Pain Medicine Advance Access published December 29, 2016
Pain Medicine 2016; 00: 1–13
doi: 10.1093/pm/pnw266
Original Research Article
Do Subjects with Whiplash-Associated
Disorders Respond Differently in the Short-Term
to Manual Therapy and Exercise than Those
with Mechanical Neck Pain?
Matteo Castaldo, PT,*,†,‡ Antonella Catena, PT,*
Alessandro Chiarotto, PT, MSc,§
ndez-de-las-Pen
César Ferna ~ as, PT, PhD, DrMedSci,†,¶
and Lars Arendt-Nielsen, PhD, DrMedSci†
*Private practice, Poliambulatorio FisioCenter,
Collecchio, Parma, Italy; †SMI, Department of Health
Science and Technology, Faculty of Medicine,
Aalborg University, Aalborg, Denmark; ‡Department of
Physical Therapy, University of Siena, Siena, Italy;
§
Department of Health Sciences, Faculty of Earth and
Life Sciences, EMGOþ Institute for Health and Care
Research, VU University, Amsterdam, the
Netherlands; ¶Department of Physical Therapy,
Occupational Therapy, Physical Medicine and
Rehabilitation, Universidad Rey Juan Carlos,
Alcorcon, Spain
Correspondence to: Lars Arendt-Nielsen, Dr.
MedSci, PhD, Department of Health Science and
Technology, Center for Sensory-Motor Interaction
(SMI), Faculty of Medicine, Aalborg University,
Fredrik Bajers Vej 7D3, DK-9220 Aalborg, Denmark.
Tel: þ45-9940-8830; Fax:
þ45-9815-4008; E-mail: lan@hst.aau.dk.
Funding sources: None.
Conflicts of Interest: The authors have no conflicts of
interests to declare.
Abstract
Objective. To compare the short-term effects of
manual therapy and exercise on pain, related dis-
ability, range of motion, and pressure pain thresh-
olds between subjects with mechanical neck pain
and whiplash-associated disorders.
C 2016 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
V 1
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Methods. Twenty-two subjects with mechanical
neck pain and 28 with whiplash-associated dis-
orders participated. Clinical and physical out-
comes including neck pain intensity, neck-related
disability, and pain area, as well as cervical range
of motion and pressure pain thresholds over the
upper trapezius and tibialis anterior muscles,
were obtained at baseline and after the interven-
tion by a blinded assessor. Each subject received
six sessions of manual therapy and specific neck
exercises. Mixed-model repeated measures ana-
lyses of covariance (ANCOVAs) were used for the
analyses.
Results. Subjects with whiplash-associated disorders
exhibited higher neck-related disability (P 5 0.021),
larger pain area (P 5 0.003), and lower pressure pain
thresholds in the tibialis anterior muscle (P 5 0.009)
than those with mechanical neck pain. The adjusted
ANCOVA revealed no between-group differences for
any outcome (all P > 0.15). A significant main effect of
time was demonstrated for clinical outcomes and cer-
vical range of motion with both groups experiencing
similar improvements (all P < 0.01). No changes in
pressure pain thresholds were observed in either
group after treatment (P > 0.222).
Conclusions. The current clinical trial found that
subjects with mechanical neck pain and whiplash-
associated disorders exhibited similar clinical and
neurophysiological responses after a multimodal
physical therapy intervention, suggesting that al-
though greater signs of central sensitization are
present in subjects with whiplash-associated dis-
orders, this does not alter the response in the short
term to manual therapy and exercises.
Key Words. Whiplash-Associated Disorders;
Mechanical Neck Pain; Manual Therapy; Exercise;
Central Sensitization
Castaldo et al.
Introduction
Neck pain is a frequent disorder associated with disabil-
ity and high health care costs [1]. It is classified as the
fourth highest cause of years lived with disability by the
Global Burden of Disease Study [2]. The economic bur-
den due to cervical disorders represents the second
after low back pain in annual workers’ compensation
costs in the United States of America [3]. Neck pain can
be traumatic, that is, after a car accident, or nontrau-
matic, that is, mechanical. Regardless of the cause of
the pain, the prognosis for individuals experiencing neck
pain is poor as many patients continue to suffer from
persistent pain and disability following treatment [4,5].
Mechanical neck pain (MNP) is a symptom-based diag-
nosis essentially conducted by exclusion that is as-
signed once serious, objective cervical spinal pathology
(e.g., whiplash trauma, malignancy, or radiculopathy)
has been ruled out [6]. Particularly, MNP affects 45% to
54% of the general population at some time during their
lives [7,8], it commonly arises insidiously and has a
multifactorial origin [9] including poor posture, anxiety,
depression, neck strain, and sport or occupational re-
petitive activities [10,11]. On the other side, the term
whiplash-associated disorders (WAD) includes several
clinical manifestations most often associated with
motor vehicle accidents affecting up to 83% of the
individuals involved in rear car collisions [12]. WAD rep-
resents a significant burden for the individual and for
the society in terms of direct and indirect costs as
approximately 50% of the patients report pain and dis-
ability up to one year after the trauma [13]. WAD in-
cludes different symptoms, for example, neck pain and
stiffness, headaches, shoulder pain, arm pain and/or
numbness, paresthesia, muscle weakness, dizziness,
and concentration problems, which can also be found
in MNP [14].
The exact causes of chronicity in WAD are not com-
pletely understood, but it has consistently been shown
that these individuals exhibit a high degree of sensitiza-
tion mechanisms manifested by decreases in thresholds
to mechanical, thermal, and electrical pain stimuli [15–
21]. The initial presence of hyperalgesia after the trauma
has been associated with a poor outcome in WAD
[15,22] and is not related to real tissue damage [23]. It
seems that peripheral sources of nociception from deep
tissues, for example, myofascial trigger points (TrPs)
[24–27] and the zygapophyseal joints [28,29], may con-
tribute to the persistent pain and the development of
sensitization in patients with chronic pain. Some authors
have suggested that myofascial TrPs play a particular
role in the genesis or maintenance of MNP [30,31]. In
fact, a recent study has observed that the presence of
TrPs was significantly different between patients with
MNP and those with WAD [27]. This difference may be
a potential factor contributing to the higher degree of
central sensitization in patients with WAD than in those
with MNP [27,32,33]. Indeed, this hyperexcitability of
the central nervous system is found just one month after
2
the trauma [15] in WAD, while in MNP patients the pres-
ence of central sensitization is under debate [34,35].
Manual therapy and exercises are often used as options
in the treatment of neck disorders, and different reviews
support their effectiveness [36–39]. However, there is no
consensus to which approach is the best to manage
these patients, but a combination of manual therapy and
exercise seems to give the best clinical outcomes. In
fact, clinical practice guidelines for physical therapy man-
agement of patients with neck pain suggest the use of a
treatment approach consisting of both manual therapies
including cervical spine manipulation and/or mobilization
and exercise programs training the deep neck flexor
muscles [40]. To the best of the authors’ knowledge, no
study has previously investigated the response to a multi-
modal therapeutic protocol including manual therapy and
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exercises between individuals with WAD and MNP.
Therefore, the aim of the current study was to evaluate
the short-term effects on clinical and experimental out-
comes of a multimodal therapeutic protocol including
manual therapy and exercises in subjects with WAD or
MNP. It is hypothesized that individuals with WAD will ex-
hibit worse clinical outcomes than those with MNP based
on the presence of higher central sensitization processes.
Methods
Participants
Consecutive subjects with neck pain symptoms who
sought treatment were screened by trained neurologists
at Poliambulatorio Dalla Rosa Prati, Parma (Italy).
For the MNP group, subjects were included if they had
neck-shoulder pain with symptoms provoked by neck
postures, neck movement, or palpation of the cervical
musculature not associated with a previous whiplash
[5]. For the WAD group, subjects were eligible if they
met the Quebec Task Force Classification of WAD,
grade I or II [41]. Subjects from both groups were
excluded if they exhibited one of the following: 1)
previous history of neck surgery, 2) any therapeutic
intervention for the cervical spine in the previous three
months, 3) any red flag (e.g., infections, malignancy,
fracture, rheumatoid arthritis or osteoporosis), or 4)
diagnosis of fibromyalgia syndrome according to the
American College of Rheumatology [42]. Informed con-
sent was obtained from all subjects according to the
Declaration of Helsinki. The study was approved by the
local ethics committee.
Procedure
Outcomes consisting of a physical examination including
cervical range of motion (ROM), pressure pain thresholds
(PPTs) and collection of demographic (gender, age) and
clinical data including neck pain on a numeric pain rate
scale (0–10), area of pain on a body chart, and neck-
related disability (neck disability index [NDI], %) were as-
sessed at baseline and immediately after the last

treatment session by an assessor blinded to the subject’s
condition (MNP or WAD). All subjects received the same
best evidence-based therapeutic protocol consisting of
soft tissue techniques targeting TrPs, spinal mobilization,
muscle energy techniques, manual traction, and specific
cervical spine exercises. The subjects received two ses-
sions per week of 30 minutes for three weeks (total six
sessions) by the same therapist trained in manual therapy
with more than eight years of clinical experience and who
was blinded to the subject’s condition for the whole dur-
ation of the study (MNP or WAD).
Self-Reported Clinical Outcomes
Participants rated the intensity of their neck pain at rest
on an 11-point numerical pain rating scale (NPRS: 0 ¼ no
pain, 10 ¼ maximum pain) [43,44]. Cleland et al. reported
that the minimal detectable change (MDC) and minimal
clinically important difference (MCID) for NPRS in patients
with neck pain were 1.3 and 2.1 points, respectively [43].
Neck-related disability was assessed with the Italian ver-
sion of the neck disability index. The questionnaire con-
sisted of 10 questions rated on a six-point scale ranging
from 0 (no disability) to 5 (full disability) [45–47]. The total
score ranged from 0 to 50 points where high values rep-
resented high neck-related disability, and the percentage
(50 points represented 100% disability) was then calcu-
lated. The NDI is a valid, reliable, and responsive instru-
ment to measure disability in patients with neck pain [48].
MacDermid et al. concluded that the MCID for the NDI
was seven points out of 50 points [47].
The subjects were asked to draw the distribution of their
pain symptoms on an anatomical body map. The pain
symptom area was measured with a digitizer (ACECAD
D9000, Taiwan) and analyzed with Vistametrix software
(SkillCrest, USA, LLC) [49,50].
Pain intensity was the main outcome, while PPTs and
NDI were considered secondary outcomes.
Physical Examination
The cervical range of motion (ROM) was recorded in
flexion, extension, both lateral flexions, and both rota-
tions with a goniometer [51,52]. Two measurements
were recorded for each motion, and the mean was
used in the main analysis. A recent study found that the
standard error of measurement (SEM) for the cervical
range of motion ranged from 5.3 to 9.9 [53].
Furthermore, another study found that changes of 5 to
10 were needed to suggest a real change in the cer-
vical range of motion in subjects with neck pain [54].
The pressure pain threshold (PPT), that is, the amount of
pressure applied for the pressure sensation to first
change into pain, was recorded using an algometer
(Somedic Production AB, Sweden). PPTs were assessed
over the upper trapezius muscle (fixed point in the middle
of the muscle) to determine localized pressure pain
Manual Therapy in WAD and MNP
hyperalgesia and over the tibialis anterior muscle (halfway
between the most superior attachment to the tibia and its
tendon in the upper third of the belly) to detect wide-
spread pressure pain hyperalgesia [55]. All participants
were instructed to press a button when the sensation first
changed from pressure to pain while the pressure was
increased at a rate of 30 kPa/s. For each point, PPTs
was performed three times with at least 30 seconds be-
tween each trial and the mean was used for the analysis.
Walton et al. reported that PPT over the neck assessed
with this algometer exhibited excellent intrarater reliability
(intraclass correlation coefficient [ICC] ¼ 0.94–0.97) and
good to excellent interrater reliability (ICC ¼ 0.79–0.90),
whereas the MDCs for PPT over the cervical spine and
tibialis anterior muscle were 47.2 kPa and 97.9 kPa, re-
spectively, in patients with neck pain [55].
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Intervention
The techniques used during the treatment sessions
were evidence-based and consisted of soft tissue tech-
niques targeting muscle trigger points (TrPs), spinal mo-
bilization, muscle energy techniques, manual traction,
and specific cervical spine exercises [36–40]. A prag-
matic clinical approach was used during which partici-
pants received all interventions included in the
therapeutic protocol but the dosage was adapted based
on clinical findings during the examination.
Manual compression was applied to active TrPs in the
suboccipital, upper trapezius, levator scapulae, and
sternocleidomastoid muscles bilaterally, with the subject
in the supine position. TrP diagnosis was performed ac-
cording to the following criteria: 1) presence of a palp-
able taut band in the muscle; 2) presence of a painful
tender spot in the taut band; 3) local twitch response
on palpation of the taut band; and 4) reproduction of
referred pain [31]. TrPs were considered active if the
pain elicited during the examination reproduced the
symptoms in the neck, whereas TrPs were considered
latent if the pain elicited during the examination did not
reproduce any symptoms [31]. Compression was con-
ducted with a flat or pincer palpation depending on the
accessibility of the muscle (Figure 1A) and the applied
force provoked a small to moderate discomfort during
the technique. The pressure was maintained for each
muscle until the subject reported a decrease of pain of
around 50%, in any case never less than one minute or
more than two minutes [56,57].
Cervical mobilization seems to have clinical effects similar
to spinal manipulation, and it is usually associated with
lesser risk of the vertebral artery [39,58,59]; therefore,
manipulation was not included. The subjects were in a
prone position and received 30-second bouts of grade
III–IV central posterior-anterior (PA) nonthrust mobilization
from C3 to T4 spinous process [60], for an overall inter-
vention time of approximately four minutes (Figure 1B).
As the upper trapezius is the muscle most commonly
affected by TrPs in individuals with neck pain [61], a
3
Castaldo et al.

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Figure 1 (A) Trigger point compression of sternocleidomastoid muscle. (B) Posterior-anterior mobilization.
(C) Muscle energy technique of the upper trapezius muscle. (D) Manual intermittent traction of the cervical spine.

4

Figure 2 (A) Cranio-cervical flexion exercise. (B) Cervical retraction exercise.
muscle energy technique of the upper trapezius
muscle was performed bilaterally with the subject in
supine. The muscle was stretched until the first ““bar-
rier”” (point of tension) (Figure 1C), and then the sub-
ject was asked to push isometrically against the hands
of the therapist with approximately 10–20% of the
maximum strength for 10 seconds (the therapist ex-
plained verbally how to dose the strength to that level).
Then, the subject was instructed to relax and the ther-
apist got a new “barrier.” This position was held for
30 seconds, and this process was repeated three
times [62,63].
Manual Therapy in WAD and MNP
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Manual traction was applied with the subject lying su-
pine, with one hand of the therapist grabbing the head
(around the occiput) of the subject and the other hand
stabilizing the cervico-thoracic junction (Figure 1D).
From this position, the therapist performed a light inter-
mittent traction for two minutes [64].
The last part of each session included specific neck ex-
ercises targeting the deep cervical flexors and extensors
[65]. The subject was supine with the knees flexed and
the head sustained by a pillow. A low-load cranio-cer-
vical flexion exercise was used to activate the deep
5
Castaldo et al.
Flow diagram
Enrollment Assessed for eligibility (n=64)
Mechanical Neck Pain (MNP) (n=22)
Whiplash Associated Disorders (WAD) (n=28)
Figure 3 Flow diagram of patient recruitment.
anterior muscles of the cervical spine including longus
colli and longus capitis muscles. The subjects were in-
structed to perform a gentle head-nodding action of
cranio-cervical flexion like saying “yes.” During the treat-
ment sessions, the therapist monitored all potential
compensations during the exercise (Figure 2A).
Subsequently, cervical retraction exercises were per-
formed with the subject sitting in a chair. The subject
was instructed to look at a fixed point on the wall and
retract the neck by pulling the head backwards (Figure
2B). The subjects were asked to perform 10 repetitions
of both exercises four to five times a day [66,67].
Sample Size Calculation
The sample size was calculated using Ene 3.0 software
(Autonomic University of Barcelona, Barcelona, Spain).
The sample size calculation was based on detecting
between-group differences of 2.1 units (MCID) on the
main outcome (pain intensity, i.e., NPRS) [43], assuming
a standard deviation of 2.1, a two-tailed test, an alpha
level (a) of 0.05, and a desired power (b) of 90%. The
estimated desired sample size was calculated to be 22
subjects per group.
Statistical Analysis
The statistical analysis was performed using SPSS soft-
ware, version 21.0 (Chicago, IL, USA). The Shapiro-
Wilks test was used to analyze the normal distribution of
6
Excluded (n=14)
♦ Not meeting inclusion criteria
(diagnosis of fibromyalgia) (n=1)
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♦ Declined to participate (dropout, not
th
reached 6 treatment) (n=13)
the data. Baseline demographic and clinical variables
were compared between both groups using independ-
ent Student t-tests for continuous data and v2 tests of
independence for categorical data when normally dis-
tributed and using the Mann-Whitney U-Test when non-
normally distributed. The primary evaluation included
mixed-model repeated measures analyses of covariance
(ANCOVAs) with time (baseline and after intervention) as
the within-subject factor and group (MNP or WAD) as
the between-subject factor and adjusted for baseline
outcomes for evaluating between-group differences in
pain intensity, neck-related disability, pain areas, and
PPTs [68]. Further, a mixed-model ANCOVA with time
(baseline and after intervention) and side (left or right) as
within-subject factors, group (MNP or WAD) as the
between-subject factor, and adjusted for baseline out-
comes was used to examine the effects of the interven-
tion on the cervical range of motion. The statistical
analysis was conducted at a 95% confidence level, and
a P value of less than 0.05 was considered statistically
significant.
Results
Between April 2013 and February 2014, 64 consecu-
tive subjects with neck pain symptoms were screened
for the eligibility criteria. Fifty (78%) subjects satisfied
all criteria and agreed to participate. The reasons for
ineligibility can be found in Figure 3, which provides a
flow diagram of the subject recruitment. Table 1 shows
 Manual Therapy in WAD and MNP

Table 1 Baseline demographics for both The mixed-model ANCOVA did not reveal a significant
groups interaction for cervical flexion/extension (Group*Time:
F ¼ 0.470, P ¼ 0.495; Group*Time*Side: F ¼ 1.739,
WAD (N ¼ 28) MNP (N ¼ 22) P ¼ 0.190), lateral-flexion (Group*Time: F ¼ 0.221,
P ¼ 0.640; Group*Time*Side: F ¼ 0.726, P ¼ 0.396), and
Gender, m/f, N 3/25 6/16 rotation (Group*Time: F ¼ 2.756, P ¼ 0.156;
Age, mean 6SD, y 43 6 13 44 6 13 Group*Time*Side: F ¼ 0.978, P ¼ 0.326); both groups
Pain intensity, mean 4.1 6 2.1 2.9 6 2.8 demonstrated similar improvements in the cervical range
6SD, 0–10 of motion (P < 0.01). Table 3 summarizes baseline and
NDI, mean 6SD, % 28.8 6 10.9 21.0 6 12.1 postintervention data, as well as within- and between-
Pain area extension, 2700.1 6 1370.5 1614.3 6 999.4 group change scores of cervical range of motion.
mean 6SD, arb
units Discussion
Pressure pain thresh-
olds, mean 6SD, The current study found no differences in short-term re-
kPa sponse in clinical outcomes between subjects with MNP

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Upper trapezius 263.1 6 118.6 307.4 6 142.3 or WAD after the application of a multimodal manual
muscle, mean 6SD therapy approach. To the best of the authors’ know-
Tibialis anterior 325.2 6 137.2 453.2 6 196.5 ledge, this is the first clinical trial investigating the re-
muscle, mean 6SD sponse to the same pragmatic manual therapy and
Cervical range of mo- exercise treatment in two neck pain populations (WAD
tion, mean 6SD, and MNP).
degrees
Flexion, mean 6SD 25.9 6 8.4 30.5 6 8.0 It is interesting to note that at baseline the WAD group
Extension, mean 36.1 6 7.5 36.1 6 8.4 showed larger pain areas, higher neck-related disability,
6SD and lower PPT in the tibialis anterior muscle than the
Left lateral flexion, 22.0 6 6.2 25.2 6 6.8
MNP group. Widespread pressure pain hyperalgesia
and large pain areas suggest high sensitization mechan-
mean 6SD
isms [69–71].
Right lateral flexion, 24.3 6 7.2 24.8 6 7.1
mean 6SD
In addition, high disability has previously been found to
Left rotation, mean 62.9 6 11.1 66.1 6 8.1
be correlated with signs of sensitization (low PPTs) in
6SD patients with chronic neck pain [72,73]. Therefore, the
Right rotation, mean 58.1 6 13.5 64.4 6 7.6 results at baseline support the idea of previous studies
6SD that patients with WAD are more sensitized than those
with MNP [15–17,32–35]. To determine potential mech-
anisms of this difference is beyond the scope of the
current study, but it is possible as MNP is more epi-
sodic than WAD. This could lead to a proper decrease
the baseline features of both groups. Subjects with in nociceptive inputs, which can turn down the patho-
WAD exhibited higher neck-related disability physiological process of central nervous system
(P ¼ 0.021), larger pain extension area (P ¼ 0.003), and hyperexcitability [74–76].
lower PPTs in the tibialis anterior muscle (P ¼ 0.009)
than those with MNP. The current clinical trial hypothesized that, assuming
these differences at baseline, it would be reasonable to
Adjusting for baseline data, the mixed-model ANCOVA believe that the WAD group would exhibit less improve-
did not find significant Group*Time interactions for pain ment after manual therapy than the MNP group as the
intensity (F ¼ 1.322, P ¼ 0.256), neck-related disability presence of widespread mechanical pain hyperalgesia
(F ¼ 0.476, P ¼ 0.494), or pain area (F ¼ 1.312, was associated with minimal improvements in individ-
P ¼ 0.258). A significant main effect of time was uals with chronic WAD [77]. Surprisingly, although indi-
observed for all clinical outcomes, with both groups viduals with MNP seem to improve more than those
experiencing similar improvements after the intervention with WAD in pain, neck-related disability, and pain area
(all P < 0.001). Similarly, no significant Group*Time inter- extension, between-group differences were not signifi-
action was observed for PPT over the trapezius muscle cant. This can be related to the fact that both groups
(F ¼ 0.001, P ¼ 0.978) or tibialis anterior muscle experienced within-group change scores and their 95%
(F ¼ 0.046, P ¼ 0.832). In this case, no main effect of confidence intervals were lower than the MCID of 2.1
time (both, P > 0.222) was found showing no significant points for neck pain. In the case of neck-related disabil-
changes in PPTs in either group. Table 2 summarizes ity, changes scored in both groups surpassed the MDID
baseline and postintervention data, as well as within- of seven points for the NDI. However, the lower bound
and between-group change scores of clinical outcomes. of the 95% confidence interval of the WAD group was

7
Castaldo et al.

Table 2 Baseline, final treatment session, and change scores of clinical and neurophysiological
outcomes

Between-group difference
Baseline, End of treatment, Within-group change in change scores
Outcome group mean 6 SD mean 6 SD scores (95% CI) (95% CI)

Neck pain intensity, 0–10

Wiplash-associated 4.1 6 2.1 2.9 6 2.6 1.2 (2.2– 0.2) 0.8 (0.5–2.1)
disorders
Mechanical neck pain 2.9 6 2.8 0.9 6 1.5 2.0 (2.9– 1.1)
Neck pain–related
disability, %
Wiplash-associated 28.8 6 11.0 19.6 6 11.3 9.2 (13.4– 4.8) 1.9 (3.6–7.4)
disorders
Mechanical neck pain 21.0 6 12.1 9.9 6 8.1 11.1 (14.3– 7.7)

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Pain area (arbitrary units)
Wiplash-associated 2,700.1 6 1,370.5 1,307.0 6 1,086.9 1393.1 (.1959.2– 827.1) 414.2 (1,141.2–312.8)
disorders
Mechanical neck pain 1,614.3 6 999.5 635.4 6 462.6 978.9 (1,409.3– 548.6)
Pressure pain thresholds in the upper trapezius muscle, kPa
Wiplash-associated 263.1 6 118.6 273.8 6 102.8 10.7 (17.2–38.5) 0.8 (59.7–61.4)
disorders
Mechanical neck pain 307.9 6 148.9 319.4 6 112.3 11.5 (49.5–72.4)
Pressure pain thresholds in the tibialis anterior muscle, kPa
Wiplash-associated 325.2 6 137.2 307.2 6 135.1 18.0 (69.8–33.9) 7.5 (78.2–63.1)
disorders
Mechanical neck pain 453.2 6 196.5 427.7 6 186.8 25.5 (73.7–22.7)

Between-group change scores are always compared in relation to the mechanical neck pain group.

Table 3 Baseline, final treatment session, and change scores of physical outcomes

Baseline, End of treatment, Within group change Between-group difference

Outcome group mean 6 SD mean 6 SD scores (95% CI) in change scores (95% CI)

Cervical flexion, degrees

Wiplash-associated disorders 25.9 6 8.4 31.0 6 7.0 5.0 (1.1–8.8) 3.7 (2.2–9.5)
Mechanical neck pain 30.5 6 8.0 31.8 6 8.1 1.3 (3.4–6.1)
Cervical extension, degrees
Wiplash-associated disorders 36.1 6 7.5 38.3 6 6.4 2.2 (0.5–5.0) 1.2 (0.7–1.7)
Mechanical neck pain 36.1 6 8.4 39.5 6 7.8 3.4 (0.3–7.0)
Cervical left side bending, degrees
Wiplash-associated disorders 22.0 6 6.2 27.5 6 6.9 5.5 (3.0–8.0) 4.4 (0.6–8.2)
Mechanical neck pain 25.2 6 6.8 26.3 6 7.3 1.1 (1.8–4.0)
Cervical right side bending, degrees
Wiplash-associated disorders 24.3 6 7.2 28.3 6 6.8 4.0 (1.9–5.9) 2.4 (0.5–5.3)
Mechanical neck pain 24.8 6 7.1 26.4 6 6.8 1.6 (0.7–3.8)
Cervical left rotation, degrees
Wiplash-associated disorders 62.9 6 11.1 66.7 6 5.5 3.8 (0.7–8.2) 1.9 (4.4–8.4)
Mechanical neck pain 66.1 6 8.1 68.0 6 7.2 1.9 (3.0–6.6)
Cervical right rotation, degrees
Wiplash-associated disorders 58.1 6 13.5 65.1 6 8.6.2 7.0 (3.4–10.8) 6.0 (0.7–11.4)
Mechanical neck pain 64.4 6 7.6 65.4 6 8.8 1.0 (3.0–5.0)

Between-group change scores are always compared in relation to the mechanical neck pain group.

8

inferior to that score. It is possible that subgroups of pa-
tients with WAD and MNP with different pain mechan-
isms exist as previously suggested [77] and that the
different treatment responses are found within the same
pain condition rather than between conditions.
Furthermore, central sensitization is not an “all or
nothing” phenomenon; different degrees may be found,
and this could have a strong influence on improvement
with manual therapy [33].
The study also demonstrated that either group experi-
enced changes in PPTs, suggesting that the multimodal
manual therapy approach did not exert any influence on
the pressure pain hyperalgesia. Discrepancies between
changes in clinical and neurophysiological outcomes are
expected, and future studies should investigate better
therapeutic approaches targeting central nervous sys-
tem excitability.
The combination of manual therapy and exercises has al-
ready been found to be more effective than exercise or
manual therapy alone in the management of neck pain
[37,38]. This clinical trial suggests that WAD subjects
seem to report similar benefits from this multimodal ap-
proach as those with MNP and they should not be con-
sidered specific subgroups for prognosis from the point of
view of the efficacy of manual therapy [78]. This is in agree-
ment with recent recommendations confirming that man-
ual therapies [79–81] and exercise [82,83] are effective
interventions for the management of neck pain disorders.
Although this is the first clinical trial investigating differ-
ent treatment responses between subjects with MNP
and WAD using a pragmatic approach, some potential
limitations should be recognized. First, the lack of a
control group not receiving treatment does not allow de-
termination of the real effectiveness of the intervention.
Second, the sample size did not allow determination of
subgroups of subjects with higher widespread pressure
pain hyperalgesia in either group, nor did it allow detec-
tion of gender differences. It would be interesting to de-
termine if these variables are related to different
treatment responses. Third, participants were recruited
from a single clinic, which may decrease the general-
izability of the results. Future multicenter studies control-
ling for site and clinician effects (cluster effects) may
enhance the generalizability of the results. Fourth, psy-
chological outcomes such as anxiety, depression, kine-
siophobia, or post-traumatic stress were not included,
which may also influence the results.
Conclusions
This study found that subjects with WAD exhibit higher
neck-related disability and widespread pressure pain
sensitivity than those with MNP. In addition, this clinical
trial observed that subjects with WAD and MNP ex-
hibited similar clinical and neurophysiological responses
after a multimodal physical therapy intervention, sug-
gesting that although substantial signs of central
Manual Therapy in WAD and MNP
sensitization are present in subjects with WAD, this
does not alter the short-term response to manual ther-
apy. Future studies should determine the existence of
subgroups of subjects with either WAD or MNP who will
benefit from a multimodal therapeutic approach includ-
ing manual therapy and exercise.
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