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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Efficacy of postural and neck-stabilization exercises for persons with acute whiplash-associated disorders: a systematic review

K Drescher, S Hardy, J MacLean, M Schindler, K Scott, and SR Harris.

Review published: 2008.

CRD summary

This review concluded there was moderate evidence to support the use of postural exercises for reducing pain in adults with acute whiplash associated disorders, but no evidence of an increase in neck range of motion. Neck stabilisation exercises gave conflicting evidence. A cautious interpretation of these findings is advised, given the differences between the studies and the paucity of data.

Authors' objectives

To assess the effect of neck stabilisation and postural exercises on pain, neck range of motion and time off work in adults with acute whiplash-associated disorders.


MEDLINE, EMBASE, CINHAL, PEDro, Cochrane Central Registry of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews and the National Research Register were searched from inception to March 2007 for studies published in English. Search terms were reported. Reference lists of Cochrane reviews and four relevant journals were handsearched for relevant studies and experts were contacted.

Study selection

Randomised controlled trials (RCTs) or quasi-RCTs of adults (older than 18 years) with acute grade 1, 2 or 3 whiplash-associated disorders (i.e. less than six months) sustained in a motor vehicle accident, were eligible for inclusion. The intervention had to involve postural and/or neck stabilisation exercises. Included studies had to include one or more of the following outcomes: pain; range of motion; length of time off work. Studies with interventions including surgery were excluded.

The participants in the included studies were mainly female and their mean age was between 29 and 35 years old. Time after injury varied from 48 hours to 20 days after motor vehicle accident (defined as acute) or six weeks to three months after motor vehicle accident (subacute). There were a variety of included interventions; physiotherapist supported exercise programmes; postural control advice; cervical rotation exercises consistent with McKenzie principles. Controls also varied. Outcomes were measured using a variety of tools (e.g. self-efficacy scales, electronic grip force instrument).

Two reviewers independently selected studies and disagreements were resolved by consensus.

Assessment of study quality

Two reviewers independently assessed the methodological quality of the included studies using the criteria of van Tulder et al., which evaluates studies in terms of randomisation, allocation concealment, baseline similarity, blinding, co-interventions, compliance, dropouts, timing of outcome assessment, and intention-to-treat analysis. A quality score of 8 points or more indicated high quality, 4 to 7 points moderate quality and 3 or less points low quality.

Data extraction

Two reviewers independently extracted study data and reported whether differences in outcome between the study groups were statistically significant.

Methods of synthesis

The studies were pooled in a narrative synthesis, grouped by type of intervention (postural exercises, neck stabilisation exercises versus control, neck stabilisation exercises versus soft collars). A table of primary study details was available for examination of between-study differences. For each comparison, a summary of the level of evidence was presented according to the criteria of van Tulder et al.

Results of the review

Eight studies were included in the review (n=502 patients); one quasi-RCT (n=108 patients) and seven RCTs (including one pair and one triplet of RCTs, n=394 patients). Quality scores ranged from 3 to 9 points; one RCT and the triplet of RCTs were of high quality, one RCT and the pair of RCTs were of moderate quality, and one RCT was of poor quality.

For the treatment of acute whiplash-associated disorders there was moderate evidence to support use of postural exercise and advice for reducing pain and time off work (based on one RCT). Evidence was conflicting regarding the use of neck stabilisation exercises compared with control (two RCTs and the pair of RCTs), but there was moderate evidence that neck stabilisation exercises were more effective than soft collars (one quasi-RCT, the triplet of RCTs and the pair of RCTs).

Authors' conclusions

For treatment of acute whiplash-associated disorders there was moderate evidence to support the use of postural exercises for decreasing pain and time off work, but no evidence that these increased neck range of motion. The evidence for use of neck stabilisation exercises was conflicting.

CRD commentary

The research question was supported by inclusion criteria for participants, study design, intervention and outcomes. The search included six appropriate databases and there was evidence that the authors searched for unpublished studies, reducing the possibility of publication bias. Only English-language studies were sought, increasing the possibility that studies in other languages may have been missed. Primary study quality was also assessed and taken into consideration in the synthesis. Study selection, validity assessment and data extraction were performed by two reviewers, reducing the risk of reviewer error and bias. As the included studies were clinically heterogeneous, the narrative synthesis appeared appropriate. The authors' conclusions reflect the limitations of the data presented, but a cautious interpretation is advised given the differences between the studies and the paucity of data.

Implications of the review for practice and research

Practice: The authors stated that postural exercises should be of value, whereas soft collars should be used sparingly.

Research: The authors stated that future research should address the optimal frequency, intensity and duration of the different exercises.


Not stated.

Bibliographic details

Drescher K, Hardy S, MacLean J, Schindler M, Scott K, Harris SR. Efficacy of postural and neck-stabilization exercises for persons with acute whiplash-associated disorders: a systematic review. Physiotherapy Canada 2008; 60(3): 215-223. [PMC free article: PMC2792777] [PubMed: 20145754]

Other publications of related interest

Verhagen AP, Scholten-Peeters GGGM, van Wijngaarden S, de Bie R, Bierma-Zeinstra SMA. Conservative treatments for whiplash. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD003338. DOI: 10.1002/14651858.CD003338.pub3.

Lundmark H, Persson AL. Physiotherapy and management in early whiplash-associated disorders (WAD): a review. Advances in Physiotherapy 2006; 8(3): 98-105.

Indexing Status

Subject indexing assigned by CRD


Exercise; Humans; Posture; Whiplash Injuries



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 20145754

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