Neck-specific Exercise in Chronic Whiplash
Condition: Whiplash Associated Disorders
MeSH terms: Whiplash Injuries
Study type: Interventional

Summary: 
      Neck pain is fourth among the most common conditions worldwide associated with longer periods
      of living with disability. Annually, about 30 000 people in Sweden undergo a whiplash trauma
      (WAD), and half of those individuals will develop chronic problems with high costs for the
      individual and society. Evidence for chronic WAD treatment is scarce, although neck-specific
      training at a physiotherapy clinic (2 times a week for 3 months) has demonstrated good
      results. A more efficient, flexible rehabilitation with reduced waiting times and lower costs
      is needed, ideally replacing lengthy on-site treatment series by health care providers.
      Internet-based care has proven to be a viable alternative to personal care meetings for a
      variety of diseases and interventions, but studies are lacking on Internet-based
      interventions for individuals with chronic neck problems. The purpose of this study is to
      investigate if A) neck-specific training delivered through Internet-based care differs from
      B) a longer series of treatments at a physiotherapy clinic regarding, e.g., work ability,
      sick-leave and disability. This prospective, randomized study involves 140 participants.
      Measurement is done at baseline, 3 months (end of treatment), and 15 months (12 months after
      end of treatment in the study) and will include ratings of work ability, sick-leave, work
      presenteeism, disability, pain, health, satisfaction with care, quality of life, and
      cost-effectiveness. The study results may contribute to the development of a more effective
      rehabilitation, flexible and equal care, shorter waiting times, increased availability and
      lower costs for health care and society. The program can be implemented on a broader scale in
      neck pain patients.
    

Detailed description: 
      The purpose of the study is to investigate if the effect of neck-specific exercises in people
      with chronic WAD (at risk for or at sick-leave) differs based on distribution via
      Internet-based care in combination with three visits (+ a first examination visit due to
      Swedish law) to the physiotherapist compared to a longer series (2 times/week for 3 months,
      i.e., 24 times + a first visit) of exercises at the physiotherapy clinic. Outcomes are for
      instance work ability, sick-leave, physical and psychological disability, pain, quality of
      life, satisfaction with treatment, and cost effectiveness. Further objectives are to a)
      describe the level of work ability, work presenteeism, and sick leave; b) determine which
      factors are related to a good work ability; c) identify factors predictive of a favourable
      outcome regarding work ability, disability, and pain; and d) describe how the participants
      perceived an Internet-based rehabilitation.

      Hypothesis: Internet-based support combined with a few (three) physiotherapist visits has an
      equivalent effect to a longer exercise period (24 times) at a physiotherapist clinic and
      yields lower economic costs for society.

      Design This is an experimental, longitudinal, prospective, multicentre randomized controlled
      trial (RCT) with two treatment arms. Treatment that has previously been shown to be effective
      (neck-specific exercises guided by a physiotherapist and performed at the physiotherapist
      clinic) for the current population constitutes the control treatment for the new
      Internet-based neck-specific exercise treatment. A total of 140 people are expected to be
      included, 70 in each group (sample size estimated by statisticians). Independent
      physiotherapists in primary care clinical practice will distribute the treatment. The project
      manager will not be a test leader.

      Recruitment and randomization Interested patients will contact the research team (experienced
      physiotherapists), and after a small survey filled in by the potential participant, a project
      team member will perform a telephone interview, ask about the medical history, and perform a
      physical examination to ensure that criteria for study participation are met. If the study
      criteria are met and after written and oral informed consent of the patient, the patient will
      fill out a questionnaire (baseline data) and undergo physical measurements of neck-related
      function. Baseline measurements must be completed for inclusion.

      The patient will be randomized through a computerized randomization list (block randomization
      conducted by a statistician, stratification by gender) to one of two groups of 3 months of
      treatment with neck-specific exercises: A) exercises at a physiotherapy clinic 2 times/week
      for 3 months; or B) Internet-based support exercises in combination with four visits to the
      physiotherapist. The test leader is blinded for group allocation. The randomization is
      performed by an independent researcher not otherwise involved in any of the test or
      treatments. The researcher sends an opaque envelope containing the name and contact details
      of the patient and information about the randomization group to the treating physiotherapist,
      who calls the patient to a new clinical examination (by law) before treatment can start. Due
      to the nature of the study neither participants nor treating therapists can be blinded,
      however all tests are done by blinded test leaders. Data collection in the form of
      questionnaires and tests of physical neck-related function occurs at baseline (before
      randomization) and after 3 months (when the treatment ends) and 15 months (12 months after
      completion of the intervention in the project). The treating physiotherapists will receive
      oral and written information and a day of practical training. The treating physiotherapist is
      also able to consult with the project managers at any time if necessary. An exercise diary is
      maintained by patients in both groups, and the number of care contacts is recorded by the
      physiotherapist. Seventy people per group, i.e., a total of 140 participants with chronic WAD
      grades 2 and 3, will be recruited.

      Intervention Group A, neck-specific exercises at a physiotherapy clinic: Participants get an
      explanation and justification for the exercise. They undergo a 12-week training program with
      a physiotherapist 2 times/week. Exercises are chosen from a clear and written frame of
      exercises, although the dosages are individually adapted. The training includes exercises
      activating the deep neck muscles, continuing with the endurance training of neck and shoulder
      muscles. The exercises are individually adjusted according to the individual's physical
      conditions and progressively increased in severity and dose. Exercise-related pain
      provocation is not accepted. The individual may also carry out home exercises. At the end of
      the treatment period, the patient is encouraged to continue practicing on their own.

      Group B, neck-specific exercises with Internet support: Participants receive the same
      information and training programs as group A but have in total only four visits (a first
      examination visit and additional three visits) to the physiotherapist. When the exercises are
      introduced, they are repeated, and control is done so that the patient has understood how to
      conduct the exercises. The exercises take place, with the help of Internet support outside
      the health care system, probably mostly at home. Photos and videos of the exercises,
      information, and answers to frequently asked questions are available on the Internet
      (web-based system designed by the project leaders at the University). Patients can contact a
      physiotherapist if necessary, and can normally expect an answer within 3 days.

      Any important harms or unintended effects in each group will be collected by the test
      leaders.

      Sample size Sample size calculations in the study regarding group differences are calculated
      by a statistician (non-inferiority trial, an assumption that treatment B is not worse than
      A), and power is calculated by the software "G-POWER" and is based on the primary outcome
      measurements WAI and NDI. Regarding WAI, it is considered important that the participants
      improve from poor to moderate work ability, i.e., an average of 6 increments in a scale 7-47
      (can also be classified into four groups: poor, moderate, good, and excellent). With a
      significance level of 5% and a power of 80%, seven people in each classification group are
      required. To get seven people in the "poor group" requires 60 people in total. To detect a
      clinically relevant improvement in NDI of 7%, 47 participants per group are needed on the
      basis of 80% power at a significance level of 5%. This value is based on the standard
      deviation (SD 13.4) in the NDI in a previous study on neck-specific exercises of individuals
      with chronic WAD grades 2 and 3. To ensure that enough people are in each group after
      drop-outs, for prediction analyses, and some possibility for subgroup analyses (e.g., WAD
      grades 2 and 3 or between men and women), the recommendation from the statistician was to
      include 70 people/group.

      Ethical considerations The study was approved by the regional ethical review board (Linköping
      Dnr 2016 / 135-31). A previous clinical study relating to three different exercise
      interventions on long-term problems after whiplash injury demonstrated good efficacy of
      neck-specific exercise performed in primary health care. Current treatment is according to
      the best scientific evidence, and exercises used in the present study have been used in daily
      clinical practice for decades in the rehabilitation of various forms of neck pain.
      Participants are included after a thorough clinical examination and signed informed (oral and
      written information) consent. The exercises are adjusted individually. A risk of muscle
      soreness is present, but otherwise no negative side effects are to be expected.

      Login is required to fill in Internet-based surveys and to gain access to the Internet-based
      exercise program. People with long-term problems often have low access to assessments and
      treatments as more acute conditions often are prioritized in the health care system. Both
      groups in the present study get active care that is expected to increase work ability. The
      benefit is deemed to be great, and there are no commercial interests.

      The results will be presented at group level, and no connection to the individual person can
      be made. All data are anonymous and subject to the official health secrets act.

      Statistical analysis Analyses will be done with parametric or non-parametric statistics,
      depending on the type of data and if the analysis is between groups or over time. Analyses
      will primarily be made on an intention-to-treat basis and as secondary as per protocol
      analysis. When suitable a linear mixed model analysis will be used. For prediction analysis,
      multivariate analysis will be performed. For calculation of cost-effectiveness,
      quality-adjusted life-years and incremental cost-effective ratios will be calculated.

      Sub-group analyses regarding gender, WAD grade, neurology, headache, dizziness and compliance
      may be done.

      Ultrasound registrations, electromyopgraphy, Magnetic Resonance Imaging and kinesthesia may
      be done on a sub-group of participants to investigate neck muscle structure and function.
      Interviews may be performed on a sub group of individuals to investigate the experience of
      function and study participation.
    

Intervention name(s): Neck-specific exercise
Intervention type(s): Other
Intervention description(s): Neck-specific exercise
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Neck pain; Rehabilitation; Exercise Therapy; Internet