A randomised clinical trial of a comprehensive exercise program for chronic whiplash: trial protocol
From: BMC Musculoskelet Disord. 2009 Dec 2;10(1):149.
The most common injury following a motor vehicle accident is a whiplash injury to the neck. This injury is of particular concern as approximately 60% of people experience persistent pain and disability 6 months after the original accident. This group of people with chronic symptoms account for a disproportionately large percentage of the economic burden associated with whiplash injury. In the United States the costs associated with whiplash are estimated to be of the order of $29 billion US dollars per annum.
Currently, there is a large number of treatments available to people suffering from whiplash symptoms including acupuncture, cervical collars, traction, exercise, massage, mobilisation techniques, electro-physical agents and the local application of heat or ice.
There is growing evidence to support multimodal treatment strategies which combine exercise, manual therapy and psychological approaches. It has been shown that this type of treatment results in larger reductions in pain, greater patient satisfaction and a quicker return to work compared with conservative electro-physical treatments in individuals with acute whiplash. In addition, the likelihood of recovery is increased when treatments are individually-tailored to specifically target individual deficits and involve active rather than passive intervention strategies.
Over the last five years the chief investigators have been working to develop an effective treatment for chronic whiplash. The first developments were two exercise programs: graded activity and specific exercise. The programs were evaluated in separate randomised controlled trials with each trial demonstrating modest effects, with 10-20% of patients having a successful outcome, defined as the achievement of minimal or no pain and disability. In the investigators’ opinion this success rate was too low to represent a solution to the problem of chronic whiplash and hence development of a more effective intervention was necessary.
Subsequently, a comprehensive exercise program was proposed which combined the two previously evaluated exercise programs. It was reasoned that rather than varying the training parameters of exercise intensity or duration (which may exacerbate people’s whiplash symptoms), combining these two programs sequentially may result in greater improvements in pain and functional capacity.
The specific motor relearning component is designed to improve cervical and scapular muscle control, strength and endurance, coordination, kinaesthesia and balance. Once any impairments in muscle control and co-ordination have been addressed, the strengthening and graded whole body exercise component is progressively introduced in order to improve participant’s functional capabilities. The proof of concept for the comprehensive exercise program was provided by a small unpublished pilot study which found that 56% of subjects reported minimal or no disability following this approach; which is a much higher success rate than the 10-20% success rate observed in the two earlier trials. However, robust evidence for the effectiveness of the new approach can only be provided by a larger controlled trial.
Therefore the aims of this study are to:
1) Establish the effectiveness of a comprehensive exercise program for chronic whiplash (defined as whiplash symptoms for greater than 3 months duration and less than 12 months duration) as measured by reductions in pain and disability, and improvements in participants’ impressions of overall recovery and quality of life.
2) Conduct an economic evaluation of the exercise program.
3) Investigate whether or not sensory hypersensitivity and symptoms of posttraumatic stress modify the effectiveness of the program.
All participants will be provided with the patient education Whiplash Injury Recovery Book: a self management guide. The book provides information about whiplash, advice on how to manage the symptoms of whiplash and outlines an exercise program to assist in reducing whiplash associated neck pain.
