Pain Science Education, Stress Management, and Cognition-Targeted Exercise Therapy in Chronic Whiplash Disorders: A Randomized Clinical Trial.

Importance: Chronic whiplash-associated disorders (cWAD) pose significant personal and societal burden, with limited evidence-based management options. Objective: To compare the efficacy of the modern pain neuroscience approach (MPNA) with usual care physiotherapy (UC) in cWAD. Design, Setting, and Participants: This multicenter randomized clinical trial with long-term follow-up was organized at 2 university hospitals and 1 regional hospital in Belgium. Participants included patients with cWAD aged 18 to 65 years. Data collection occurred between August 2017 and July 2022. Final analyses were performed from June to August 2024. Interventions: Participants were randomized into MPNA or UC and received 18 sessions during 16 weeks. MPNA included pain neuroscience education, stress management, and cognition-targeted, time-contingent exercise therapy. UC included biomedically focused education and symptom-contingent exercise therapy. Main Outcomes and Measures: The primary end point was pain-related disability (ie, Neck Disability Index) at the 6-month follow-up. Exploratory secondary outcomes included pain, pain cognitions, quality of life, physical functioning, and cost utility, with assessments until 12 months after the intervention. Results: A total of 120 participants (mean [SD] age, 41.4 [11.3] years; 89 [74.2%] women) were included. Mean neck pain-related disability decreased by 5.74 points (33.3%) in the MPNA group and 3.22 points (15.8%) in the UC group. There was no significant difference at 6 months (mean group difference [MGD], 2.38 [95% CI, -0.12 to 4.89] points; P = .15; Cohen d = 0.646), but significant differences favored MPNA immediately after treatment (MGD, 3.55 [95% CI, 1.12-6.26] points; P = .006; Cohen d = 0.999) and at 12-month follow-up (MGD, 3.54 [95% CI, 0.81-6.28] points; P = .02; Cohen d = 0.947). On an explorative basis, MPNA consistently outperformed UC in improving fear-avoidance behavior (Cohen d range, 0.906-1.112) and self-reported central sensitization symptoms (Cohen d range, 1.158-1.834) and was cost-effective, saving US $854.01 with an increase of 0.035 quality-adjusted life-years. No group differences were found for quality of life, (experimental) pain, and pain catastrophizing. However, 14 (23.3%) of the MPNA group was free of pain (ie, 0 or 1 of 10 in pain intensity score) directly after treatment vs only 3 (5.0%) in the UC group. Conclusions and Relevance: In this randomized clinical trial, no significant differences were observed between groups for the primary outcome at 6 months. MPNA was more effective than UC in reducing neck pain-related disability immediately after treatment and at 12-month follow-up, with additional benefits in pain-related anxiety, self-reported central sensitization symptoms, and cost-effectiveness. Overall, MPNA shows promise for managing cWAD. Trial Registration: ClinicalTrials.gov Identifier: NCT03239938.