ROM and Strengthening Exercises as a Treatment Option

There are multiple kinds of exercise that could be beneficial in treating acute whiplash. Literature shows exercises such as a McKenzie treatment, postural training exercise, endurance strengthening and motor control, eye fixation, isometric exercises, and resistive exercises. In reviewing the literature, these exercises were combined with other treatment strategies such as modalities or mobilization to get the most effective outcome.
Also, at this point although there is a large amount of research done on treatment of whiplash injury, the conclusions that are made from this literature conflict each other. However, there is a consensus that excessive treatment of whiplash associated disorder may be counterproductive in the acute stages of injury. (Cochrane review) The evidence does not support episodes of care that last longer than 6-8 weeks with any one or combination of noninvasive interventions.
If the intervention that is being attempted at that time is unsuccessful, it is then recommended that a different intervention be attempted. (Cochrane review) Based on this information, if active ROM and strengthening exercises are to be used, the intensity and frequency should be monitored closely to avoid increased injury. In comparing the effectiveness of these exercises, many studies compared them to periods of “standard care”. Standard Care included rest, analgesia, and general advice on gradual mobilization after a short period of rest.

McKenzie treatment is based on the principle of centralization of pain and the use of exercises to reduce the stress on the surrounding neck musculature. For acute WAD patient’s, the goal is to stretch and decrease the tightness of the cervical extensor muscles, which may be overly contracted in this patient population. A common exercise to accomplish this is the chin tuck, where the patient retracts their chin and repeats this activity for a given number of repetitions. In a study by McKinney et al, three groups of patients with WAD were placed in 3 treatment categories and compared by outcome measures.
The treatment categories included a home mobilization group who were instructed in postural correction, analgesia, collar, muscle relaxation and mobilization exercises. The second group was a group who received outpatient physiotherapy, including; McKenzie treatment, heat, cold, diathermy, traction, Maitland mobilization, postural correction and home exercise. The final group compared in this study received standard care as defined above. (Seferiadis, European spine journal)
All treatments were given over a period of 6 weeks for 24 visits, with the follow up visits at 2 weeks. Cochrane review- exercises for mechanical neck disorders) Patients who received outpatient physiotherapy, including McKenzie treatment demonstrated improved cervical ROM and pain intensity in comparison to the treatment group receiving standard care. However, there was no difference in effectiveness between the outpatient physiotherapy group and home mobilization group. In a second study by Rosenfeld et al, the standard treatment for WAD was compared to active intervention that included McKenzie treatment and active cervical ROM.
The group receiving active intervention demonstrated the most benefit when treatment was provided within 96 hours of initial injury. This group also demonstrated lower pain intensity and amount of sick leave, as well as improved cervical ROM in comparison to the standard care group. These outcomes were maintained at a 6 month and 3 year follow up (Seferiadis, European spine journal). Based on this literature and the results of the studies, McKenzie exercises have shown to be beneficial in reducing pain in patients with WAD.
Postural training exercises as defined by a systematic review by Drescher et al, includes any correction, exercise or advice with the aim of improving posture. (Drescher) Postural training would be important for patients with WAD to avoid further exacerbation of muscle injury or reinjury at a later date. This could further carry over to job related tasks, as many people spend their day working at a desk sitting for long periods of time. Postural exercises may help patients to be more aware of their posture and make self-corrections to avoid future injury throughout the workday.
In the systematic review by Drescher (Reference 22), the study compared a group receiving postural exercises to a control group who were not receiving postural exercises. It was found that the group that completed postural exercises demonstrated decreased pain and increased cervical ROM. Another high quality study (references 17-19) within this review compared an intervention group receiving postural exercises to the control group.
The postural exercise group showed significant reduction in pain at both the 6 onth and 3 year follow up, as well as a lower amount of sick days taken from work at the 3 year study. There was no significant different in cervical ROM improvement in these two groups. Initially the cost of this postural training was higher, however ended up being lower when taking into account the cost of sick-leave days, loss of productivity and other interventions. (Drescher) In a study by Schnabel et al, it was determined that active therapy including postural advice and exercise was superior to passive modalities such as massage and ultrasound.
There is limited evidence on specific postural exercises which would best benefit this population, however there has been some proof that this is a beneficial treatment. Therefore, further research into specific exercises and training strategies may be warranted to determine the best options for patients with WAD. A common side effect of whiplash is dizziness, which can limit patient’s ability to perform quick head movements and functional activities such as looking over their shoulder while walking.
This dizziness is something which has been addressed by eye fixation exercises in the literature. Eye fixation exercises may also be known as proprioceptive exercise and can include; target exercises with varying degrees of difficulty by changing input from other body systems, and vestibular ocular reflexes with either a target moving or the target moving in the opposite direction of the patient’s head with the patient’s eyes maintaining focus on the target at all times.
Eye-fixation exercises are used to restore coordinated movement and proprioceptive movement, which will decrease the degree of dizziness in the patient with WAD. Individually these programs have not shown to be beneficial, however when combined with other therapy treatments there has been minimal to moderate benefit. Based on a Cochrane review of exercises for mechanical neck disorder, it was found that including eye-fixation exercises into a complete physical therapy program showed moderate evidence of benefit for pain and function for acute whiplash disorder.
This is also supported in a study by Provinciali, where one group was treated with eye fixation exercises to treat dizziness, along with mobilization and additional neck exercises. This group had significant results in decreased pain on the VAS scale over the group that received TENS and pulsed EMG (Cochrane – exercises). Based on these studies, if a patient with WAD is experiencing dizziness as a symptom, eye fixation exercises may be a beneficial addition to the treatment plan.
Another treatment option that has shown positive results in the literature is the use of isometric resistive exercises to strengthen the cervical muscles. Isometric exercises are strengthening exercises designed to strengthen the musculature while maintaining the body in one position. This may be beneficial for patients with acute WAD who are unable to move through a large range of motion, as they will still receive the benefit of strengthening exercises. A study done by Soderlund et al. compared two groups of patients receiving treatment for acute whiplash.
The first group was receiving regular treatment that included instructions on what activities to avoid and what activities to continue with. Table 1 describes the treatment plan given to both the normal treatment group and the additional treatment group. Patients in the additional exercise group were instructed to follow all instructions given to the normal treatment group, as well as perform additional isometric exercises. This exercise is described as the patient lying down on the ground, and imagines a “quadrangle” behind their head.
They are then instructed to imagine pushing their head into each corner of the quadrangle, and repeat the cycle 3 times. The result of this study found that patients in the additional treatment group were able to continue to decrease their pain rating at follow up periods of three and six months, whereas the normal treatment group had the same amount of pain at these follow up visits. This study would indicate that the additional treatments are beneficial to help decrease the patient’s pain longer after injury.