TABLE 3.

Summary of studies evaluating exercise programs for acute whiplash-associated disorder (WAD)

Reference, year, country, score	Population and methods	Outcome measures	Results
Vassiliou et al (15), 2006, Germany, PEDro score = 7	Randomized controlled trial. 200 patients with WAD for less than 48 h were prescribed an NSAID and an antihistamine. Immobilization group patients wore a soft collar continuously for the first 7 days postinjury, after which they could seek treatment at their discretion. Physiotherapy group patients had 10 sessions during the first 2 weeks postinjury, which included heat application, lymphatic drainage and massage; active resistance exercises were performed daily at home. Collar use was permitted for the first 2 days	Primary outcomes were pain intensity and disability (on a scale from 0 to 10). The secondary outcome was the proportion of patients with residual pain (defined as pain severity of less than 1 of 10). Assessment was conducted during the first treatment week, and at 6 weeks and 6 months postinjury	Although between-group differences were not significant during the first week, patients in the physiotherapy group reported significantly less pain (1.5±2.3 versus 2.7±2.8, P<0.01) and disability (1.3±2.2 versus 2.5±2.7, P<0.01) at 6 months. These differences were maintained at 6 months in terms of both pain (1.2±2.1 versus 2.3±2.6, P<0.001) and disability (1.1±1.2 versus 2.0±2.4, P<0.001). Furthermore, more physiotherapy patients (81.9%) than immobilization patients (62.7%) reported no pain at 6 months (P<0.01), but not at 6 weeks
Soderlund (17), 2000, Sweden, PEDro score = 4	Randomized controlled trial. 59 patients with acute WAD were included. Control group patients were instructed to complete arm, neck and breathing exercises at least 3 times daily; alternate rest with activity; protect their neck from cold; walk daily; maintain good posture; avoid lifting; and refrain from collar use. Patients in the experimental group completed the same exercise program, complemented by the addition of exercises to improve kinesthetic sensibility and neck muscle coordination	The Pain Disability Index, Self-Efficacy Scale, CSQ, cervical ROM, cervicothoracic posture and kinesthetic sensibility were assessed at baseline, and at 3 months and 6 months follow-up	Although both groups showed improvement over time, the two groups did not differ significantly in terms of any of the outcome measures. However, patients in the experimental group reported a greater increase in perceived ability to decrease pain (P<0.01), although this result is based on a single item on the CSQ
McKinney et al (14), 1989, Northern Ireland, PEDro score = 6	Randomized controlled trial. 247 patients with acute WAD received mobilization advice (n=66), physiotherapy (n=71) or rest (n=33). Those in the rest group were given general advice to mobilize after 10 to 14 days of rest. Physiotherapy included multimodal therapy and active and passive repetitive movements (10 h over 6 weeks). Mobilization advice (one 30 min session) included a demonstration of neck exercises	Neck pain intensity (VAS) and cervical ROM (assessed with a goniometer) were assessed initially, and at 1- and 2-month review sessions. Lateral flexion was used as a proxy for full ROM	Although patients in the physiotherapy and advice groups did not differ with respect to pain intensity or cervical ROM at any time, both groups demonstrated greater improvement than those in the rest group in terms of mean ROM (64±12.9 and 64.1±12.7 versus 55.1±14.8, P<0.01) and median pain severity (1.9 and 1.8 versus 3.0, P<0.01) at the 2-month follow-up session
McKinney (16), 1989, Northern Ireland	Follow-up study. A 2-year follow-up to the McKinney et al (14) study	The presence of symptoms and time to recovery were recorded at 2 years postinjury via a mailed follow-up questionnaire	The proportion of patients without persistent symptoms did not differ significantly between the physiotherapy (56%) and rest (54%) groups; however, a significantly greater proportion of advice group patients (77%) were symptom free at 2 years (P<0.05) compared with those in the physiotherapy and rest groups
Baltaci et al (18), 2003, Turkey, no score	Case series. 45 patients with WAD of unspecified duration completed an individualized program (3 weeks, 3 day per week) of passive mobilization based on the Cyriax approach. Mobilization was complemented with a home exercise program consisting of arm and shoulder movements while holding a 0.5 kg weight	Pain intensity (VAS) was assessed before treatment, and at 3 weeks, 6 weeks and 12 weeks postinjury. Cervical ROM was assessed before and after treatment	Pain intensity was significantly reduced at both the 3-week (P<0.05) and 6-week (P<0.05) follow-ups. Cervical ROM increased 10° in flexion, 20° in extension, 15° in right lateral flexion, 10° in left lateral flexion, 15° in right rotation and 10° in left rotation from pre- to post-treatment; significance levels were not reported

CSQ Coping Strategies Questionnaire; NSAID Nonsteroidal anti-inflammatory drug; PEDro Physiotherapy Evidence Database; ROM Range of motion; VAS Visual analogue scale