Clinical Characteristics and Patient-Reported Outcomes of Primary Care Physiotherapy in Patients with Whiplash-Associated Disorders: A Longitudinal Observational Study

Figures & data

Table 1 Phase- and Profile-Based Treatment Goals and Physiotherapy Treatment Modalities, Together with Outcomes for Management in Patients with Whiplash-Associated Disorders (WAD)

Phase After Whiplash-Related Injury^a, Combined with Prognostic Health Profile^b	Treatment Goals	Interventions^c	Outcomes
Phase 1 (<7 days) Profile A	Reducing pain Providing information Explaining consequences for functioning and underlying pain mechanisms	Education Coaching Active exercise therapy If indicated: cervical soft collar (<1 week)	Patient-reported outcomes. Pain intensity. Functioning/Activity limitations. Perceived recovery. Return to work participation Care-related outcomes. Subjective evaluation. Reason for discharge. Duration of treatment period. Number of treatment sessions
Phase 2 (1–3 weeks) Profile A	See Phase 1 + improving musculoskeletal function	See Phase 1 If indicated: massage therapy (<2 weeks) and manual therapy (mobilization)
Phase 3 (4–6 weeks) Profile A	See Phase 2 + increasing activities and participation	See Phase 1 Physical loading exercise therapy
Phase 3 (4–6 weeks) Profile B	Explaining underlying pain mechanisms Improving active coping Decreasing fear avoidance Increasing physical capacity Increasing activities and participation	Pain education Exercise therapy based on cognitive and physical principles
Phase 4 (7–12 weeks) Profile A	See Phase 3a + minimizing delay in work participation	See Phase 3a Exercise therapy (graded activity)
Phase 4 (7 −12 weeks) Profile B	See Phase 3b	See Phase 3b Exercise therapy (graded exposure)
Phase 5 (3–6 months) Profile C	See Phase 3b	See Phase 4
Phase 6 (>6 months) Profile C	See Phase 3b	See Phase 5

Notes: ^aPhases after whiplash-related injury: Phase 1: <7 days; acute; normal recovery: Phase 2: 1–3 weeks; acute; normal recovery: Phase 3a: 4–6 weeks; sub-acute; inconclusive recovery: Phase 3b: 4–6 weeks; sub-chronic; delayed recovery: Phase 4a: 7–12 weeks; sub-acute; inconclusive recovery: Phase 4b: 7–12 weeks; sub-chronic; delayed recovery: Phase 5: 3–6 months; chronic; no recovery: Phase 6: >6 months; chronic; no recovery: ^bPrognostic health profile: Profile A: normal recovery, low intensity of pain, decreasing pain, increasing activities, active coping, no fear avoidance: Profile B: inconclusive recovery, middle intensity of pain, persistent pain, persistent activity limitations, inconclusive coping, inconclusive fear avoidance: Profile C: delayed recovery, high intensity of pain, increasing pain, decreasing activities, passive coping, fear avoidance: ^cClassification Allied Health Care, version Physiotherapy: 1. History Taking; 2. Inspection and observation; 3. Palpation; 4. Active exercise therapy; 5. Passive exercise therapy (manual therapy); 6. Massage therapy; 7. Modalities of physical therapy (ie, low- and high-frequency electrotherapy); 8. Coaching; 9. Education.

Table 2 Baseline Characteristics in Physiotherapy Management in Patients with Whiplash-Associated Disorders

Total n=523: n (%) Unless Otherwise Stated
Sociodemographic characteristics
Age (year) (mean; SD) Female Male	43.4 (13.1) 39.8 (13.4)
Gender (female)	396 (75.7)
Educational level Lower (primary school) Intermediate (secondary school) Higher (post-secondary school)	283 (54.1) 147 (28.1) 93 (17.8)
Employment status Unemployed/job seeking In work Retired	180 (34.4) 277 (53.0) 66 (12.6)
Accident-related characteristics
Direction of impact (back)	356 (68.2)
Anticipated collision (no)	414 (79.2)
Type of trauma Neck Neck and head Other type	349 (66.7) 138 (26.4) 36 (6.9)
Classification WAD^a WAD-1 WAD-2 WAD-3 WAD-4	38 (7.3) 406 (77.6) 79 (15.1) -
Period since accident <7 days 1–3 weeks 4–6 weeks 7–12 weeks 3–6 months >6 months	14 (2.7) 98 (18.7) 118 (22.6) 114 (21.8) 123 (23.5) 56 (10.7)
Onset of symptoms Immediately ≤2 days 3–7 days >1 week	109 (20.8) 336 (64.2) 78 (14.9) -
Pre-existing health status
Functioning problems Activity limitation (yes) Participation problems (yes) Job-related problems (yes)	91 (17.4) 74 (14.1) 60 (11.5)
Relevant medication use (yes)	74 (14.1)
Previous whiplash injury (yes)	55 (10.5)
Previous neck pain and stiffness (yes)	96 (18.4)
Pain elsewhere (yes)	115 (22.0)
Previous diagnostics and treatment
Medical imaging diagnostics (yes)	90 (17.2)
Cervical soft collar (yes) Weeks (mean; SD)	295 (56.4) 3.5 (1.6)
Pain medication (yes)	221 (42.3)
(Manual) physiotherapy (yes; n=234) Active exercise therapy Manual therapy Active exercise therapy + manual therapy Massage therapy Combined therapy	76 (32.5) 36 (15.4) 25 (10.7) 20 (8.5) 77 (32.9)
Recovery after treatment Fully Partially Stabilization Deterioration Inconclusive	- 27 (5.2) 104 (19.9) 212 (40.5) 180 (34.4)
Current health status and recovery rate
Recovery since accident Normal Inconclusive Deterioration	40 (7.6) 339 (64.8) 144 (27.5)
Functioning problems Impairments in musculoskeletal neck functions (yes) Activity limitation (yes) Participation problems (yes) Job-related problems (yes)	523 (100) 522 (99.8) 523 (100) 312 (59.7)
Pain medication (yes)	131 (25.0)
Type and number of symptoms ≤3: neck pain, stiffness, decreased ROM^b 4–6: + dizziness, headache and tinnitus 7–9: + cognitive impairments >9: + rest	10 (1.9) 165 (31.5) 344 (65.8) 4 (0.8)
Pain intensity (VAS-P ≥55 mm; 0–100 mm)^c	330 (63.1)
Functioning (NDI >29%; 0–50 points)^d	514 (98.3)
Current pain behavior and fear avoidance
Observation pain behavior (yes)	510 (97.5)
Modified Waddell’s non-organic physical signs^e ≤3 >3	9 (1.7) 514 (97.5)
Pain Coping Inventory^e PCI-Active (score: 12–48) (mean; SD) Active coping (score ≥24) PCI-Passive (score 21–84) (mean; SD) Passive coping (score ≥42)	27.1 (6.1) 396 (75.7) 54.2 (13.3) 416 (79.5)
Fear Avoidance Beliefs Questionnaire^f FABQ-Activities (score: 0–24) (mean; SD) Risk for pain avoiding behavior (score >15) FABQ-Work (score: 0–42) (n=354) (mean; SD) Risk for no return to work (score >34)	16.0 (3.4) 346 (66.2) 29.3 (7.7) 137 (38.7)

Notes: ^aClassification WAD: Whiplash-Associated Disorders: WAD 0: no neck symptoms, no physical sign(s); WAD 1: neck pain, stiffness or tenderness only, no physical sign(s); WAD 2: neck symptoms and musculoskeletal sign(s); WAD 3: neck symptoms and neurological sign(s); WAD 4: neck symptoms and fracture or dislocation ^bROM: Range of Motion. ^cVAS-P: Visual Analogue Scale for Pain: horizontal line of 100 mm scored from 0 (no pain) to 100 (worst imaginable pain). ^dNDI: Neck Disability Index: 10 items scored from 0 (no activity limitation) to 5 (major activity limitation); total score 0–50. ^eModified Waddell’s non-organic physical signs: superficial tenderness, non-anatomical tenderness, pain simulation test, cervical ROM, regional disturbance, overreaction^ePain Coping Inventory (PCI): 33-item questionnaire measuring active coping (PCI-Active: 12 items [12–48]; ≥24 active coping) and passive coping (PCI-P: 21 items [21–84]; ≥42 passive coping). Items are scored on a 4-point Likert scale ranging from 1 (hardly ever) to 4 (very often). ^fFear Avoidance Beliefs Questionnaire (FABQ): 16-item questionnaire measuring fear avoidance beliefs related to physical activities (FABQ-Activities: 4 items [0–24]; >15 at risk for pain avoiding behavior), and work-related activities (FABQ-Work: 7 items [0–42]; >34 at risk for no return to work). Items are scored on a 7-point Likert scale ranging from 0 (completely disagree) to 6 (completely agree)

Table 3 10 Year Related Outcomes for Physiotherapy Management in Patients with Whiplash-Associated Disorders (WAD) (n=523)

Year of Referral^a	Pain Intensity^b					Functioning Activity Limitation^c					Perceived Improvement^d
n (%)	Pre-treatment score Mean (SD)	Post-treatment score Mean (SD)	Effect size^#	Difference Mean (95% CI)	MCID ≥30% n (%)	Pre-treatment score Mean (SD)	Post-treatment score Mean (SD)	Effect size^#	Difference Mean (95% CI)	MCID ≥11 pts n (%)	Improved n (%)	No change n (%)	Worse n (%)
1 (n=66) (12.6)	56.1 (17.6)	27.7 (17.6)	1.61	28.4* (25.5–31.4)	54 (83.3)	27.9 (8.6)	13.1 (9.4)	1.64	14.8* (13.2–16.5)	49 (74.2)	31 (47.0)	24 (36.4)	11 (16.6)
2 (n=57) (10.9)	59.6 (14.8)	29.2 (14.5)	2.07	30.4* (27.6–33.3)	51 (89.5)	29.5 (7.2)	16.4 (8.2)	1.70	13.1* (11.5–14.7)	37 (64.9)	29 (50.9)	22 (38.6)	6 (10.5)
3 (n=48) (9.2)	57.5 (13.5)	30.8 (11.6)	2.12	26.7* (22.7–30.7)	35 (72.9)	27.5 (6.9)	14.3 (6.2)	2.01	13.2* (11.5–15.0)	34 (80.8)	21 (43.8	16 (33.3)	11 (22.9)
4 (n=50) (9.6)	59.1 (14.7)	28.9 (10.3)	2.38	30.3* (26.6–33.9)	40 (80.0)	29.7 (6.9)	16.6 (7.0)	1.88	12.8* (10.8–14.7)	32 (64.0)	22 (44.0)	21 (42.0)	7 (14.0)
5 (n=30) (5.7)	58.5 (11.2)	33.2 (13.7)	2.02	25.2* (20.9–29.6)	25 (82.3)	27.8 (5.7)	17.0 (9.0)	1.43	10.8* (7.7–14.0)	16 (53.3)	9 (30.0)	18 (60.0)	3 (10.0)
6 (n=43) (8.2)	56.1 (12.8)	30.7 (14.4)	1.86	25.4* (21.8–29.1)	35 (81.4)	27.4 (5.9)	17.1 (9.0)	1.35	10.3* (8.1–12.5)	21 (48.8)	18 (41.9)	17 (39.5)	8 (18.6))
7 (n=44) (8.4)	59.6 (16.0)	32.9 (13.8)	1.79	26.8* (22.1–31.4)	34 (77.3)	29.4 (8.9)	18.3 (9.5)	1.21	11.1* (9.0–13.2)	24 (54.5)	14 (31.8)	18 (40.9)	12 (27.3)
8 (n=60) (11.5)	53.4 (11.7)	27.4 (11.8)	2.21	25.9* (22.8–29.1)	50 (83.3)	25.4 (6.6)	14.1 (7.3)	1.61	11.3* (9.5–13.1)	33 (55.0)	29 (48.3)	19 (31.7)	12 (20.0))
9 (n=58) (11.1)	58.4 (14.4)	29.5 (13.8)	2.05	29.0* (26.1–31.9)	51 (87.9)	28.6 (7.9)	16.5 (9.8)	1.36	12.1* (10.4–13.9)	31 (53.4)	31 (53.4)	20 (34.5)	7 (12.0)
10 (n=67) (12.8)	59.9 (15.0)	28.9 (11.1)	2.07	31.1* (28.6–33.5)	63 (94.0)	29.1 (7.9)	17.0 (8.8)	1.45	12.2* (10.7–13.6)	35 (52.2)	37 (55.2)	24 (35.8)	6 (9.0)
Total (n=523)	57.8 (14.5)	29.6 (13.5)	2.01	28.2* (27.2–29.3)	443 (83.7)	28.2 (7.5)	15.9 (8.6)	1.52	12.3* (11.8–12.9)	312 (59.7)	241 (46.1)	199 (38.0)	83 (15.9)

Notes: ^aYear of referral: 2002–2011 (1-10). ^bPain intensity: Visual Analogue Scale for Pain (VAS-P): horizontal line of 100 mm scored from 0 (no pain) to 100 (worst imaginable pain). ^#Effect size: Cohen’s d 0.21–0.50 small; 0.51–0.80 medium; >0.81 large. *Statistical significance P< 0.001 (paired sample t-test; individual delta pre-post) MCID: Minimal Clinically Important Difference: VAS-P ≥30% of pretreatment score (mm). ^cFunctioning/Activity limitation: Neck Disability Index (NDI): 10 items scored from 0 (no activity limitation) to 5 (major activity limitation); total score 0–50 points. # Effect size: see Pain Intensity. *Statistical significance: see Pain Intensity MCID: Minimal Clinically Important Difference: NDI ≥11 points ^dGlobal Perceived Effect: “improved” (’complete improved’; “much improved”; “slightly improved”); “no change”; “worse” (slightly worse’; “much worse”).

Table 4 Phase-Related Outcomes for Physiotherapy Management in Patients with Whiplash-Associated Disorders (WAD) (N=523)

Phases After Whiplash-Related Injury^a	Pain Intensity^b					Functioning Activity Limitation^c					Perceived Improvement^d
n (%)	Pre- treatment score Mean (SD)	Post-treatment score Mean (SD)	Effect size^#	Difference Mean (95% CI)	MCID ≥30% n (%)	Pre-treatment score Mean (SD)	Post-treatment score Mean (SD)	Effect size^#	Difference Mean (95% CI)	MCID ≥11 pts n (%)	Improved n (%)	No change (same as before) n (%)	Worse n (%)
Phase 1 (>7 days) n=14 (2.7)	47.5 (18.5)	21.2 (15.6)	1.54	26.3* (20.9–31.7)	12 (85.7)	22.4 (8.7)	10.6 (9.7)	1.28	12.1* (8.4–15.7)	8 (57.1)	9 (64.3)	4 (28.6)	1 (7.1))
Phase 2 (1–3 weeks) n=98 (18.7)	57.5 (14.1)	30.0 (13.5)	1.99	27.6* (25.1–30.1)	78 (79.6)	28.4 (7.5)	15.0 (7.8)	1.73	13.4* (12.0–14.7)	67 (68.4)	39 (39.8)	43 (43.9)	16 (16.3)
Phase 3 (4–6 weeks) n=118 (22.6)	56.7 (16.7)	28.7 (15.4)	1.74	28.2* (26.1–30.2)	102 (86.4)	27.6 (8.5)	15.7 (9.9)	1.29	12.2* (11.1–13.3)	73 (61.9)	54 (45.8)	43 (36.4)	21 (17.8)
Phase 4 (7–12 weeks) n=114 (22.0)	57.9 (14.1)	29.1 (12.0)	2.20	28.8* (26.4–31.2)	98 (86.0)	28.4 (7.1)	16.1 (7.7)	1.56	12.3* (11.1–13.5)	66 (57.9)	60 (52.6)	39 (34.2)	15 (13.1)
Phase 5 (3–6 months) n=123 (23.5)	57.8 (12.5)	30.0 (13.0)	2.18	27.7* (25.6–29.8)	105 (85.4)	28.3 (6.5)	16.0 (8.0)	1.69	12.2* (11.4–13.8)	68 (55.3)	54 (43.9)	50 (40.7)	19 (15.4)
Phase 6 (>6 months) n=56 (10.7)	63.0 (12.9)	33.2 ( 11.8)	2.41	29.7* (26.1–33.3)	46 (82.1)	30.3 (7.2)	18.9 (8.8)	1.42	11.3* (9.4–13.6)	30 (53.6)	25 (44.6)	20 (35.7)	11 (19.7
Total n=523	57.8 (14.5)	29.6 (13.5)	2.01	28.2* (27.2–29.3)	443 (84.7)	28.2 (7.5)	15.9 (8.6)	1.52	12.3 (11.8–12.9)	312 (59.7)	241 (46.1)	199 (38.0)	83 (15.9)

Notes: ^aPhase after whiplash-related injury: Phase 1: <7 days; acute; normal recovery Phase 2: 1–3 weeks; acute; normal recovery Phase 3a: 4–6 weeks; sub-acute; inconclusive recovery Phase 3b: 4–6 weeks; sub-chronic; delayed recovery Phase 4a: 7–12 weeks; sub-acute; inconclusive recovery Phase 4b: 7–12 weeks; sub-chronic; delayed recovery Phase 5: 3–6 months; chronic; no recovery Phase 6: > 6 months; chronic; no recovery. ^bPain intensity: Visual Analogue Scale for Pain (VAS-P): horizontal line of 100 mm scored from 0 (no pain) to 100 (worst imaginable pain) # Effect size: Cohen’s d 0.21–0.50 small; 0.51–0.80 medium; >0.81 large *Statistical significance P< 0.001 (paired sample t-test; individual delta pre-post) -MCID: Minimal Clinically Important Difference: VAS-P ≥30% of pretreatment score (mm). ^cFunctioning/Activity limitation: Neck Disability Index (NDI): 10 items scored from 0 (no activity limitation) to 5 (major activity limitation); total score 0–50 points -^#Effect size: see Pain Intensity* Statistical significance: P< 0.001 (paired sample t-test; individual delta pre-post) MCID: Minimal Clinically Important Difference: NDI ≥11 points. ^dGlobal Perceived Effect: perceived improvement -“improved” (’complete improved’; “much improved”; “slightly improved”); “no change”; “worse” (slightly worse’; “much worse”).

Table 5 Health Profile-Related Outcomes for Physiotherapy Management in Patients with Whiplash-Associated Disorders (WAD) (n=523)

Health Profile^a	Pain Intensity^b					Functioning Activity Limitation^c					Perceived improvement^d
n (%)	Pre-treatment score Mean (SD)	Post-treatment score Mean (SD)	Effect size^#	Difference Mean (95% CI)	MCID ≥30% n (%)	Pre-treatment score Mean (SD)	Post-treatment score Mean (SD)	Effect size^#	Difference Mean (95% CI)	MCID ≥11 pts n (%)	Improved n (%)	No change (same as before) n (%)	Worse n (%)
Profile A n=40 (7.6)	40.8 (15.7)	13.9 (12.5)	1.89	26.9* (23.3–30.5)	37 (95.0)	20.6 (8.8)	7.4 (7.7)	1.60	13.2* (11.6–14.7)	27 (67.5)	34 (85.0)	4 (10.0)	2 (5.0)
Profile B n=339 (64.8)	55.6 (11.7)	29.4 (11.8)	2.23	26.2* (24.9–27.4)	277 (81.3)	27.2 (6.3)	15.4 (7.8)	1.66	11.8* (11.1–12.5)	194 (57.2)	150 (44.2)	135 (39.5)	54 (15.9)
Profile C n=144 (27.5)	67.5 (13.6)	34.4 (14.0)	2.40	33.3* (31.3–35.4)	125 (86.8)	32.7 (7.4)	19.3 (8.8)	1.65	13.4* (12.3–14.6)	91 (63.2)	57 (39.6)	68 (41.7)	27 (18.8)
Total (n=523)	57.8 (14.5)	29.6 (13.5)	2.01	28.2* (27.2–29.3)	443 (84.7)	28.2 (7.5)	15.9 (8.6)	1.52	12.3* (11.8–12.9)	312 (59.7)	241 (46.1)	199 (38.0)	83 (15.9)

Notes: ^aPrognostic health profile: Profile: normal recovery, low intensity of pain, decreasing pain, increasing activities, active coping, no fear avoidance Profile B: inconclusive recovery, middle intensity of pain, persistent pain, persistent activity limitations, inconclusive coping, inconclusive fear avoidance -Profile C: delayed recovery, high intensity of pain, increasing pain, decreasing activities, passive coping, fear avoidance. ^bPain intensity: Visual Analogue Scale for Pain (VAS-P): horizontal line of 100 mm scored from 0 (no pain) to 100 (worst imaginable pain) -^#Effect size: Cohen’s d 0.21–0.50 small; 0.51–0.80 medium; >0.81 large *Statistical significance P< 0.001 (paired sample t-test; individual delta pre-post) MCID: Minimal Clinically Important Difference: VAS-P ≥30% of pretreatment score (mm). ^cFunctioning/Activity limitation: Neck Disability Index (NDI): 10 items scored from 0 (no activity limitation) to 5 (major activity limitation); total score 0–50 points ^#Effect size: see Pain Intensity*Statistical significance: P< 0.001 (paired sample t-test; individual delta pre-post) MCID: Minimal Clinically Important Difference: NDI ≥11 points. ^dGlobal Perceived Effect: perceived improvement “improved” (’complete improved’; “much improved”; “slightly improved”); “no change”; “worse” (slightly worse’; “much worse”).