Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE)

Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE)

Evidence indicates that brief physiotherapy programmes are as effective for acute whiplash-associated disorders as more comprehensive programmes; however, whether this also the case for chronic whiplash-associated disorders is unknown. The study sought to estimate the effectiveness of a comprehensive exercise programme delivered by physiotherapists compared with advice in people with a chronic whiplash-associated disorder. PROMISE is a two group, pragmatic randomised controlled trial in patients with chronic (>3 months and <5 years) grade 1 or 2 whiplash-associated disorder. Participants were randomly assigned by a computer-generated randomisation schedule to receive either the comprehensive exercise programme (20 sessions) or advice (one session and telephone support). Sealed opaque envelopes were used to conceal allocation. The primary outcome was pain intensity measured on a 0-10 scale. Outcomes were measured at baseline, 14 weeks, 6 months, and 12 months by a masked assessor. Analysis was by intention to treat, and treatment effects were calculated with linear mixed models. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12609000825257. 172 participants were placed in either the comprehensive exercise programme (n=86) or advice group (n=86); 157 (91%) were followed up at 14 weeks, 145 (84%) at 6 months, and 150 (87%) at 12 months. A comprehensive exercise programme wasn't more effective than advice alone for pain reduction in the participants. At 14 weeks the treatment effect on a 0-10 pain scale was 0·0 (95% CI -0·7 to 0·7), at 6 months 0·2 (-0·5 to 1·0), and at 12 months -0·1 (-0·8 to 0·6). CNS hyperexcitability and symptoms of post-traumatic stress did not alter the effect of treatment. No serious adverse events were recorded.

This study has shown that simple advice is equal in efficacy to a more intense and comprehensive physiotherapy exercise programme. The need to identify effective and affordable strategies to prevent and treat acute through to chronic whiplash associated disorders is a significant health priority. Future avenues of research could include improving understanding of the mechanisms responsible for persistent pain and disability, examining the effectiveness and timing of drugs, and study of content and delivery of education and advice.

Neck Pain

Out of all 291 conditions studied in the Global Burden of Disease 2010 Study, neck pain ranked 4th highest in terms of disability and 21st in terms of overall burden.

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