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Liew, B. X. W., Scutari, M., Peolsson, A., Peterson, G., Ludvigsson, M. L. & Falla, D. (2019). Investigating the Causal Mechanisms of Symptom Recovery in Chronic Whiplash-associated Disorders Using Bayesian Networks. The Clinical Journal of Pain, 35(8), 647-655
Open this publication in new window or tab >>Investigating the Causal Mechanisms of Symptom Recovery in Chronic Whiplash-associated Disorders Using Bayesian Networks
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2019 (English)In: The Clinical Journal of Pain, ISSN 0749-8047, E-ISSN 1536-5409, Vol. 35, no 8, p. 647-655Article in journal (Refereed) Published
Abstract [en]

Objectives: The present study's objective was to understand the causal mechanisms underpinning the recovery of individuals with whiplash-associated disorders (WAD). We applied Bayesian Networks (BN) to answer 2 study aims: (1) to identify the causal mechanism(s) of recovery underpinning neck-specific exercise (NSE), and (2) quantify if the cyclical pathway of the fear-avoidance model (FAM) is supported by the present data.

Materials and Methods: We analyzed a prospective cohort data set of 216 individuals with chronic WAD. Fifteen variables were used to build a BN model: treatment group (NSE with or without a behavioral approach, or general physical activity), muscle endurance, range of motion, hand strength, neck proprioception, pain catastrophizing, fear, anxiety, depression, self-efficacy, perceived work ability, disability, pain intensity, sex, and follow-up time.

Results: The BN model showed that neck pain reduction rate was greater after NSE compared with physical activity prescription (beta=0.59 points per month [P<0.001]) only in the presence of 2 mediators: global neck muscle endurance and perceived work ability. We also found the following pathway of variables that constituted the FAM: anxiety, followed by depressive symptoms, fear, catastrophizing, self-efficacy, and consequently pain.

Conclusions: We uncovered 2 mediators that explained the mechanisms of effect behind NSE, and proposed an alternative FAM pathway. The present study is the first to apply BN modelling to understand the causal mechanisms of recovery in WAD. In doing so, it is anticipated that such analytical methods could increase the precision of treatment of individuals with chronic WAD.

Place, publisher, year, edition, pages
LIPPINCOTT WILLIAMS & WILKINS, 2019
Keywords
whiplash, pain, mediation analysis, Bayesian Networks, fear avoidance model
National Category
Physiotherapy
Identifiers
urn:nbn:se:uu:diva-390387 (URN)10.1097/AJP.0000000000000728 (DOI)000475938200001 ()31169550 (PubMedID)
Funder
Swedish Research CouncilMedical Research Council of Southeast Sweden (FORSS)
Available from: 2019-08-09 Created: 2019-08-09 Last updated: 2019-08-09Bibliographically approved
Peolsson, A., Karlsson, A., Ghafouri, B., Ebbers, T., Engstrom, M., Jonsson, M., . . . Peterson, G. (2019). Pathophysiology behind prolonged whiplash associated disorders: study protocol for an experimental study. BMC Musculoskeletal Disorders, 20, Article ID 51.
Open this publication in new window or tab >>Pathophysiology behind prolonged whiplash associated disorders: study protocol for an experimental study
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2019 (English)In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 20, article id 51Article in journal (Refereed) Published
Abstract [en]

BackgroundThere is insufficient knowledge of pathophysiological parameters to understand the mechanism behind prolonged whiplash associated disorders (WAD), and it is not known whether or not changes can be restored by rehabilitation. The aims of the projects are to investigate imaging and molecular biomarkers, cervical kinaesthesia, postural sway and the association with pain, disability and other outcomes in individuals with longstanding WAD, before and after a neck-specific exercise intervention. Another aim is to compare individuals with WAD with healthy controls.MethodsParticipants are a sub-group (n=30) of individuals recruited from an ongoing randomized controlled study (RCT). Measurements in this experimental prospective study will be carried out at baseline (before intervention) and at a three month follow-up (end of physiotherapy intervention), and will include muscle structure and inflammation using magnetic resonance imaging (MRI), brain structure and function related to pain using functional MRI (fMRI), muscle function using ultrasonography, biomarkers using samples of blood and saliva, cervical kinaesthesia using the butterfly test and static balance test using an iPhone app. Association with other measures (self-reported and clinical measures) obtained in the RCT (e.g. background data, pain, disability, satisfaction with care, work ability, quality of life) may be investigated. Healthy volunteers matched for age and gender will be recruited as controls (n=30).DiscussionThe study results may contribute to the development of improved diagnostics and improved rehabilitation methods for WAD.Trial registrationClinicaltrial.gov Protocol ID: NCT03664934, initial release 09/11/2018.

Place, publisher, year, edition, pages
BMC, 2019
Keywords
Whiplash injury, Neck, Spine, Chronic, Physiotherapy, Rehabilitation, Exercise therapy, Randomized, Follow-up study, Outcome, Physiopathology, Diagnostic imaging, MRI, Scan, Ultrasonography, Biomarkers
National Category
Physiotherapy
Identifiers
urn:nbn:se:uu:diva-377208 (URN)10.1186/s12891-019-2433-3 (DOI)000457465500001 ()30711003 (PubMedID)
Funder
Swedish Research Council
Available from: 2019-02-25 Created: 2019-02-25 Last updated: 2019-02-25Bibliographically approved
Peolsson, A., Peterson, G., Hermansen, A., Ludvigsson, M. L., Dedering, Å. & Löfgren, H. (2019). Physiotherapy after anterior cervical spine surgery for cervical disc disease: study protocol of a prospective randomised study to compare internet-based neck-specific exercise with prescribed physical activity. BMJ Open, 9(2), Article ID e027387.
Open this publication in new window or tab >>Physiotherapy after anterior cervical spine surgery for cervical disc disease: study protocol of a prospective randomised study to compare internet-based neck-specific exercise with prescribed physical activity
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2019 (English)In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, no 2, article id e027387Article in journal (Refereed) Published
Abstract [en]

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

Place, publisher, year, edition, pages
BMJ Publishing Group Ltd, 2019
National Category
Physiotherapy
Identifiers
urn:nbn:se:uu:diva-390591 (URN)10.1136/bmjopen-2018-027387 (DOI)000471124600275 ()30782952 (PubMedID)
Funder
Östergötland County Council
Available from: 2019-08-13 Created: 2019-08-13 Last updated: 2019-08-13Bibliographically approved
Landén Ludvigsson, M., Peterson, G. & Peolsson, A. (2019). The effect of three exercise approaches on health-related quality of life, and factors associated with its improvement in chronic whiplash-associated disorders: analysis of a randomized controlled trial.. Quality of Life Research, 28(2), 357-368
Open this publication in new window or tab >>The effect of three exercise approaches on health-related quality of life, and factors associated with its improvement in chronic whiplash-associated disorders: analysis of a randomized controlled trial.
2019 (English)In: Quality of Life Research, ISSN 0962-9343, E-ISSN 1573-2649, Vol. 28, no 2, p. 357-368Article in journal (Refereed) Published
Abstract [en]

PURPOSE: The aim was to evaluate whether neck-specific exercise, with (NSEB) or without (NSE) a behavioural approach, improves health-related quality of life (HRQoL) compared to physical activity prescription (PPA) in chronic whiplash-associated disorders (WAD) grades 2 and 3. A secondary aim was to identify factors associated with HRQoL and HRQoL improvement following exercise interventions.

METHODS: This is a secondary analysis of a multicentre randomized clinical trial. Participants (n = 216) with chronic WAD grades 2 and 3 were randomized to 12 weeks of PPA or physiotherapist-led NSE or NSEB. The EQ-5D 3L/EQ-VAS and SF-36v2 physical (PCS) and mental (MCS) component summaries were collected together with several neck-related and psychosocial outcomes at baseline, after 3, 6 and 12 months, and were analysed with linear mixed models (all time points) and multivariate linear regressions (baseline, 6 months).

RESULTS: NSE/NSEB resulted in better outcomes than PPA (EQ-VAS and SF-36 PCS, both groups, p < 0.01) but not in a higher EQ-5D score. Improvement over time was seen in EQ-5D/EQ-VAS for the NSEB group (p < 0.01), and for NSE/NSEB as measured with the PCS (p < 0.01). Factors associated with baseline HRQoL and change to 6 months in HRQoL (R2 = 0.38-0.59) were both neck-related and psychosocial (e.g. depression, work ability).

CONCLUSION: Neck-specific exercise, particularly with a behavioural approach, may have a more positive impact on HRQoL than physical activity prescription in chronic WAD grades 2 and 3. HRQoL is however complex, and other factors also need to be considered. Factors associated with HRQL and improvements in HRQoL following exercise are multidimensional.

TRIAL REGISTRATION NUMBER: ClinicalTrials.gov, No. NCT01528579.

Keywords
Chronic, Exercise, Physiotherapy, Quality of life, Spine, Whiplash
National Category
Physiotherapy
Identifiers
urn:nbn:se:uu:diva-374022 (URN)10.1007/s11136-018-2004-3 (DOI)000457880300006 ()30225786 (PubMedID)
Funder
Swedish Research Council, 521-2014-2982
Available from: 2019-01-17 Created: 2019-01-17 Last updated: 2019-03-05Bibliographically approved
Peterson, G., O'Leary, S., Nilsson, D., Moodie, K., Tucker, K., Trygg, J. & Peolsson, A. (2019). Ultrasound imaging of dorsal neck muscles with speckle tracking analyses - the relationship between muscle deformation and force. Scientific Reports, 9, Article ID 13688.
Open this publication in new window or tab >>Ultrasound imaging of dorsal neck muscles with speckle tracking analyses - the relationship between muscle deformation and force
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2019 (English)In: Scientific Reports, ISSN 2045-2322, E-ISSN 2045-2322, Vol. 9, article id 13688Article in journal (Refereed) Published
Abstract [en]

The development of methods of non-invasive measurement of neck muscle function remains a priority in the clinical sciences. In this study, dorsal neck muscle deformation vs time curves (deformation area) were evaluated against incremental force, recorded from non-invasive real-time ultrasound measurement. The results revealed subject-specific moderate to strong linear or non-linear relationships between deformation and force. Test-retest variability showed strong reliability for all five neck muscles summed together and fair to good reliability for the five muscles evaluated separately. Multivariate statistics were used to analyse the interactions between the dorsal neck muscles during different percentages of maximal voluntary contraction (MVC). Low force (10-20% MVC) was related to muscle shortening; higher force (40-80% MVC) showed combination of shortening and elongation deformation in the muscle interactions. The muscle interactions during isometric MVC test were subject-specific, with different combinations and deformations of the five neck muscles. Force >= 40% MVC were associated with a forward movement of the cervical spine that affected the ultrasound measurement of the dorsal neck muscles. Ultrasound with speckle-tracking analyses may be best used to detect low levels (<40% MVC) of neck muscle activity.

National Category
Physiotherapy
Identifiers
urn:nbn:se:uu:diva-395799 (URN)10.1038/s41598-019-49916-1 (DOI)000487216300008 ()31548564 (PubMedID)
Funder
Swedish Research CouncilSwedish Society of Medicine
Available from: 2019-10-25 Created: 2019-10-25 Last updated: 2019-10-25Bibliographically approved
Enthoven, P., Peolsson, A., Landen Ludvigsson, M., Wibault, J., Peterson, G. & Oberg, B. (2019). Validity, internal consistency and self-rated change of the patient enablement instrument in patients with chronic musculoskeletal pain. Journal of Rehabilitation Medicine, 51(8), 587-597
Open this publication in new window or tab >>Validity, internal consistency and self-rated change of the patient enablement instrument in patients with chronic musculoskeletal pain
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2019 (English)In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 51, no 8, p. 587-597Article in journal (Refereed) Published
Abstract [en]

Objective: Patient enablement reflects patient's understanding of and coping with illness. The aim of this study was to investigate the content validity, construct validity, internal consistency and selfrated change (SRC) of the Patient Enablement Instrument (PEI) in patients with whiplash-associated disorders, cervical radiculopathy and mixed chronic pain treated in different settings.

Design: Psychometric analyses. Participants: Patients with disabling non-malignant chronic musculoskeletal pain.

Methods: Participants answered questionnaires on disability (Neck Disability Index (NDI) or Functional Rating Index (FRI)), anxiety/depression (Hospital Anxiety and Depression Scale; HADS) and general health (EuroQol; EQ-5D). Content validity, construct validity (confirmatory factor analysis), internal consistency and cut-off for SRC were investigated for the PEI after treatment. The SRC value was the receiver operating characteristic (ROC) curve optimal cut-off point.

Results: After treatment all items were completed by 516 patients (mean standard deviation (SD) age 45.1 years (SD 10.1), women 75% (n=385)). The 1-factor PEI model had approximate fit to the data. The internal consistency Cronbach's alpha was between 0.878 and 0.929 for the 3 groups. Correlations between the PEI and the NDI/FRI, HADS and EQ-5D were fair to good. The SRCROC for whiplash-associated disorders, cervical radiculopathy and mixed chronic pain groups was 5, 6 and 4 points in the PEI, respectively.

Conclusion: The PEI showed fair content validity, construct validity and internal consistency. However, the scale needs further development to improve measurement of change.

Keywords
validity, reliability, primary care, whiplash injury, neck pain, chronic pain, outcome assessment
National Category
Other Medical Sciences not elsewhere specified Physiotherapy
Identifiers
urn:nbn:se:uu:diva-394252 (URN)10.2340/16501977-2573 (DOI)000483931500006 ()31198975 (PubMedID)
Funder
Swedish Research Council
Available from: 2019-10-08 Created: 2019-10-08 Last updated: 2019-10-08Bibliographically approved
Rahnama, L., Peterson, G., Kazemnejad, A., Trygg, J. & Peolsson, A. (2018). Alterations in the Mechanical Response of Deep Dorsal Neck Muscles in Individuals Experiencing Whiplash-Associated Disorders Compared to Healthy Controls: An Ultrasound Study. American Journal of Physical Medicine & Rehabilitation, 97(2), 75-82
Open this publication in new window or tab >>Alterations in the Mechanical Response of Deep Dorsal Neck Muscles in Individuals Experiencing Whiplash-Associated Disorders Compared to Healthy Controls: An Ultrasound Study
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2018 (English)In: American Journal of Physical Medicine & Rehabilitation, ISSN 0894-9115, E-ISSN 1537-7385, Vol. 97, no 2, p. 75-82Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: The aim of this study was to investigate and compare the mechanical responses of dorsal neck muscles in individuals with whiplash-associated disorders (WAD) versus healthy individuals.

DESIGN: This study included 36 individuals with WAD (26 women and 10 men) and 36 healthy controls (26 women and 10 men). Ultrasound imaging with speckle tracking was used to measure deformation and deformation rate in five dorsal neck muscles during a neck extension task.

RESULTS: Compared with controls, individuals with WAD showed higher deformations of the semispinalis cervicis (P = 0.02) and multifidus (P = 0.002) muscles and higher deformation rates (P = 0.03 and 0.0001, respectively). Among individuals with WAD, multifidus deformation and deformation rate were significantly associated with pain, disability, and fatigue (r = 0.31-0.46, P = 0.0001-0.01).

CONCLUSIONS: These findings indicate that the mechanical responses of the deep dorsal neck muscles differ between individuals with WAD and healthy controls, possibly reflecting that these muscles use altered strategies while performing a neck extension task. This finding provides new insight into neck muscles pathology in patients with chronic WAD and may help improve rehabilitation programs.

National Category
Physiotherapy Physiology
Identifiers
urn:nbn:se:uu:diva-342507 (URN)10.1097/PHM.0000000000000845 (DOI)000423729500004 ()29016400 (PubMedID)
Funder
Swedish Research CouncilSwedish Social Insurance Agency, RS2010/009
Available from: 2018-02-21 Created: 2018-02-21 Last updated: 2018-03-19Bibliographically approved
Lo, H. K., Johnston, V., Landén Ludvigsson, M., Peterson, G., Overmeer, T., David, M. & Peolsson, A. (2018). Factors associated with work ability following exercise interventions for people with chronic whiplash-associated disorders: Secondary analysis of a randomized controlled trial. Journal of Rehabilitation Medicine, 50(9), 828-836
Open this publication in new window or tab >>Factors associated with work ability following exercise interventions for people with chronic whiplash-associated disorders: Secondary analysis of a randomized controlled trial
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2018 (English)In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 50, no 9, p. 828-836Article in journal (Refereed) Published
Abstract [en]

Objective: To investigate the efficacy of exercise interventions and factors associated with changes in work ability for people with chronic whiplash-associated disorders.

Design: Secondary analysis of a single-blind, randomized multi-centre controlled trial.

Setting: Interventions were conducted in Swedish primary care settings.

Patients: A total of 165 individuals with chronic whiplash-associated disorders grade II–III.

Methods: Participants were randomly allocated to neck-specific exercise, neck-specific exercise with a behavioural approach, or prescribed physical activity interventions. Work ability was evaluated with the Work Ability Index at baseline, 3, 6 and 12 months.

Results: The neck-specific exercise with a behavioural approach intervention significantly improved work ability compared with the prescribed physical activity intervention (3 months, p = 0.03; 6 months, p = 0.01; 12 months, p = 0.01), and neck-specific exercise at 12 months (p = 0.01). Neck-specific exercise was better than the prescribed physical activity intervention at 6 months (p = 0.05). An increase in work ability from baseline to one year for the neck-specific exercise with a behavioural approach group (p < 0.01) was the only significant within-group difference. Higher self-rated physical demands at work, greater disability, greater depression and poorer financial situation were associated with poorer work ability (p < 0.01).

Conclusion: This study found that neck-specific exercise with a behavioural approach intervention was better at improving self-reported work ability than neck-specific exercise or prescribed physical activity. Improvement in work ability is associated with a variety of factors.

Keywords
employment, whiplash injuries, exercise, persistent neck pain
National Category
Physiotherapy
Identifiers
urn:nbn:se:uu:diva-375820 (URN)10.2340/16501977-2374 (DOI)000447771700008 ()30132011 (PubMedID)
Funder
Swedish Research CouncilSwedish Social Insurance Agency
Available from: 2019-02-01 Created: 2019-02-01 Last updated: 2019-05-27Bibliographically approved
Peterson, G., Nilsson, D., Trygg, J. & Peolsson, A. (2018). Neck-specific exercise improves impaired interactions between ventral neck muscles in chronic whiplash: A randomized controlled ultrasound study. Scientific Reports, 8, Article ID 9649.
Open this publication in new window or tab >>Neck-specific exercise improves impaired interactions between ventral neck muscles in chronic whiplash: A randomized controlled ultrasound study
2018 (English)In: Scientific Reports, ISSN 2045-2322, E-ISSN 2045-2322, Vol. 8, article id 9649Article in journal (Refereed) Published
Abstract [en]

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.

Place, publisher, year, edition, pages
NATURE PUBLISHING GROUP, 2018
National Category
Physiotherapy
Identifiers
urn:nbn:se:uu:diva-360009 (URN)10.1038/s41598-018-27685-7 (DOI)000436078500012 ()29941911 (PubMedID)
Funder
Swedish Research Council
Available from: 2018-09-13 Created: 2018-09-13 Last updated: 2018-09-13Bibliographically approved
Ludvigsson, M. L., Peterson, G. & Peolsson, A. (2018). Neck-specific exercise may reduce radiating pain and signs of neurological deficits in chronic whiplash: Analyses of a randomized clinical trial. Scientific Reports, 8, Article ID 12409.
Open this publication in new window or tab >>Neck-specific exercise may reduce radiating pain and signs of neurological deficits in chronic whiplash: Analyses of a randomized clinical trial
2018 (English)In: Scientific Reports, ISSN 2045-2322, E-ISSN 2045-2322, Vol. 8, article id 12409Article in journal (Refereed) Published
Abstract [en]

Up to 90% of people with neurological deficits following a whiplash injury do not recover and cervical muscle dysfunction is common. The aim of this multicentre, randomized controlled trial was to examine whether two versions of neck-specific exercise or prescription of physical activity (PPA) can improve radiating arm pain and clinical signs that can be associated with neurological deficits in people with chronic whiplash associated disorders (WAD). Participants with chronic WAD, arm symptoms and signs associated with neurological deficits (n = 171) were randomized to: 12 weeks of neck-specific exercise without (NSE) or with a behavioural approach (NSEB), or PPA. Pain/bothersomeness frequency, six measures of arm pain/paraesthesia (VAS scales), and four clinical neurological tests were evaluated after 3 months. The NSE group reported the lowest frequency and lowest levels of arm pain, the highest proportion of participants with at least 50% pain reduction and the highest proportion of normal arm muscle force. The NSEB group reported increased normal tendon reflexes. No improvements were recorded for the PPA group. Neck-specific exercise may improve arm pain and decrease signs of neurological deficits, but the addition of a behavioural approach does not seem to be of additional benefit.

Place, publisher, year, edition, pages
NATURE PUBLISHING GROUP, 2018
National Category
Physiotherapy
Identifiers
urn:nbn:se:uu:diva-364393 (URN)10.1038/s41598-018-30556-w (DOI)000441876700112 ()30120313 (PubMedID)
Funder
Swedish Research CouncilRegion Östergötland, LIO-533041Region Östergötland, LIO-439541Region Östergötland, LIO-197631Region Östergötland, LIO-276151Region Östergötland, LIO-354241
Available from: 2018-11-01 Created: 2018-11-01 Last updated: 2018-11-01Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0003-2492-0306

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