As both physical and psychological factors are present in both acute and chronic WAD and there is evidence of close relationships between these factors,48 management approaches should be in accordance with the current biopsychosocial model. Surprisingly for a condition that incurs significant

personal and economic burden, there have been relatively few trials of treatment compared to some other musculoskeletal IOX1 mouse pain conditions. The mainstay of management for acute WAD is the provision of advice encouraging return to usual activity and exercise, and this approach is advocated in current clinical guidelines.37 Various types of exercise have been investigated, including range-of-movement exercises, McKenzie exercises, Trichostatin A postural exercises, and strengthening and motor control exercises.49 However, the treatment effects of exercise are generally small, with recent systematic reviews concluding that there is only modest evidence available supporting activity/exercise for acute WAD.49 and 50 It is not clear which type of exercise is more effective or if specific exercise is more effective than general activity or merely advice to remain active.49 Nevertheless, activity and exercise are superior to restricting movement with a soft collar, where there is strong evidence that immobilisation (collars, rest) is ineffective

for the management of acute WAD.49 Inspection of data from clinical trials reveals that despite active approaches being superior to rest, a significant proportion of people still develop almost chronic pain and disability.51, 52, 53, 54, 55, 56, 57, 58, 59 and 60 This was also the case in a recent randomised trial conducted in emergency departments of UK hospitals. The results of the trial demonstrated that six sessions of physiotherapy (a multimodal approach of exercise and manual therapy) was only slightly more effective than a single session of advice from a physiotherapist.55 However, only 45–50% of participants in either treatment group reported their condition

as being ‘much better’ or ‘better’ at short- (4 months) and long-term follow-up (12 months) – a low recovery rate that is little different to the usual natural recovery following the injury.10 Whilst there may be a slightly greater number of treatment trials for chronic WAD than acute WAD, they are still sparse compared to other musculoskeletal conditions. A recent systematic review identified only 22 randomised trials that met the criteria for inclusion, and only 12 were of good quality.56 The authors concluded that exercise programs are effective at relieving pain, although it does not appear that these gains are maintained over the long term.56 Similar to the situation with acute WAD, it is not clear if one form of exercise is more effective than another.