Fear and avoidance of activity may play a role in fostering disability in whiplash-associated disorders (WAD). This study examined the role of fear after WAD and assessed the effectiveness of 3 treatments targeting fear. People still symptomatic from WAD grade I to II injuries approximately 3 months previously (n = 191) completed questionnaires (eg, Neck Disability Index (NDI)) and were randomized to 1 of the treatments: (1) informational booklet (IB) describing WAD and the importance of resuming activities, (2) IB+didactic discussions (DD) with clinicians reinforcing the booklet, and (3) IB+imaginal and direct exposure desensitization (ET) to feared activities. DD and ET participants received three 2-hour treatment sessions. Absolute improvements in NDI were in predicted direction (ET = 14.7, DD = 11.9, IB = 9.9). ETs reported significantly less posttreatment pain severity compared with the IB (mean 1.5 versus 2.3, p < 0.001, d = 0.6) and DD (mean 1.5 versus 2.0, p = 0.039, d = 0.6) groups. Reduction in fear was the most important predictor of improvement in NDI (beta = 0.30, p < 0.001), followed by reductions in pain (beta = 0.20, p = 0.003) and depression (beta = 0.18, p = 0.004). The mediational analysis confirmed that fear reduction significantly mediated the effect of treatment group on outcome. Results highlight the importance of fear in individuals with subacute WAD and suggest the importance of addressing fear via exposure therapy and/or educational interventions to improve function.

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