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

Gunnel Peterson, Anneli Peolsson, Gunnel Peterson, Anneli Peolsson

Abstract

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://ichgcp.net/clinical-trials-registry/NCT03022812.

Keywords: chronic pain; digital health; digital health intervention; exercise; internet-based; internet-based intervention; neck; neck pain; pain management; physical therapy; physiotherapist; physiotherapy; rehabilitation; telehealth; telemedicine; telerehabilitation; whiplash; whiplash associated disorders.

Conflict of interest statement

Conflicts of Interest: None declared.

©Gunnel Peterson, Anneli Peolsson. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 20.06.2023.

Figures

Figure 1
Figure 1
Flowchart of participants in the study. WAD: whiplash-associated disorder.
Figure 2
Figure 2
Proportion of responders to treatment at 3- and 15-month follow-up. Data labels above the bar show the absolute number and the total number of participants (absolute/total) for each measurement. The proportion of responders achieving a clinically important difference in the NDI (≥7%), Visual Analog Scale (≥50% neck pain reduction), and PSFS (≥2 points improvement in PSFS work, leisure time, and physical activity). NDI: Neck Disability Index; NSE: neck-specific exercise at a physiotherapy clinic; NSEIT: neck-specific exercise with internet support; PSFS: Patient Specific Functional Scale.

References

    1. Holm LW, Carroll LJ, Cassidy JD, Hogg-Johnson S, Côté P, Guzman J, Peloso P, Nordin M, Hurwitz E, van der Velde G, Carragee E, Haldeman S. The burden and determinants of neck pain in whiplash-associated disorders after traffic collisions: results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders. J Manipulative Physiol Ther. 2009 Feb;32(2 Suppl):S61–69. doi: 10.1016/j.jmpt.2008.11.011.S0161-4754(08)00338-2
    1. Gustafsson M, Stigson H, Krafft M, Kullgren A. Risk of permanent medical impairment (RPMI) in car crashes correlated to age and gender. Traffic Inj Prev. 2015;16(4):353–361. doi: 10.1080/15389588.2014.940459.
    1. Carroll LJ, Holm LW, Hogg-Johnson S, Côtè P, Cassidy JD, Haldeman S, Nordin M, Hurwitz EL, Carragee EJ, van der Velde G, Peloso PM, Guzman J. Course and prognostic factors for neck pain in whiplash-associated disorders (WAD): results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders. J Manipulative Physiol Ther. 2009 Feb;32(2 Suppl):S97–S107. doi: 10.1016/j.jmpt.2008.11.014.S0161-4754(08)00341-2
    1. Sterling M. Physiotherapy management of whiplash-associated disorders (WAD) J Physiother. 2014 Mar;60(1):5–12. doi: 10.1016/j.jphys.2013.12.004. S1836-9553(14)00005-8
    1. Carragee EJ, Hurwitz EL, Cheng I, Carroll LJ, Nordin M, Guzman J, Peloso P, Holm LW, Côté P, Hogg-Johnson S, van der Velde G, Cassidy JD, Haldeman S, Bone and Joint Decade 2000-2010 Task Force on Neck Pain Its Associated Disorders Treatment of neck pain: injections and surgical interventions: results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders. Spine (Phila Pa 1976) 2008;33(4 Suppl):S153–S169. doi: 10.1097/BRS.0b013e31816445ea. 00007632-200802151-00017
    1. Rebbeck T. The role of exercise and patient education in the noninvasive management of whiplash. J Orthop Sports Phys Ther. 2017;47(7):481–491. doi: 10.2519/jospt.2017.7138.
    1. Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, Zeiss E. Scientific monograph of the quebec task force on whiplash-associated disorders: redefining "whiplash" and its management. Spine (Phila Pa 1976) 1995;20(8 Suppl):1S–73S.
    1. Michaleff ZA, Maher CG, Lin CWC, Rebbeck T, Jull G, Latimer J, Connelly L, Sterling M. Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial. Lancet. 2014;384(9938):133–141. doi: 10.1016/S0140-6736(14)60457-8.S0140-6736(14)60457-8
    1. Stewart MJ, Maher CG, Refshauge KM, Herbert RD, Bogduk N, Nicholas M. Randomized controlled trial of exercise for chronic whiplash-associated disorders. Pain. 2007;128(1-2):59–68. doi: 10.1016/j.pain.2006.08.030.S0304-3959(06)00455-6
    1. Ludvigsson Ml, Peterson G, Dedering A, Peolsson A. One- and two-year follow-up of a randomized trial of neck-specific exercise with or without a behavioural approach compared with prescription of physical activity in chronic whiplash disorder. J Rehabil Med. 2016;48(1):56–64. doi: 10.2340/16501977-2041. doi: 10.2340/16501977-2041.
    1. Ludvigsson ML, Peterson G, Dedering A, Falla D, Peolsson A. Factors associated with pain and disability reduction following exercise interventions in chronic whiplash. Eur J Pain. 2016;20(2):307–315. doi: 10.1002/ejp.729.
    1. Jull G, Kristjansson E, Dall'Alba P. Impairment in the cervical flexors: a comparison of whiplash and insidious onset neck pain patients. Man Ther. 2004;9(2):89–94. doi: 10.1016/S1356-689X(03)00086-9. S1356689X03000869
    1. Schomacher J, Farina D, Lindstroem R, Falla D. Chronic trauma-induced neck pain impairs the neural control of the deep semispinalis cervicis muscle. Clin Neurophysiol. 2012;123(7):1403–1408. doi: 10.1016/j.clinph.2011.11.033. S1388-2457(11)00828-5
    1. Elliott JM, Courtney DM, Rademaker A, Pinto D, Sterling MM, Parrish TB. The rapid and progressive degeneration of the cervical multifidus in whiplash: an MRI study of fatty infiltration. Spine (Phila Pa 1976) 2015;40(12):E694–E700. doi: 10.1097/BRS.0000000000000891.
    1. Peterson G, Nilsson D, Trygg J, Peolsson A. Neck-specific exercise improves impaired interactions between ventral neck muscles in chronic whiplash: a randomized controlled ultrasound study. Sci Rep. 2018;8(1):9649. doi: 10.1038/s41598-018-27685-7. doi: 10.1038/s41598-018-27685-7.
    1. Peolsson A, Ludvigsson ML, Tigerfors AM, Peterson G. Effects of neck-specific exercises compared to waiting list for individuals with chronic whiplash-associated disorders: a prospective, randomized controlled study. Arch Phys Med Rehabil. 2016;97(2):189–195. doi: 10.1016/j.apmr.2015.10.087. S0003-9993(15)01344-1
    1. Schäfer AGM, Zalpour C, von Piekartz H, Hall TM, Paelke V. The efficacy of electronic health-supported home exercise interventions for patients with osteoarthritis of the knee: systematic review. J Med Internet Res. 2018;20(4):e152. doi: 10.2196/jmir.9465. v20i4e152
    1. Garg S, Garg D, Turin TC, Chowdhury MFU. Web-based interventions for chronic back pain: a systematic review. J Med Internet Res. 2016;18(7):e139. doi: 10.2196/jmir.4932. v18i7e139
    1. Jahangiry L, Farhangi MA, Shab-Bidar S, Rezaei F, Pashaei T. Web-based physical activity interventions: a systematic review and meta-analysis of randomized controlled trials. Public Health. 2017;152:36–46. doi: 10.1016/j.puhe.2017.06.005. S0033-3506(17)30208-1
    1. van Vugt VA, de Kruif AJ, van der Wouden JC, van der Horst HE, Maarsingh OR. Experiences of patients and physiotherapists with blended internet-based vestibular rehabilitation: a qualitative interview study. BJGP Open. 2020;4(5):bjgpopen20X101092. doi: 10.3399/bjgpopen20X101092. bjgpopen20X101092
    1. Peolsson A, Landén Ludvigsson M, Peterson G. 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. BMC Musculoskelet Disord. 2017;18(1):524. doi: 10.1186/s12891-017-1853-1. 10.1186/s12891-017-1853-1
    1. Global recommendations on physical activity for health. World Health Organization. 2010. [2021-08-29]. .
    1. Vernon H. The neck disability index: state-of-the-art, 1991-2008. J Manipulative Physiol Ther. 2008;31(7):491–502. doi: 10.1016/j.jmpt.2008.08.006.S0161-4754(08)00210-8
    1. Cleland JA, Fritz JM, Whitman JM, Palmer JA. The reliability and construct validity of the neck disability index and patient specific functional scale in patients with cervical radiculopathy. Spine (Phila Pa 1976) 2006;31(5):598–602. doi: 10.1097/01.brs.0000201241.90914.22. 00007632-200603010-00019
    1. Dworkin RH, Turk DC, McDermott MP, Peirce-Sandner S, Burke LB, Cowan P, Farrar JT, Hertz S, Raja SN, Rappaport BA, Rauschkolb C, Sampaio C. Interpreting the clinical importance of group differences in chronic pain clinical trials: IMMPACT recommendations. Pain. 2009;146(3):238–244. doi: 10.1016/j.pain.2009.08.019.00006396-200912050-00007
    1. Willis C, Niere KR, Hoving JL, Green S, O'Leary EF, Buchbinder R. Reproducibility and responsiveness of the whiplash disability questionnaire. Pain. 2004;110(3):681–688. doi: 10.1016/j.pain.2004.05.008.00006396-200408000-00022
    1. Stewart M, Maher CG, Refshauge KM, Bogduk N, Nicholas M. Responsiveness of pain and disability measures for chronic whiplash. Spine (Phila Pa 1976) 2007;32(5):580–585. doi: 10.1097/01.brs.0000256380.71056.6d.00007632-200703010-00014
    1. Soer R, Reneman MF, Speijer BLGN, Coppes MH, Vroomen PCAJ. Clinimetric properties of the EuroQol-5D in patients with chronic low back pain. Spine J. 2012;12(11):1035–1039. doi: 10.1016/j.spinee.2012.10.030. S1529-9430(12)01306-X
    1. Kamper SJ, Maher CG, Mackay G. Global rating of change scales: a review of strengths and weaknesses and considerations for design. J Man Manip Ther. 2009;17(3):163–170. doi: 10.1179/jmt.2009.17.3.163.
    1. Vernon H, Mior S. The neck disability index: a study of reliability and validity. J Manipulative Physiol Ther. 1991;14(7):409–415.
    1. Peolsson A, Hermansen A, Peterson G, Strid EN. Return to work a bumpy road: a qualitative study on experiences of work ability and work situation in individuals with chronic whiplash-associated disorders. BMC Public Health. 2021;21(1):785. doi: 10.1186/s12889-021-10821-w. 10.1186/s12889-021-10821-w
    1. Shukla H, Nair SR, Thakker D. Role of telerehabilitation in patients following total knee arthroplasty: evidence from a systematic literature review and meta-analysis. J Telemed Telecare. 2017;23(2):339–346. doi: 10.1177/1357633x16628996.
    1. Newby J, Robins L, Wilhelm K, Smith J, Fletcher T, Gillis I, Ma T, Finch A, Campbell L, Andrews G. Web-based cognitive behavior therapy for depression in people with diabetes mellitus: a randomized controlled trial. J Med Internet Res. 2017;19(5):e157. doi: 10.2196/jmir.7274. v19i5e157
    1. Steele L, Lade H, McKenzie S, Russell TG. Assessment and diagnosis of musculoskeletal shoulder disorders over the internet. Int J Telemed Appl. 2012;2012:945745. doi: 10.1155/2012/945745. doi: 10.1155/2012/945745.
    1. Russell T, Truter P, Blumke R, Richardson B. The diagnostic accuracy of telerehabilitation for nonarticular lower-limb musculoskeletal disorders. Telemed J E Health. 2010;16(5):585–594. doi: 10.1089/tmj.2009.0163.
    1. Griffin AR, Moloney N, Leaver A, Jagnoor J, Michaleff ZA, Lin CW, Trudy R. Defining recovery in chronic whiplash: a qualitative study. Clin J Pain. 2020;36(7):505–515. doi: 10.1097/AJP.0000000000000825. 00002508-202007000-00002
    1. Andersen TE, Ravn SL, Armfield N, Maujean A, Requena SS, Sterling M. Trauma-focused cognitive behavioural therapy and exercise for chronic whiplash with comorbid posttraumatic stress disorder: a randomised controlled trial. Pain. 2021;162(4):1221–1232. doi: 10.1097/j.pain.0000000000002117. 00006396-202104000-00023
    1. Panjabi MM. The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. J Spinal Disord. 1992;5(4):383–389. doi: 10.1097/00002517-199212000-00001. discussion 397.
    1. Peterson G, Nilsson D, Trygg J, Falla D, Dedering A, Wallman T, Peolsson A. Novel insights into the interplay between ventral neck muscles in individuals with whiplash-associated disorders. Sci Rep. 2015;5(1):15289. doi: 10.1038/srep15289. doi: 10.1038/srep15289.srep15289
    1. Woodhouse A, Vasseljen O. Altered motor control patterns in whiplash and chronic neck pain. BMC Musculoskelet Disord. 2008;9(1):90. doi: 10.1186/1471-2474-9-90. 1471-2474-9-90

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