 12 months postinjury .  Coping  was measured at 6 weeks using the Pain Management Inventory  , and neck pain recovery was assessed at each subsequent follow-up , using a 100 mm  visual analogue scale ( VAS ) . Disability was assessed at each follow-up using the Pain Disability Index ( PDI ) . Pain recovery was defined as a VAS score of 0 to 10 ; disability recovery was defined as a PDI score of 0 to 4 . Data analysis used multivariable Cox proportional hazards models . Results : Those using high versus low levels of passive coping at 6 weeks postinjury experienced 28 % slower pain recovery and 43 % slower disability recovery . Adjusted hazard rate ratios for pain recovery and disability recovery were 0.72 ( 95 % CI , 0.59 - 0.88 ) and 0.57 ( 95 % CI , 0.41 - 0.78 ) , respectively . Active coping was not associated with recovery of neck pain or disability . Conclusions : Passive coping style predicts neck pain and self-assessed disability recovery . It may be beneficial to assess and improve coping style early in WAD A classification of injury and a follow-up schedule were proposed by the Quebec Task Force ( QTF ) in 1995 . No general agreement about the clinical usefulness of the WAD-classification or of the suggested follow-up regimen exists . A series of 186 consecutive cases seen in the emergency room during the acute phase after a whiplash injury was prospect ively studied for 1 year . All findings including history and physical findings were recorded using st and ardized QTF protocol s. In one group follow-up visits were done according to the QTF regimen : at 1 , 3 , 6 , 12 weeks and 1 year after the accident ; in a control group no visit was scheduled . The outcome variable was neck pain at 1 year after the accident . After 1 year , 18 % of the total number of patients had significant neck pain . Risk factors for chronic neck pain at 1 year after whiplash injury were : neck pain before the accident and a high degree of emotional distress at the time of the accident ; both factors independently associated with a tenfold increased risk of developing chronic neck pain . Neither the WAD classification nor the QTF follow-up regimen could be linked to a better outcome . In this study the outcome was associated with patient-specific characteristics and not with physical signs of injury , the depth of the initial evaluation or the follow-up regimen The chronic state of whiplash-associated disorder ( WAD ) might be understood as a somatization of existential pain . Intervention aim ed to improve quality of life ( QOL )  seemed to be a solution for such situations . The basic idea behind the intervention was holistic , restoring quality of life and relationship with self , in order to diminish tension in the locomotion system , especially the neck . A psychosomatic theory for WAD is proposed . Our treatment was a short 2-day course with teachings in philosophy of life , followed by 6 to 10 individual sessions in gestalt psychotherapy and body therapy ( Rosen therapy and Cranio Sacral therapy ) , followed by a 1-day course approximately 2 months later , closing the intervention . Two independent institutions did the intervention and the assessment s. In a r and omized , clinical ly controlled setting , 87 chronic WAD patients were included with a median duration of 37 months from their whiplash accidents . One patient never started . Forty-three had the above intervention ( female/male = 36/7 , ages 22—49 , median 37 years ) and another 43 were assigned to a nontreated control group ( female/male = 35/8 , ages 1848 , median 38 ) . Six had disability pension and 27 had pending medicolegal issues in each group . Effect variables were pain in neck , arm , and /or head ; measures of quality of life and daily activities ; as well as general physical or mental health . Wilcoxon test for between-groups comparisons with intention-to-treat analyses was conducted ; the square curve paradigm testing for immediate improvements of health and quality of life was also used . The groups were comparable at baseline . From the intervention group , 11 dropped out during the intervention ( 4 of those later joined the follow-up investigation ) , 22 of the remaining 32 graduated the course , and 35 of the 43 controls did as well . Approximately 3 months later , we found no clinical ly relevant or significant increase in any effect measure . The above version of a quality of life intervention based on alternative therapy had no effect on patients with chronic WAD Background Whiplash associated disorders ( WAD ) have dramatic consequences for individual and public health . Risk factors for better and worse outcomes are important to optimize management . This study aim ed to determine short- and mid-term associative co-factors of neck pain relief , improved physical functioning , and improved working capacity ( dependent variables ) in patients suffering from whiplash associated disorder who participated in a st and ardized , inpatient pain management program .  Methods Naturalistic , observational , prospect i ve cohort study . Outcome was measured by st and ardized assessment instruments . Co-factors covered sociodemographics , comorbidities , social participation , affective health , and coping abilities . Stepwise , multivariate linear regression analysis was performed at discharge and at the 6-month follow-up . Results All regression models explained high proportions of variance ( 53.3 % – 72.1 % ) . The corresponding baseline level was significantly associated with a change in every dependent variable ( explained variances : 11.4%-56.7 % ) . Pain relief significantly depended on improved function and vice-versa ( 3.4%-14.8 % ) . Improved ability to decrease pain was associated with pain relief at discharge ( 9.6 % ) . Functional improvement was associated with decreased catastrophizing ( 19.4 % ) at discharge and decreased depression ( 20.5 % ) at the 6 month follow-up . Conclusions Pain relief , improved physical function and working capacity were associated with each other . Improved coping ( catastrophizing and ability to decrease pain ) and reduced depression may act as important predictors for pain relief and improved function . These findings offer toe-holds for optimized therapy of chronic WAD Objective : To compare two different home exercise programmes for patients with acute whiplash-associated disorders ( WAD ) . A further aim was to describe the initial prognostic variables related to self-reported pain at six months follow-up . Design : A r and omized treatment study with a follow-up period of six months . Setting s : The study was undertaken in an orthopaedic clinic at a university hospital . Subjects : A total of 59 symptomatic ( neck pain , stiffness , etc . ) patients with acute whiplash injury . Interventions : Patients were r and omized to a regular treatment group ( RT group ) and an additional-exercise treatment group ( AT group ) . Main outcome measures : Pain Disability Index ( PDI ) , Self-Efficacy Scale ( SES ) , Coping Strategies Question naire ( CSQ ) , neck range of motion ( ROM ) , head posture , kinaesthetic sensibility , visual analogue scale ( VAS ) . Results : Patients given an additional exercise did not improve more than patients with regular treatment . Only one CSQ item , ‘ Ability to decrease pain ' , showed a significant difference between the groups in its pattern of change over time : the AT group had a significant increase between three and six months whilst values in the RT group decreased . Nonsymptomatic patients at six months follow-up were characterized by initially better self-efficacy , lower disability and significantly different patterns in the use of ‘ behavioural coping strategies ' when compared with symptomatic patients . The nonsymptomatic patients also reported more frequent training than symptomatic patients , i.e. they complied better with the treatment regime . Conclusion : This home exercise programme , including training of neck and shoulder ROM , relaxation and general advice seems to be sufficient treatment for acute WAD patients when used on a daily basis . Additionally , patients reporting low self-efficacy and high disability levels may profit from more attention initially , as these psychological factors are significant predictors of pain at long-term follow-up Study Design . R and omized , parallel-group trial . Objective . To compare the effect of 3 early intervention strategies following whiplash injury . Summary of Background Data . Long-lasting pain and disability , known as chronic whiplash-associated disorder ( WAD ) , may develop after a forced flexion-extension trauma to the cervical spine . It is unclear whether this , in some cases disabling , condition can be prevented by early intervention . Active interventions have been recommended but have not been compared with information only . Methods . Participants were recruited from emergency units and general practitioners within 10 days after a whiplash injury and r and omized to : 1 ) immobilization of the cervical spine in a rigid collar followed by active mobilization , 2 ) advice to “ act-as-usual , ” or 3 ) an active mobilization program ( Mechanical Diagnosis and Therapy ) . Follow-up was carried out after 3 , 6 , and 12 months postinjury . Treatment effect was measured in terms of headache and neck pain intensity ( 0–10 ) , disability , and work capability . Results . A total of 458 participants were included . At the 1-year follow-up , 48 % of participants reported considerable neck pain , 53 % disability , and 14 % were still sick listed at 1 year follow-up . No significant differences were observed between the 3 interventions group . Conclusion . Immobilization , “ act-as-usual , ” and mobilization had similar effects regarding prevention of pain , disability , and work capability 1 year after a whiplash injury Study Design . Concealed allocation , multicenter , single-blind , r and omized controlled clinical trial . Objective . To assess the efficacy of an educational video in the tertiary prevention of persistent WAD symptoms following rear-end motor vehicle collisions ( MVCs ) . Summary of Background Data . Whiplash-associated disorders ( WAD ) are an important and costly health problem . There is a lack of high quality evidence surrounding efficacy of treatments for WAD . Existing research supports active interventions and early return to regular activities . Methods . Consecutive patients presenting to four tertiary care emergency departments following rear-end MVCs were eligible . Following informed consent , patients were allocated , using central r and omization , to receive an educational video plus usual care or usual care alone . The video provided reassurance , and advice about posture , return to regular activities , exercises , and pain-relief methods . Data were collected by telephone using st and ardized question naires . The primary outcome was presence of Persistent WAD Symptoms at 24 weeks postinjury , based on the frequency and severity of neck , shoulder , or upper back pain . The absolute difference in proportion of patients with persistent WAD symptoms and rate ratios were calculated . Changes in pain scores were compared using the Mann-Whitney U test . Results . The  intervention ( n = 206 ) and control ( n = 199 ) groups were similar at baseline ( mean age 38.4 years ; 64 % female ) . Overall , the proportion of subjects with Persistent WAD Symptoms decreased from 89.1 % at baseline to 33.6 % at 24 weeks after injury . At 24 weeks , the proportion of subjects with persistent WAD symptoms in the intervention group was 7.9 % ( 95 % CI , −2.0 , 17.8 ) lower than the control group . The median improvement in pain score at 24 weeks was 3 for the intervention group and 2 for the control group ( P = 0.016 ) . Conclusion . The presence of persistent WAD symptoms following simple rear-end MVCs was high in this sample . The video group demonstrated a trend toward less severe WAD symptoms . We recommend evaluating other educational interventions that could reduce WAD symptoms Background Neck pain in adults is common and a leading cause of physical disability . Recently , a guideline was developed for the management of non-specific neck pain ( NSNP ) with an aim to improve the quality of the delivery of chiropractic care . One key guideline recommendation is to undertake multimodal care for patients with NSNP . The aim of this pilot study is to determine the feasibility of implementing a multifaceted knowledge translation intervention by promoting the use of multimodal care by chiropractors managing patients with NSNP . Methods / design The design is a cluster-r and omized controlled pilot and feasibility trial . Chiropractors in private practice in Canada will be approached to participate in the study . Thirty consenting chiropractors will be r and omized to receive either a theory-based educational intervention in the experimental group or simply a printed copy of the guideline in the control group .  Each chiropractor will recruit five neck pain patients ( a total of 150 patients ) into the study . Development of the multifaceted intervention was informed by the results of a related qualitative study based on the Theoretical Domains Framework and consists of a series of three webinars , two online case scenarios , a self-management video on Brief Action Planning , and a printed copy of the practice guideline . Primary feasibility outcomes for both chiropractors and patients include rates of ( 1 ) recruitment , ( 2 ) retention , and ( 3 ) adherence to the intervention . A checklist of proxy measures embedded within patient encounter forms will be used to assess chiropractors ’ compliance with guideline recommendations ( e.g. exercise and self-care prescriptions ) at study onset and at 3 months . Secondary outcomes include scores of behavioural constructs ( level of knowledge and self-efficacy ) for recommended multimodal care . Clinical outcomes include pain intensity and neck pain-specific disability . Analyses from this study will focus on generating point estimates and corresponding 95 % confidence intervals for parameters of a priori interest ( recruitment , retention , adherence , pain intensity , Neck Disability Index ) . Discussion Results of this study will inform the design of a larger cluster-r and omized controlled trial aim ed at evaluating the effectiveness of the theory-based tailored intervention and increasing the use of multimodal care by chiropractors managing patients with NSNP.Trial registration https:// clinical trials.gov/ , INTRODUCTION Whiplash-associated disorders ( WAD ) are a huge worldwide health and economic burden . The propensity towards developing into chronic , disabling conditions drives the rise in health and economic costs associated with treatment , productivity loss and compulsory third party insurance cl aims . Current treatments fail to address the well-documented heterogeneity of WAD and often result in poor outcomes . A novel approach is to evaluate whether the care provided according to the estimated risk of poor prognosis improves health outcomes while remaining cost-effective . RESEARCH QUESTIONS ( 1 ) Does a guideline -based clinical pathway of care improve health outcomes after whiplash injury compared to usual care ? ( 2 ) Does risk of recovery have a differential effect on health outcomes for the clinical pathway of care ? ( 3 ) Is the clinical pathway of care intervention cost-effective ? ( 4 ) What are the variations in professional practice between usual care and the clinical pathway of care ? DESIGN Multi-centre , r and omised , controlled trial conducted over two Australian states : Queensl and and New South Wales . PARTICIPANTS AND SETTING 236 people with WAD ( grade I-III , within 6 weeks of injury ) and their primary healthcare providers . INTERVENTION A clinical pathway of care , with care matched to the predicted risk of poor recovery . Participants at low risk of ongoing pain and disability ( hence , predicted to fully recover ) will receive up to three sessions of guideline -based advice and exercise with their primary healthcare provider . Participants at medium/high risk of developing ongoing pain and disability will be referred to a specialist ( defined as a practitioner with expertise in whiplash ) who will conduct a more in-depth physical and psychological assessment . As a result , the specialist will liaise with the original primary healthcare provider and determine one of three further pathways of care . CONTROL Usual care provided by the primary healthcare provider that is based on clinical judgment . MEASUREMENTS Primary ( global rating of change and neck-related disability ) and secondary ( self-efficacy , pain intensity , general health and disability and psychological health ) outcomes will be collected using vali date d scales . Direct ( eg , professional care , transportation costs , time spent for care , co-payments ) and indirect ( eg , lost economic productivity ) costs will be obtained through an electronic cost diary . Health and cost outcomes will be assessed at baseline , 3 , 6 and 12 months after r and omisation . Professional practice outcomes will be evaluated through question naires completed by healthcare providers and their patients at 3 months . PROCEDURE Potential participants ( patients ) will be identified through emergency departments , primary health clinics and advertisements . Eligible participants will complete baseline assessment s and will be categorised into low or medium/high risk of poor recovery using a clinical prediction rule . After this assessment , participants will be r and omly allocated to either a  control group ( n=118 ) or intervention group ( n=118 ) , stratified by risk subgroup and treatment site . The participants ' nominated primary healthcare providers will be informed of their involvement in the trial . Consent will be obtained from the primary healthcare providers to participate and to obtain information about professional practice . Participants in the intervention group will additionally have access to an interactive website that provides information about whiplash and recovery relative to their risk category . ANALYSIS Analysis will be conducted on an intention-to-treat basis . Outcomes will be analysed independently through cross-sectional analyses using generalised linear models methods , with an appropriate link function , to test for an intervention effect , adjusted for the baseline values . The risk category will be tested for its association with treatment effect by adding risk group to the regression equation . Cost-effectiveness will be calculated using utility weights and the result ing measure will be cost per quality -adjusted life year ( QALY ) saved . Professional practice outcomes will be analysed using descriptive statistics . DISCUSSION This research is significant as it will be the first study to address the heterogeneity of whiplash by implementing a clinical pathway of care that matches evidence -based interventions to projected risk of poor recovery . The results of this trial have the potential to change clinical practice for WAD , thereby maximising treatment effects , improving patient outcomes , reducing costs and maintaining the compulsory third party system Although 14 % to 42 % of people with whiplash injuries end up with chronic debilitating pain , there is still a paucity of empirically supported treatments for this group of patients . In chronic pain management , there is increasing consensus regarding the importance of a behavioural medicine approach to symptoms and disability . Cognitive behaviour therapy has proven to be beneficial in the treatment of chronic pain . An approach that promotes acceptance of , or willingness to experience , pain and other associated negative private events ( e.g. fear , anxiety , and fatigue ) instead of reducing or controlling symptoms has received increasing attention . Although the empirical support for treatments emphasizing exposure and acceptance ( such as acceptance and commitment therapy ) is growing , there is clearly a need for more outcome studies , especially r and omized controlled trials . In this study , participants ( N = 21 ) with chronic pain and whiplash‐associated disorders were recruited from a patient organization and r and omized to either a treatment or a wait‐list control condition . Both groups continued to receive treatment as usual . In the experimental condition , a learning theory framework was applied to the analysis and treatment . The intervention consisted of a 10‐session protocol emphasizing values‐based exposure and acceptance strategies to improve functioning and life satisfaction by increasing the participants ' abilities to behave in accordance with values in the presence of interfering pain and distress ( psychological flexibility ) . After treatment , significant differences in favor of the treatment group were seen in pain disability , life satisfaction , fear of movements , depression , and psychological inflexibility . No change for any of the groups was seen in pain intensity . Improvements in the treatment group were maintained at 7‐month follow‐up . The authors discuss implication s of these findings and offer suggestions for further research in this area PURPOSE To evaluate whether psychological factors and personality traits influence recovery in terms of quality of life in patients with subacute whiplash associated disorders ( WAD ) . METHOD The data was obtained from a r and omized controlled trial ( RCT ) on 47 patients . The patients completed measures of pain intensity , affective dimension of pain , pain location , psychological stress , heightened somatic awareness , depression , catastrophizing , self-efficacy , fear of movement (re)injury , and physical disability . After three months of physiotherapy interventions , the outcome of quality of life was measured with the Short Form Health survey ( SF-12 ) . All variables were entered in a multiple regression analysis , after controlling for age and sex . RESULTS Forty patients ( 85 % ) completed the trial . The self-efficacy scale ( SES ) was the only variable in the model that significantly explained the fraction of the SF12-score . The correlation between the SES and SF-12 was B = 0.64 ( p < 0.01 ) , and the adjusted R(2 ) was 0.40 ( p < 0.05 ) , which means that 40 % of the variation in the SF12 outcomes was explained by the SES . CONCLUSION In order to improve health-related quality of life in patients with WAD , the present study stresses the importance of targeting self-efficacy . A special effort should be made to enhance these beliefs in the rehabilitation process 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 ) . Material s and Methods : A total of 216 volunteers with chronic whiplash-associated disorders participated in this r and omized , 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 result ed 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 Background The management of Whiplash Associated Disorders is one of the most complicated challenges with high expenses for the health care system and society . There are still no general guidelines or scientific documentation to unequivocally support any single treatment for acute care following whiplash injury . The main purpose of this study is to try a new behavioural medicine intervention strategy at acute phase aim ed to reduce the number of patients who have persistent problems after the whiplash injury . The goal is also to identify which of three different interventions that is most cost-effective for patients with Whiplash Associated Disorders . In this study we are controlling for two factors . First , the effect of behavioural medicine approach is compared with st and ard care . Second , the manner in which the behavioural medicine treatment is administered , Internet or face-to-face , is evaluated in it 's effectiveness and cost-effectiveness . Methods / Design The study is a r and omized , prospect i ve , experimental three-group study with analyses of cost-effectiveness up to two-years follow-up . Internet – based programme and face-to-face group treatment programme are compared to st and ard-treatment only . Patient follow-ups take place three , six , twelve and 24 months , that is , short-term as well as long-term effects are evaluated . Patients will be enrolled via the emergency ward during the first week after the accident . Discussion This new self-help management will concentrate to those psychosocial factors that are shown to be predictive in long-term problems in Whiplash Associated Disorders , i.e. the importance of self-efficacy , fear of movement , and the significance of catastrophizing as a coping strategy for restoring and sustaining activities of daily life . Within the framework of this project , we will develop , broaden and evaluate current physical therapy treatment methods for acute Whiplash Associated Disorders . The project will contribute to the creation of a cost-effective  behavioural medicine approach to management of acute Whiplash Associated Disorders . The results of this study will answer an important question ; on what extent and how should these patients be treated at acute stage and how much does the best management cost . Trial registration numberCurrent Controlled Trials IS RCT OBJECTIVE To assess the sensitivity to change of three algofunctional scales for neck pain . METHODS Observational , prospect i ve study . Patients with neck disorders were included .  Pain and patients ' perceived h and icap assessed on visual analogue scales ( VAS Pain , VAS H and icap ) , and functional disability measures ( Neck Disability Index , Neck Pain and Disability Scale , Northwick Park Neck Pain Question naire  )  were recorded twice , at baseline and at an 11-month follow-up assessment . Sensitivity to change was assessed using the effect size ( ES ) and the st and ardised response mean ( SRM ) , and the non-parametric Spearman 's rank correlation coefficient ( r ) was used to assess the correlation between quantitative variable changes and patients ' overall opinion . Analysis of variance ( ANOVA ) followed by a Tukey-test was performed to determine if the scales distinguished improved , stable , and deteriorated patients . RESULTS Seventy-one patients ( 43 women , mean age 49 years ) were included and evaluated twice at an interval of 11 + /- 2 months . The three scales showed good sensitivity to change . The ANOVA showed a group effect , and individual changes in the scales scores were statistically different in two-by-two comparisons ( improved , stable or deteriorated patients ) . Changes in NPDS scores had the highest correlation with patient 's overall assessment ( r = 0.592 ) . CONCLUSION The three scales can detect changes in patients with neck disorders . Changes in NPDS score had the best correlation with patients ' overall opinion concerning their neck disorder and this question naire should be given preference in clinical trials AIM To investigate the effect of combining pain education , specific exercises and grade d physical activity training ( exercise ) compared with pain education alone ( control ) on physical health-related quality of life ( HR-QoL ) in chronic neck pain patients . METHODS A multicentre r and omised controlled trial of 200 neck pain patients receiving pain education .  The exercise group received additional exercises for neck/shoulder , balance and oculomotor function , plus grade d physical activity training .  Patient-reported outcome measures ( Short Form-36 Physical and Mental component summary scores , EuroQol-5D , Beck Depression Inventory-II , Neck Disability Index , Pain Bothersomeness , Patient-Specific Functioning Scale , Tampa Scale of Kinesiophobia , Global Perceived Effect ) and clinical tests ( Aastr and Physical Fitness , cervical Range of Motion , Pressure Pain Threshold at infraspinatus , tibialis anterior and cervical spine , Cranio-cervical Flexion , Cervical Extension muscle function , and oculomotion ) were recorded at baseline and after 4 months . RESULTS The exercise group showed statistically significant improvement in physical HR-QoL , mental HR-QoL , depression , cervical pressure pain threshold , cervical extension movement , muscle function , and oculomotion . Per protocol analyses confirmed these results with additional significant improvements in the exercise group compared with controls . CONCLUSIONS This multimodal intervention may be an effective intervention for chronic neck pain patients . TRIAL REGISTRATION The trial was registered on www . Clinical Trials.govNCT01431261 and at the Regional Scientific Ethics Committee of Southern Denmark S-20100069
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 .
Results suggest that structured patient education alone can not 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
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 up date 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 ) .
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 .