Intense exercise treatment no better than simple advice and self-directed exercise at reducing pain from chronic whiplash

Main Points:

Results of a new trial of treatments for chronic whiplash pain, published in The Lancet, suggest that expensive, intense physiotherapy sessions do not show any additional benefit over a single physiotherapy session of education and advice with phone follow-up.

Published in:

The Lancet

Study Further:

The findings are in line with previous studies on the subject, which have reported minimal additional benefit of longer physiotherapy programmes over briefer physiotherapy programmes for acute whiplash-associated disorders. The current study supports those claims, finding that while intensive physiotherapy has remained the recommended intervention, a briefer programme encouraging self-management might be equally effective.*

Study participants were solicited in Sydney and Brisbane, Australia, through advertisements in local newspapers, radio, and online, and via referral from a statutory authority set up to monitor motor vehicle and personal injury insurance plans.

The study included participants who had suffered a motor vehicle accident resulting in chronic whiplash, recruiting patients whose accident occurred no sooner than three months prior to signing up to the study, and no later than five years after the accident. Patients were enrolled between September 2009 and February 2012.

A total of 172 people were enrolled into the study, with participants randomly divided into two groups. The advice group received a single half-hour consultation with a trained physiotherapist who went over a pamphlet that provided information on whiplash-related disorders, suggestions on how to self-manage pain, and a simple exercise routine.  Participants assigned to this group could have two additional phone consultations with the physiotherapists if desired.

Study participants included in the exercise group received a more complex treatment, including twenty individually tailored physiotherapy sessions lasting one hour each, over the course of twelve weeks. These sessions included a comprehensive exercise programme, posture re-education, stretching training and exercises, scapular training, aerobic exercise, and strength training.

The primary outcome of the study, in which the authors had expected to see a difference between groups of patients, was reduction in pain reported during the previous week, measured at 14 weeks, six months, and 12 months after the intervention. Secondary outcomes included pain during the previous twenty four hours, self-reported recovery, and an improvement in flexibility. However, no clinically meaningful differences were reported between groups for either primary or secondary outcomes during any of the reporting periods.

According to study author Dr Zoe Michaleff, of The University of Sydney, Australia, “Musculoskeletal disorders are one of the leading causes of disability and chronic pain globally. The need to identify effective and affordable strategies to prevent and treat musculoskeletal disorders should be an important health priority. This is especially true for those with chronic whiplash-associated disorders because most patients have tried and failed previous treatments, and their continuing symptoms mean they would be unlikely to pursue more of the same approaches. The need for an extended course of treatment for whiplash-associated disorders is being challenged, and our study provides further evidence that prolonged expensive clinical interventions for chronic whiplash injury are no more effective than briefer treatment programs that teach the patient how to self-manage their pain.”**

Writing in a linked Comment, Jo Nijs and Kelly Ickmans, of Vrije Universiteit Brussel, in Brussels, Belgium, said, “The study by Michaleff and colleagues advances our understanding of whiplash-associated disorders and provides physiotherapists with clear information about how to treat patients with chronic whiplash-associated disorders. These findings should not be interpreted as encouragement to abandon exercise therapy in these patients: the question is how and when to exercise people with chronic whiplash-associated disorders.”


Zoe A Michaleff, Chris G Maher, Chung-Wei Christine Lin, Trudy Rebbeck, Gwendolen Jull, Jane Latimer, Luke Connelly, Michele Sterling. Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomized controlled trial. The Lancet (2014).

Notes to Editors:

The study was funded by The National Health and Medical Research Council of Australia, Motor Accidents Authority of New South Wales, and Motor Accident Insurance Commission of Queensland.

*Exercise based interventions are recommended by leading whiplash guidelines worldwide. The UK NICE guidelines specifically cite physiotherapy as a possible treatment option and the Australian NHMRC/TracSA guidelines recommend treatments such as exercise for whiplash. Other professional guidelines, eg, physiotherapy and chiropractic guidelines of Canada and the USA, also recommend the use of exercise to treat whiplash associated disorders.

**Quote direct from author and cannot be found in text of Article.


Article: For Dr Zoe Michaleff, The George Institute for Global Health, The University of Sydney, Sydney, Australia, contact Ellie Martel, Media Advisor Australia, The George Institute for Global Health T) + 61 410 411 983 E)

Comment: Dr Jo Nijs, Pain in Motion research group, Vrije Universiteit Brussel, Brussels, Belgium.  T) + 32 496 462 572  E)

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