{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,29]],"date-time":"2025-10-29T11:52:24Z","timestamp":1761738744457,"version":"build-2065373602"},"reference-count":36,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2025,10,27]],"date-time":"2025-10-27T00:00:00Z","timestamp":1761523200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Muscles"],"abstract":"<jats:p>Chronic whiplash-associated disorders describe a cluster of symptoms that result from a sudden neck acceleration\/deceleration movement, including pain, musculoskeletal and neurological signs, inducing functional disability. The aim of this study was to compare the effects of physiotherapy treatment based on neck-specific exercises, with or without a behavioral approach, in individuals with whiplash-associated disorders. Computerized research was performed in PubMed, PEDro, National Institute for Health and Care Excellence, and ScienceDirect to identify randomized controlled trials that evaluated the effectiveness of neck-specific exercises, with or without a behavioral approach, for chronic whiplash. For the meta-analysis, the outcomes of pain and disability were assessed. Thirteen studies were included in the systematic review, with a total of 2427 participants of both sexes, with ages between 18 and 63 years. Although interventions with a behavioral approach decreased pain and disability more significantly in 4 and 6 studies when compared to neck-specific exercises without such an approach, respectively, the meta-analysis revealed no differences between them. Although interventions for chronic whiplash-associated disorders based on neck-specific exercises with a behavioral approach seem to be more effective in reducing pain and disability, there is no quantitative difference favoring one over the other.<\/jats:p>","DOI":"10.3390\/muscles4040049","type":"journal-article","created":{"date-parts":[[2025,10,29]],"date-time":"2025-10-29T04:26:29Z","timestamp":1761711989000},"page":"49","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["The Effect of Neck-Specific Exercise with or Without a Behavioral Approach in Chronic Whiplash-Associated Disorders: A Systematic Review and Meta-Analysis"],"prefix":"10.3390","volume":"4","author":[{"given":"Lu\u00eds","family":"Correia","sequence":"first","affiliation":[{"name":"CIR, E2S, Polytechnic of Porto, Rua Dr. Ant\u00f3nio Bernardino de Almeida, 4200-072 Porto, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0133-3929","authenticated-orcid":false,"given":"Paulo","family":"Carvalho","sequence":"additional","affiliation":[{"name":"RISE-HEALTH, Center for Translational Health and Medical Biotechnology Research (TBIO), E2S, Polytechnic of Porto, Rua Dr. Ant\u00f3nio Bernardino de Almeida, 4200-072 Porto, Portugal"}]},{"given":"Lu\u00edsa","family":"Amaral","sequence":"additional","affiliation":[{"name":"FP-I3ID, FP-BHS, Escola Superior de Sa\u00fade Fernando Pessoa, Rua Delfim Maia 334, 4200-256 Porto, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9138-3972","authenticated-orcid":false,"given":"M\u00e1rio","family":"Esteves","sequence":"additional","affiliation":[{"name":"FP-I3ID, FP-BHS, Escola Superior de Sa\u00fade Fernando Pessoa, Rua Delfim Maia 334, 4200-256 Porto, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4422-8440","authenticated-orcid":false,"given":"Rui","family":"Vilarinho","sequence":"additional","affiliation":[{"name":"CIR, E2S, Polytechnic of Porto, Rua Dr. Ant\u00f3nio Bernardino de Almeida, 4200-072 Porto, Portugal"},{"name":"FP-I3ID, FP-BHS, Escola Superior de Sa\u00fade Fernando Pessoa, Rua Delfim Maia 334, 4200-256 Porto, Portugal"}]},{"given":"Mariana","family":"Cervaens","sequence":"additional","affiliation":[{"name":"FP-I3ID, FP-BHS, Escola Superior de Sa\u00fade Fernando Pessoa, Rua Delfim Maia 334, 4200-256 Porto, Portugal"},{"name":"RISE-HEALTH, Universidade Fernando Pessoa, Pra\u00e7a de 9 de Abril 349, 4249-004 Porto, Portugal"}]}],"member":"1968","published-online":{"date-parts":[[2025,10,27]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"462","DOI":"10.2519\/jospt.2017.7455","article-title":"An Integrated Model of Chronic Whiplash-Associated Disorder","volume":"47","author":"Walton","year":"2017","journal-title":"J. Orthop. Sports Phys. Ther."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1302\/2048-0105.41.360315","article-title":"Whiplash Associated Disorder","volume":"4","author":"Gwilym","year":"2015","journal-title":"Bone Jt. 360"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"739","DOI":"10.1016\/j.pmrj.2012.05.010","article-title":"A 10-Year Incidence of Acute Whiplash Injuries After Road Traffic Crashes in a Defined Population in Northern Sweden","volume":"4","author":"Styrke","year":"2012","journal-title":"PM&R"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"880","DOI":"10.1097\/j.pain.0000000000001805","article-title":"Neck Pain and Headache after Whiplash Injury: A Systematic Review and Meta-Analysis","volume":"161","author":"Ashina","year":"2020","journal-title":"Pain"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Carstensen, T.B., Fink, P., Oernboel, E., Kasch, H., Jensen, T.S., and Frostholm, L. (2015). Sick Leave within 5 Years of Whiplash Trauma Predicts Recovery: A Prospective Cohort and Register-Based Study. PLoS ONE, 10.","DOI":"10.1371\/journal.pone.0130298"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"2885","DOI":"10.1097\/00007632-199612150-00020","article-title":"The Quebec Task Force Classification for Spinal Disorders and the Severity, Treatment, and Outcomes of Sciatica and Lumbar Spinal Stenosis","volume":"21","author":"Atlas","year":"1996","journal-title":"Spine"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"305","DOI":"10.3901\/JME.2009.12.305","article-title":"Biomechanics of Whiplash Injury","volume":"12","author":"Chen","year":"2009","journal-title":"Chin. J. Traumatol. (Engl. Ed.)"},{"key":"ref_8","first-page":"466","article-title":"Biomechanics of Neck Injuries Resulting from Rear-End Vehicle Collisions","volume":"24","author":"Erbulut","year":"2014","journal-title":"Turk. Neurosurg."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"S309","DOI":"10.1097\/BRS.0b013e318238842a","article-title":"The Role of Tissue Damage in Whiplash-Associated Disorders: Discussion Paper 1","volume":"36","author":"Curatolo","year":"2011","journal-title":"Spine"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"243","DOI":"10.1007\/s10067-008-1083-x","article-title":"Rehabilitation of Chronic Whiplash: Treatment of Cervical Dysfunctions or Chronic Pain Syndrome?","volume":"28","author":"Nijs","year":"2009","journal-title":"Clin. Rheumatol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"828","DOI":"10.2340\/16501977-2374","article-title":"Factors Associated with Work Ability Following Exercise Interventions for People with Chronic Whiplash-Associated Disorders: Secondary analysis of a randomized controlled trial","volume":"50","author":"Lo","year":"2018","journal-title":"J. Rehabil. Med."},{"key":"ref_12","first-page":"351","article-title":"The Efficacy of Patient Education in Whiplash Associated Disorders: A systematic review","volume":"15","author":"Meeus","year":"2012","journal-title":"Pain Physician"},{"key":"ref_13","first-page":"487279","article-title":"A Research Synthesis of Therapeutic Interventions for Whiplash-Associated Disorder (WAD): Part 4\u2014Noninvasive Interventions for Chronic WAD","volume":"15","author":"Teasell","year":"2010","journal-title":"Pain Res. Manag."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"122","DOI":"10.1016\/j.math.2015.10.017","article-title":"Balance, Dizziness and Proprioception in Patients with Chronic Whiplash Associated Disorders Complaining of Dizziness: A Prospective Randomized Study Comparing Three Exercise Programs","volume":"22","author":"Treleaven","year":"2016","journal-title":"Man. Ther."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1016\/S0140-6736(14)60457-8","article-title":"Comprehensive Physiotherapy Exercise Programme or Advice for Chronic Whiplash (PROMISE): A Pragmatic Randomised Controlled Trial","volume":"384","author":"Michaleff","year":"2014","journal-title":"Lancet"},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Ludvigsson, M.L., Peterson, G., and Peolsson, A. (2018). Neck-Specific Exercise May Reduce Radiating Pain and Signs of Neurological Deficits in Chronic Whiplash\u2014Analyses of a Randomized Clinical Trial. Sci. Rep., 8.","DOI":"10.1038\/s41598-018-30556-w"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"640","DOI":"10.2519\/jospt.2016.6136","article-title":"Satisfaction with the Outcome of Physical Therapist\u2013Prescribed Exercise in Chronic Whiplash\u2013Associated Disorders: Secondary Analysis of a Randomized Clinical Trial","volume":"46","author":"Ardern","year":"2016","journal-title":"J. Orthop. Sports Phys. Ther."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 statement: An Updated Guideline for Reporting Systematic Reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"l4898","DOI":"10.1136\/bmj.l4898","article-title":"Rob 2: A Revised Tool for Assessing Risk of Bias in Randomised Trials","volume":"366","author":"Sterne","year":"2019","journal-title":"BMJ"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"713","DOI":"10.1093\/ptj\/83.8.713","article-title":"Reliability of the Pedro Scale for Rating Quality of Randomized Controlled Trials","volume":"83","author":"Maher","year":"2003","journal-title":"Phys. Ther."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1016\/j.jphys.2019.08.005","article-title":"Clinimetrics: Physiotherapy Evidence Database (Pedro) Scale","volume":"66","author":"Cashin","year":"2020","journal-title":"J. Physiother."},{"key":"ref_22","unstructured":"Higgins, J.P.T., Thomas, J., Chandler, J., Cumpston, M., Li, T., Page, M.J., and Welch, V.A. (2024). Cochrane Handbook for Systematic Reviews of Interventions Version 6.5 (Updated August 2024), Cochrane."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Ludvigsson, M.L., Peterson, G., and Peolsson, A. (2020). Neck-Specific Exercise for Radiating Pain and Neurological Deficits in Chronic Whiplash, a 1-Year Follow-up of a Randomised Clinical Trial. Sci. Rep., 10.","DOI":"10.1038\/s41598-020-62722-4"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"e4430","DOI":"10.1097\/MD.0000000000004430","article-title":"The Effect of Neck-Specific Exercise with or without a Behavioral Approach on Psychological Factors in Chronic Whiplash-Associated Disorders: A Randomized Controlled Trial with a 2-Year Follow-up","volume":"95","author":"Overmeer","year":"2016","journal-title":"Medicine"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"56","DOI":"10.2340\/16501977-2041","article-title":"One- and Two-Year Follow-up of a Randomized Trial of Neck-Specific Exercise with or without a Behavioural Approach Compared with Prescription of Physical Activity in Chronic Whiplash Disorder","volume":"48","author":"Ludvigsson","year":"2016","journal-title":"J. Rehabil. Med."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"465","DOI":"10.1016\/j.jmpt.2015.06.011","article-title":"The Effect of 3 Different Exercise Approaches on Neck Muscle Endurance, Kinesiophobia, Exercise Compliance, and Patient Satisfaction in Chronic Whiplash","volume":"38","author":"Peterson","year":"2015","journal-title":"J. Manip. Physiol. Ther."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"294","DOI":"10.1097\/AJP.0000000000000123","article-title":"The Effect of Neck-Specific Exercise with, or without a Behavioral Approach, on Pain, Disability, and Self-Efficacy in Chronic Whiplash-associated Disorders: A Randomized Clinical Trial","volume":"31","author":"Ludvigsson","year":"2015","journal-title":"Clin. J. Pain"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"357","DOI":"10.1007\/s11136-018-2004-3","article-title":"The Effect of Three Exercise Approaches on Health-Related Quality of Life, and Factors Associated with Its Improvement in Chronic Whiplash-Associated Disorders: Analysis of a randomized controlled trial","volume":"28","author":"Ludvigsson","year":"2019","journal-title":"Qual. Life Res."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"607","DOI":"10.23736\/S1973-9087.21.06518-7","article-title":"Neck-Related Function and Its Connection with Disability in Chronic Whiplash-Associated Disorders: Secondary Analysis of a Randomized Controlled Study","volume":"57","author":"Peterson","year":"2021","journal-title":"Eur. J. Phys. Rehabil. Med."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"307","DOI":"10.1002\/ejp.729","article-title":"Factors Associated with Pain and Disability Reduction Following Exercise Interventions in Chronic Whiplash","volume":"20","author":"Ludvigsson","year":"2016","journal-title":"Eur. J. Pain"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"e7274","DOI":"10.1097\/MD.0000000000007274","article-title":"Cost-Effectiveness of Neck-Specific Exercise with or without a Behavioral Approach Versus Physical Activity Prescription in the Treatment of Chronic Whiplash-Associated Disorders: Analyses of a Randomized Clinical Trial","volume":"96","author":"Ludvigsson","year":"2017","journal-title":"Medicine"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"694","DOI":"10.2519\/jospt.2010.3396","article-title":"Comparison of Graded Exercise and Graded Exposure Clinical Outcomes for Patients with Chronic Low Back Pain","volume":"40","author":"George","year":"2010","journal-title":"J. Orthop. Sports Phys. Ther."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"2564","DOI":"10.1097\/00007632-200211150-00033","article-title":"Behavioral and Cognitive\u2013Behavioral Treatment for Chronic Pain: Outcome, Predictors of Outcome, and Treatment Process","volume":"27","author":"McCracken","year":"2002","journal-title":"Spine"},{"key":"ref_34","first-page":"pzab259","article-title":"Effectiveness of Specific Neck Exercise for Nonspecific Neck Pain; Usefulness of Strategies for Patient Selection and Tailored Exercise\u2014A Systematic Review with Meta-Analysis","volume":"102","author":"Falla","year":"2021","journal-title":"Phys. Ther."},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Sanabria-Mazo, J.P., Colomer-Carbonell, A., Fern\u00e1ndez-V\u00e1zquez, \u00d3., Noboa-Rocamora, G., Cardona-Ros, G., McCracken, L.M., Montes-P\u00e9rez, A., Casta\u00f1o-Asins, J.R., Edo, S., and Borr\u00e0s, X. (2023). A Systematic Review of Cognitive Behavioral Therapy-Based Interventions for Comorbid Chronic Pain and Clinically Relevant Psychological Distress. Front. Psychol., 14.","DOI":"10.3389\/fpsyg.2023.1200685"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1016\/j.jphys.2013.12.004","article-title":"Physiotherapy Management of Whiplash-Associated Disorders (WAD)","volume":"60","author":"Sterling","year":"2014","journal-title":"J. Physiother."}],"container-title":["Muscles"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2813-0413\/4\/4\/49\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,29]],"date-time":"2025-10-29T05:23:33Z","timestamp":1761715413000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2813-0413\/4\/4\/49"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,10,27]]},"references-count":36,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2025,12]]}},"alternative-id":["muscles4040049"],"URL":"https:\/\/doi.org\/10.3390\/muscles4040049","relation":{},"ISSN":["2813-0413"],"issn-type":[{"value":"2813-0413","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,10,27]]}}}