Risk factors for chronic disability in a cohort of patients with acute whiplash associated disorders seeking physiotherapy treatment for persisting symptoms

Results of neck-specific exercise for altered postural sway in individuals with chronic whiplash-associated disorders: a longitudinal case-control study

Postural sway has not been investigated before or after a neck exercise intervention in individuals with chronic whiplash-associated disorders (WAD). The aim of the study was to investigate postural sway in individuals with chronic WAD grades 2 and 3: (a) compared with healthy matched controls at baseline; (b) after three months of neck-specific exercise and (c) to investigate the correlation between postural sway with self-reported dizziness during motion and balance problems/unsteadiness. This is a longitudinal prospective experimental case-control intervention study. Individuals with WAD (n = 30) and age- and gender-matched healthy volunteers (n = 30) participated. Postural sway was assessed using an iPhone application. Measurements were carried out at baseline, and for those with WAD a second measurement was performed at the three-month follow-up when neck-specific exercise intervention ended. The WAD group performed significantly worse than the healthy group in both pathway and ellipse area double stance eyes closed at baseline (main outcome), but not at the three-month follow-up. The WAD group significantly improved after rehabilitation in both pathway double stance eyes closed and pathway single stance eyes open. The correlation between postural sway and self-rated dizziness during motion and balance problems was low to moderate. One may conclude that postural sway was improved after a neck-specific exercise programme. The study results strengthen earlier findings that individuals with WAD have worse balance outcome when they have to rely on neck proprioception (eyes closed). The study results may be important for the development of improved rehabilitation methods for WAD.

Which muscles exhibit increased stiffness in people with chronic neck pain? A systematic review with meta-analysis

Introduction

Chronic neck pain (CNP) substantially impacts quality of life, posing both personal challenges and economic strains. This systematic review sought to discern muscle-specific stiffness differences between CNP patients and individuals without CNP.

Methods

We searched the PubMed, Scopus, and PEDro databases for studies using ultrasound elastography or myotonometry to compare muscle stiffness between CNP patients and asymptomatic controls. Using a meta-analysis with a random-effects model, we derived the pooled effect as standardized mean difference (SMD).

Results

Out of the six studies selected, the adjusted Newcastle-Ottawa rating scale for cross-sectional studies denoted three as moderate-quality and three as high-quality. Our findings indicate that the upper trapezius (UT) stiffness was elevated in CNP patients compared to their counterparts without CNP (SMD = 0.39, 95% CI = 0.05 to 0.74; p = 0.03; small effect size). The data for other muscles remained inconclusive.

Discussion

Given the case-control design of all reviewed studies, a direct causative link between UT stiffness and CNP is yet to be confirmed. As such, recommending a reduction in trapezius muscle stiffness as a primary rehabilitation strategy for CNP patients is still inconclusive and further research is needed.

Cervical and scapula-focused resistance exercise program versus trapezius massage in patients with chronic neck pain: A randomized controlled trial

OBJECTIVE

The purpose of this study was to investigate the effects of resistance exercise in comparison with those of common exercise on chronic neck pain (CNP) to provide useful clinical guidelines for reducing pain or increasing cervical range of motion (ROM), upper trapezius tone, disability level, and quality of life (QOL).

METHODS

The subjects were randomized into a cervical and scapula-focused resistance exercise group (CSREG, n = 21) or trapezius massage group (TMG, n = 20). All groups received a 4-week, five times per week CSRE or TM program for CNP. The visual analogue scale (VAS) score, cervical ROM, myotonometer measures (upper trapezius tone, stiffness, and elasticity), neck disability index (NDI), and short form-36 (SF-36) were identified as the primary outcomes.

RESULTS

Within-group changes in VAS, cervical ROM, myotonometer measures, NDI, and SF-36 were significant in the CSREG and TMG (P < .05). The between-group changes in VAS, cervical rotation, myotonometer (upper trapezius tone and stiffness), NDI, and SF-36 after intervention showed significant differences between the CSREG and TMG (P < .05).

CONCLUSION

These results suggest that the CSRE program is effective in improving pain, cervical ROM, upper trapezius tone, disability level, and QOL in patients with CNP. More comprehensive studies with longer follow-up durations are needed to better understand the potential effects of the CSRE program in patients with CNP.

Negative Psychological Factors' Influence on Delayed Onset Muscle Soreness Intensity, Reduced Cervical Function and Daily Activities in Healthy Participants

We examined the influence of negative psychological factors (catastrophizing, distress and kinesiophobia) on delayed onset muscle soreness (DOMS) intensity, cervical function (strength and range of motion) and on daily activities (ADL), and the suitability of an exercise protocol designed to induce DOMS within the cervical region. Psychological factors and cervical function were assessed in 86 healthy participants at baseline before applying a DOMS provocation protocol in the cervical flexor muscles. After 24hour, cervical function was reassessed. In addition, at 24hour and 48hour, the intensity of DOMS and its impact on ADL were assessed using the visual analog scale (VAS). The protocol was effective given that it generated low-moderate intensity DOMS (VAS≈30 -40mm) and a statistically significant reduction in cervical strength and range of motion. Psychological distress (anxiety and depression), but not kinesiophobia and catastrophism, predicted a loss of cervical strength (explained 43% of the variance) and range of motion (explained 22% of the variance) after induction of DOMS. In addition, participants' anxiety level predicted DOMS intensity at 24hour (explained 19% of the variance). PERSPECTIVE: The present findings highlight the relevance of evaluating psychological distress as a preventive/therapeutic measure, given that high levels of distress could lead to more intense and disabling pain in acute injuries, and all these aspects are considered risk factors for the chronification of symptoms.

Socioeconomic status and ADL disability of the older adults: Cumulative health effects, social outcomes and impact mechanisms

INTRODUCTION

Socioeconomic status (SES) is one of the important indicators affecting individual's social participation and resource allocation, and it also plays an important role in the health shock of individuals. Faced by the trend of aging society, more and more nations across the world began to pay attention to prevent the risk of health shock of old adults.

METHODS

Based on the data of China Health and Retirement Longitudinal Study (CHARLS) in 2013, 2015 and 2018, this study uses path analysis and ologit model to empirically estimate the effects of SES and health shock on the activities of daily living (ADL) disability of old adults.

RESULTS

As a result, first, it was found that SES has significant impact on the disability of old adults. Specifically, economic conditions (income) plays dominant role. Economic status affects the risk of individual disability mainly through life security and health behavior. Secondly, SES significantly affecting health shock, with education and economic status showing remarkable impact, and there is an apparent group inequality. Furthermore, taking high education group as reference, the probability of good sight or hearing ability of the low education group was only 49.76% and 63.29% of the high education group, respectively, while the rates of no pain and severe illness were 155.50% and 54.69% of the high education group. At last, the estimation of path effect of SES on ADL disability indicates evident group inequality, with health shock plays critical mediating role.

CONCLUSIONS

SES is an important factor influencing residents' health shock, and health shocks like cerebral thrombosis and cerebral hemorrhage will indirectly lead to the risk of individual ADL disability. Furthermore, among the multi-dimensional indicators of SES, individual income and education are predominant factors affecting health shock and ADL disability, while occupation of pre-retirement have little impact.

There's Nothing Broken. You've Had a Whiplash, That's It: A Qualitative Study of Comorbid Posttraumatic Stress Disorder and Whiplash Associated Disorders

BACKGROUND

Posttraumatic stress disorder (PTSD) symptoms are common in chronic Whiplash associated disorders (WAD) and have been found to be associated with higher levels of pain and disability. Theoretical frameworks have suggested that PTSD and pain not only coexist, but also mutually maintain one another. Although the comorbidity has been subject to increasing quantitative research, patients' experiences of the comorbidity and symptom interaction remain largely uninvestigated using qualitative methods.

OBJECTIVE

The present study set out to explore the potential relationship of PTSD and pain in people with WAD and properly assessed PTSD after motor vehicle accidents.

METHODS

A qualitative explorative study of eight individual face-to-face semistructured interviews were conducted. Interviews were recorded and transcribed verbatim and analyzed using framework analysis.

RESULTS

Through the analysis, we developed three overarching themes. The first theme illustrated the complex and burdensome comorbidity with overlapping and transdiagnostic symptoms, whereas the second theme highlighted how several circumstances, some related to the health care system, could extend and amplify the traumatic response. The final theme illustrated symptom associations and interactions, particularly between pain and PTSD, both supporting and rejecting parts of the mutual maintenance framework.

CONCLUSIONS

These findings underlined the great complexity and variability of the comorbidity and the traumatic event, but also emphasized how experiences of psyche and soma seem closely connected in these patients. The results provide support for the importance of thorough assessment by multidisciplinary teams, minimizing distress post-injury, and a critical approach to the idea of mutual maintenance between pain and PTSD.

The effect of indirect vision skills on head and shoulder posture amongst Korean dental hygienists

OBJECTIVES

This study aimed to investigate the effects of indirect vision skills on head and shoulder posture in dental hygienists.

MATERIALS AND METHODS

This cross-sectional study included a total of 100 female clinical dental hygienists. It evaluated musculoskeletal symptoms of the neck, shoulders and back, head and shoulder posture (craniovertebral angle [CVA] and sagittal shoulder posture angle [SSPA]). Indirect vision skills were assessed using the O'Connor tweezer test under indirect vision with a mirror. To analyse factors associated with the CVA and SSPA, an independent t test, one-way ANOVA, and multiple linear regression analysis were conducted, respectively.

RESULTS

The body region in which the greatest number of symptoms of work-related musculoskeletal disorders was recognised was the neck (89.0%). In the multiple linear regression model, which adjusted for other factors associated with musculoskeletal disorders, dental hygienists with poor indirect vision skills showed relatively small SSPA value (P < .05). However, indirect vision skills were not associated with the CVA value.

CONCLUSIONS

Good indirect vision skills contribute to the prevention of rounded shoulders in dental hygienists. Therefore, where possible, dental hygienists should perform clinical procedures using indirect vision with a dental mirror to maintain a balanced posture and reduce flexion of the back or the neck. A dental hygiene curriculum should include training to improve clinical skills, as well as education regarding dental ergonomics and a monitoring system to determine whether ergonomic principles are well observed.

Is kinesiophobia and pain catastrophising at baseline associated with chronic pain and disability in whiplash-associated disorders? A systematic review

BACKGROUND

Kinesiophobia and pain catastrophising may be associated with patients' transition from having acute to chronic pain following a whiplash injury.

OBJECTIVE

To systematically review and critically appraise the literature to determine whether kinesiophobia and pain catastrophising are associated with greater likelihood of patients developing chronic pain and disability following a whiplash injury.

DESIGN

A systematic review of the literature DATA SOURCES: Electronic searches of PubMed, AMED, CINAHL, PsycINFO, and PubPsych, and grey literature were undertaken from inception to September 2017.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Study selection was based on longitudinal studies evaluating how kinesiophobia and/or pain catastrophising at baseline are associated with pain intensity, disability or both after a whiplash injury.

RESULTS

We included 14 longitudinal studies that described 12 independent cohorts with a total sample of 2733 participants with whiplash-associated disorder. Kinesiophobia at baseline was not associated with pain intensity over time (three studies). Whether kinesiophobia at baseline was associated with disability was unclear as results were conflicting (six studies). There were also conflicting results when we examined the association between pain catastrophising and both pain intensity (five studies) and disability (eight studies).

SUMMARY/CONCLUSIONS

Kinesiophobia at baseline was not associated with pain intensity over time. There were conflicting results for the remaining analyses. The size of the associations was small. The overall quality of the evidence was very low.

TRIAL REGISTRATION NUMBER

CRD42016053864.

Acceptance: a factor to consider in persistent pain after neck trauma

Background and aims

Studies on the interaction between acceptance and pain-related processes after neck trauma are to our knowledge sparse and such treatment strategies are rarely incorporated in management and treatment of posttraumatic neck pain. Thus, the aim of the present study is to investigate how acceptance relates to persistent pain in patients after neck trauma, when controlling for the influence of other psychological factors, trauma characteristics and demographic variables.

Methods

Consecutive patients with persistent pain and disability after neck trauma (n = 565) were assessed by a multi-professional team at a specialized pain rehabilitation clinic. Separate regression analyses were conducted with three outcomes: pain distribution, pain interference, and pain severity. Predictors were age, sex, education, time since trauma, type of trauma, anxiety, depression, and acceptance.

Results

Acceptance was the only factor associated with all outcomes, and patients with lower acceptance displayed more widespread pain and greater interference and severity of pain. The results also showed that higher depression was associated with worse pain interference and severity, whilst anxiety only mattered significantly for pain severity and not for pain interference. Female sex was related to more widespread pain and greater pain interference.

Conclusions

Overall acceptance stood out as the most important factor for the different outcomes and lower acceptance was associated with more widespread pain distribution and greater pain interference and severity.

Implications

The findings of this study add to a growing body of literature confirming that the development of chronicity after neck trauma should be understood as a multidimensional process, best described by a biopsychosocial model. The results also suggest that psychological factors and especially acceptance might be important processes with implications for enhanced recovery after neck trauma.

A cluster randomised, double-blind pilot and feasibility trial of an active behavioural physiotherapy intervention for acute whiplash-associated disorder (WAD)II

Whiplash-associated disorder (WAD) causes substantial social and economic burden, with ≥70% patients classified as WADII (neck complaint and musculoskeletal sign(s)). Effective management in the acute stage is required to prevent development of chronicity; an issue for 60% of patients. An Active Behavioural Physiotherapy Intervention (ABPI) was developed to address both physical and psychological components of WAD. The ABPI is a novel complex intervention designed through a rigorous sequential multiphase project to prevent transition of acute WAD to chronicity. An external pilot and feasibility cluster randomised double-blind (assessor, participants) parallel two-arm clinical trial was conducted in the UK private sector. The trial compared ABPI versus standard physiotherapy to evaluate trial procedures and feasibility of the ABPI for managing acute WADII in preparation for a future definitive trial. Six private physiotherapy clinics were recruited and cluster randomised using a computer-generated randomisation sequence. Twenty-eight (20 ABPI, 8 standard physiotherapy) participants [median age 38.00 (IQR = 21.50) years] were recruited. Data were analysed descriptively with a priori establishment of success criteria. Ninety-five percent of participants in the ABPI arm fully recovered (Neck Disability Index ≤4, compared to 17% in the standard physiotherapy arm); required fewer treatment sessions; and demonstrated greater improvement in all outcome measures (pain intensity, Cervical Range of Motion, Pressure Pain Threshold, EuroQol-5 Dimensions) except for the Impact of Events Scale and Fear Avoidance Beliefs Questionnaire. The findings support the potential value of the ABPI, and that an adequately powered definitive trial to evaluate effectiveness (clinical, cost) is feasible with minor modifications to procedures.

Thoracic dysfunction in whiplash associated disorders: A systematic review

BACKGROUND

Research investigating Whiplash Associated Disorder (WAD) has largely focused on the cervical spine yet symptoms can be widespread. Thoracic spine pain prevalence is reported ~66%; perhaps unsurprising given the forceful stretch/eccentric loading of posterior structures of the spine, and the thoracic spine's contribution to neck mobility/function. Approximately 50% WAD patients develop chronic pain and disability resulting in high levels of societal and healthcare costs. It is time to look beyond the cervical spine to fully understand anatomical dysfunction in WAD and provide new directions for clinical practice and research.

PURPOSE

To evaluate the scope and nature of dysfunction in the thoracic region in patients with WAD.

METHODS

A systematic review and data synthesis was conducted according to a pre-defined, registered (PROSPERO, CRD42015026983) and published protocol. All forms of observational study were included. A sensitive topic-based search strategy was designed from inception to 1/06/16. Databases, grey literature and registers were searched using a study population terms and key words derived from scoping search. Two reviewers independently searched information sources, assessed studies for inclusion, extracted data and assessed risk of bias. A third reviewer checked for consistency and clarity. Extracted data included summary data: sample size and characteristics, outcomes, and timescales to reflect disorder state. Risk of bias was assessed using the Newcastle-Ottawa Scale. Data were tabulated to allow enabling a semi-qualitative comparison and grouped by outcome across studies. Strength of the overall body of evidence was assessed using a modified GRADE.

RESULTS

Thirty eight studies (n>50,000) which were conducted across a range of countries were included. Few authors responded to requests for further data (5 of 9 contacted). Results were reported in the context of overall quality and were presented for measures of pain or dysfunction and presented, where possible, according to WAD severity and time point post injury. Key findings include: 1) high prevalence of thoracic pain (>60%); higher for those with more severe presentations and in the acute stage, 2) low prevalence of chest pain (<22%), 3) evidence of thoracic outlet syndrome, with some association to and involvement of the brachial plexus, 4) muscle dysfunction in the form of heightened activity of the sternocleidomastoid or delayed onset of action of the serratus anterior, 5) high prevalence of myofascial pain and trigger points in the scalene muscles, sternocleidomastoid and mid/lower fibres of trapezius muscle (48-65%), and 6) inconclusive evidence of altered thoracic posture or mobility.

CONCLUSIONS

Considerable evidence supports thoracic pain and dysfunction in patients with WAD, involving primarily nerves and muscles. Notwithstanding the low/very low level of evidence from this review, our findings do support a more extensive clinical evaluation of patients presenting with WAD. Additional high quality research is required to further characterise dysfunction across other structures in the thoracic region, including but not limited to the thoracic spine (mobility and posture) and thoracic muscles (stiffness, activation patterns). In turn this may inform the design of clinical trials targeting such dysfunction.

Few promising multivariable prognostic models exist for recovery of people with non-specific neck pain in musculoskeletal primary care: a systematic review

QUESTION

Which multivariable prognostic model(s) for recovery in people with neck pain can be used in primary care?

DESIGN

Systematic review of studies evaluating multivariable prognostic models.

PARTICIPANTS

People with non-specific neck pain presenting at primary care.

DETERMINANTS

Baseline characteristics of the participants.

OUTCOME MEASURES

Recovery measured as pain reduction, reduced disability, or perceived recovery at short-term and long-term follow-up.

RESULTS

Fifty-three publications were included, of which 46 were derivation studies, four were validation studies, and three concerned combined studies. The derivation studies presented 99 multivariate models, all of which were at high risk of bias. Three externally validated models generated usable models in low risk of bias studies. One predicted recovery in non-specific neck pain, while two concerned participants with whiplash-associated disorders (WAD). Discriminative ability of the non-specific neck pain model was area under the curve (AUC) 0.65 (95% CI 0.59 to 0.71). For the first WAD model, discriminative ability was AUC 0.85 (95% CI 0.79 to 0.91). For the second WAD model, specificity was 99% (95% CI 93 to 100) and sensitivity was 44% (95% CI 23 to 65) for prediction of non-recovery, and 86% (95% CI 73 to 94) and 55% (95% CI 41 to 69) for prediction of recovery, respectively. Initial Neck Disability Index scores and age were identified as consistent prognostic factors in these three models.

CONCLUSION

Three externally validated models were found to be usable and to have low risk of bias, of which two showed acceptable discriminative properties for predicting recovery in people with neck pain. These three models need further validation and evaluation of their clinical impact before their broad clinical use can be advocated.

REGISTRATION

PROSPERO CRD42016042204. [Wingbermühle RW, van Trijffel E, Nelissen PM, Koes B, Verhagen AP (2018) Few promising multivariable prognostic models exist for recovery of people with non-specific neck pain in musculoskeletal primary care: a systematic review. Journal of Physiotherapy 64: 16-23].

Prediction models of health-related quality of life in different neck pain conditions: a cross-sectional study

PURPOSE

The main aim of the study was to predict the health-related quality of life (HRQoL) based on physical, functional, and psychological measures in patients with different types of neck pain (NP).

MATERIALS AND METHODS

This cross-sectional study included 202 patients from a primary health center and the physiotherapy outpatient department of a hospital. Patients were divided into four groups according to their NP characteristics: chronic (CNP), acute whiplash (WHIP), chronic NP associated with temporomandibular dysfunction (NP-TMD), or chronic NP associated with chronic primary headache (NP-PH). The following measures were performed: Short Form-12 Health Survey (SF-12), Neck Disability Index (NDI), visual analog scale (VAS), State-Trait Anxiety Inventory (STAI), Beck Depression Inventory (BECK), and cervical range of movement (CROM).

RESULTS

The regression models based on the SF-12 total HRQoL for CNP and NP-TMD groups showed that only NDI was a significant predictor of the worst HRQoL (48.9% and 48.4% of the variance, respectively). In the WHIP group, the regression model showed that BECK was the only significant predictor variable for the worst HRQoL (31.7% of the variance). Finally, in the NP-PH group, the regression showed that the BECK, STAI, and VAS model predicted the worst HRQoL (75.1% of the variance).

CONCLUSION

Chronic nonspecific NP and chronic NP associated with temporomandibular dysfunction were the main predictors of neck disability. In addition, depression, anxiety, and pain were the main predictors of WHIP or primary headache associated with CNP.

Prognostic factors for recovery following acute lateral ankle ligament sprain: a systematic review

Background

One-third of individuals who sustain an acute lateral ankle ligament sprain suffer significant disability due to pain, functional instability, mechanical instability or recurrent sprain after recovery plateaus at 1 to 5 years post injury. The identification of early prognostic factors associated with poor recovery may provide an opportunity for early-targeted intervention and improve outcome.

Methods

We performed a comprehensive search of AMED, EMBASE, Psych Info, CINAHL, SportDiscus, PubMed, CENTRAL, PEDro, OpenGrey, abstracts and conference proceedings from inception to September 2016. Prospective studies investigating the association between baseline prognostic factors and recovery over time were included. Two independent assessors performed the study selection, data extraction and quality assessment of the studies. A narrative synthesis is presented due to inability to meta-analyse results due to clinical and statistical heterogeneity.

Results

The search strategy yielded 3396 titles/abstracts after duplicates were removed. Thirty-six full text articles were then assessed, nine of which met the study inclusion criteria. Six were prospective cohorts, and three were secondary analyses of randomised controlled trials. Results are presented for nine studies that presented baseline prognostic factors for recovery after an acute ankle sprain. Age, female gender, swelling, restricted range of motion, limited weight bearing ability, pain (at the medial joint line and on weight-bearing dorsi-flexion at 4 weeks, and pain at rest at 3 months), higher injury severity rating, palpation/stress score, non-inversion mechanism injury, lower self-reported recovery, re-sprain within 3 months, MRI determined number of sprained ligaments, severity and bone bruise were found to be independent predictors of poor recovery. Age was one prognostic factor that demonstrated a consistent association with outcome in three studies, however cautious interpretation is advised.

Conclusions

The associations between prognostic factors and poor recovery after an acute lateral ankle sprain are largely inconclusive. At present, there is insufficient evidence to recommend any factor as an independent predictor of outcome. There is a need for well-conducted prospective cohort studies with adequate sample size and long-term follow-up to provide robust evidence on prognostic factors of recovery following an acute lateral ankle sprain.

Trial registration

Prospero registration: CRD42014014471

Electronic supplementary material

The online version of this article (10.1186/s12891-017-1777-9) contains supplementary material, which is available to authorized users.

Motor evoked potentials in patients with chronic whiplash-associated disorder grade II

BACKGROUND AND PURPOSE

It is common belief that psychological problems influence the persistence of complains in patients with so-called mild whiplash-associated disorders (WADs). The usefulness of motor evoked potentials (MEPs) is investigated in patients with grade II WAD and remaining complains for more than 6 months.

PATIENTS AND METHODS

Twenty consecutive patients, aged between 24 and 58 years, with persistent neck pain for months after a car accident were included. All patients had a magnetic resonance imaging (MRI) of the cervical spine and cord. Central (CMCT) and peripheral motor conduction times (PMCT) were evaluated by registration in the biceps brachii muscle (C5-C6) and in the abductor digiti minimi muscle (C7-C8-Th1).

RESULTS

Thirteen patients had prolonged CMCT or/and PMCT compared to 7 with normal values. On MRI discus bulging C5-C6, without abnormal signal changes in the cervical spinal cord was observed in 6 of the patients with disturbed MEPs compared to 3 without. Out of 7 patients, who had repeated MEPs after 6 months, 3 of them had an improvement of their conduction time. The patients with prolonged MEP conduction times were older than those with normal values (p=0.007).

CONCLUSIONS

MEP examination has to be performed in all patients with persistent complains even in the absence of objective neurological signs and non-significant changes on imaging.

Clinical prediction rules for prognosis and treatment prescription in neck pain: A systematic review

Clinical prediction rules (CPRs) developed to identify sub-groups of people with neck pain for different prognoses (i.e. prognostic) or response to treatments (i.e. prescriptive) have been recommended as a research priority to improve health outcomes for these conditions. A systematic review was undertaken to identify prognostic and prescriptive CPRs relevant to the conservative management of adults with neck pain and to appraise stage of development, quality and readiness for clinical application. Six databases were systematically searched from inception until 4th July 2016. Two independent reviewers assessed eligibility, risk of bias (PEDro and QUIPS), methodological quality and stage of development. 9840 records were retrieved and screened for eligibility. Thirty-two studies reporting on 26 CPRs were included in this review. Methodological quality of included studies varied considerably. Most prognostic CPR development studies employed appropriate designs. However, many prescriptive CPR studies (n = 12/13) used single group designs and/or analysed controlled trials using methods that were inadequate for identifying treatment effect moderators. Most prognostic (n = 11/15) and all prescriptive (n = 11) CPRs have not progressed beyond the derivation stage of development. Four prognostic CPRs relating to acute whiplash (n = 3) or non-traumatic neck pain (n = 1) have undergone preliminary validation. No CPRs have undergone impact analysis. Most prognostic and prescriptive CPRs for neck pain are at the initial stage of development and therefore routine clinical use is not yet supported. Further validation and impact analyses of all CPRs are required before confident conclusions can be made regarding clinical utility.

Recovery Pathways and Prognosis After Whiplash Injury

Synopsis Recovery from a whiplash injury is varied and complex. Some individuals recover quickly and fully, while others experience ongoing pain and disability. Three distinct patterns of predicted recovery (trajectories) have been identified using disability and psychological outcome measures. These trajectories are not linear, and show that recovery, if it is going to occur, tends to happen within the first 3 months of the injury, with little improvement after this period. Identification of factors associated with poor recovery is accumulating, and since 2000 there have been at least 10 published systematic reviews on prognostic factors for whiplash-associated disorder. Poor recovery has been consistently reported to be associated with high initial neck pain intensity and neck-related disability, posttraumatic stress symptoms, pain catastrophizing, and, to a lesser extent, low self-efficacy and cold hyperalgesia. Evidence regarding factors, including compensation status, psychological factors, structural pathology, and preinjury health status, remains equivocal. Given the huge number of predictive factors and various interpretations of recovery, adapting these data for use in clinical practice is difficult. Tools such as clinical prediction rules (CPRs), by statistically quantifying relevant data, may help to predict the probability of diagnosis, prognosis, or response to treatment. Numerous CPRs have been derived for individuals with whiplash; however, to date, only 3 prognostic CPRs have undergone external validation, and none have yet undergone impact analysis, a necessary step in providing information about the rules' ability to improve clinically relevant outcomes. J Orthop Sports Phys Ther 2016;46(10):851-861. Epub 3 Sep 2016. doi:10.2519/jospt.2016.6918.

Does a combination of physical training, specific exercises and pain education improve health-related quality of life in patients with chronic neck pain? A randomised control trial with a 4-month follow up

AIM

To investigate the effect of combining pain education, specific exercises and graded physical activity training (exercise) compared with pain education alone (control) on physical health-related quality of life (HR-QoL) in chronic neck pain patients.

METHODS

A multicentre randomised controlled trial of 200 neck pain patients receiving pain education. The exercise group received additional exercises for neck/shoulder, balance and oculomotor function, plus graded physical activity training. Patient-reported outcome measures (Short Form-36 Physical and Mental component summary scores, EuroQol-5D, Beck Depression Inventory-II, Neck Disability Index, Pain Bothersomeness, Patient-Specific Functioning Scale, Tampa Scale of Kinesiophobia, Global Perceived Effect) and clinical tests (Aastrand Physical Fitness, cervical Range of Motion, Pressure Pain Threshold at infraspinatus, tibialis anterior and cervical spine, Cranio-cervical Flexion, Cervical Extension muscle function, and oculomotion) were recorded at baseline and after 4 months.

RESULTS

The exercise group showed statistically significant improvement in physical HR-QoL, mental HR-QoL, depression, cervical pressure pain threshold, cervical extension movement, muscle function, and oculomotion. Per protocol analyses confirmed these results with additional significant improvements in the exercise group compared with controls.

CONCLUSIONS

This multimodal intervention may be an effective intervention for chronic neck pain patients.

TRIAL REGISTRATION

The trial was registered on www.ClinicalTrials.govNCT01431261 and at the Regional Scientific Ethics Committee of Southern Denmark S-20100069.

Predicting nonrecovery among whiplash patients in the emergency room and in an insurance company setting

PURPOSE

To construct and validate a prediction instrument for early identification of patients with a high risk of delayed recovery after whiplash injuries (PPS-WAD) in an insurance company setting.

METHODS

Prospective cohort study. On the basis of a historic cohort (n = 130) of patients with a whiplash injury identified in an emergency room (ER, model-building set), we used logistic regression to construct an instrument consisting of two demographic variables (i.e. questions of educational level and work status) and the patient-rated physical and mental status during the acute phase to predict self-reported nonrecovery after 6 months. We evaluated the instrument's ability to predict nonrecovery in a new cohort (n = 204) of patients originating from an insurance company setting (IC, validation set).

RESULTS

The prediction instrument had low reproducibility when the setting was changed from the ER cohort to the IC cohort. The overall percentage of correct predictions of nonrecovery in the ER cohort was 78 % compared with 62 % in the IC cohort. The sensitivity and specificity in relation to nonrecovery were both 78 % in the ER cohort. The sensitivity and specificity in the insurance company setting was lower, 67 and 50 %.

CONCLUSION

Clinical decision rules need validation before they are used in a new setting. An instrument consisting of four questions with an excellent possibility of identifying patients with a high risk of nonrecovery after a whiplash injury in the emergency room was not as useful in an insurance company setting. The importance and type of the risk factors for not recovering probably differ between the settings, as well as the individuals.

Acute Whiplash Injury Study (AWIS): a protocol for a cluster randomised pilot and feasibility trial of an Active Behavioural Physiotherapy Intervention in an insurance private setting

INTRODUCTION

Whiplash-associated disorder (WAD) causes substantial social and economic burden internationally. Up to 60% of patients with WAD progress to chronicity. Research therefore needs to focus on effective management in the acute stage to prevent the development of chronicity. Approximately 93% of patients are classified as WADII (neck complaint and musculoskeletal sign(s)), and in the UK, most are managed in the private sector. In our recent systematic review, a combination of active and behavioural physiotherapy was identified as potentially effective in the acute stage. An Active Behavioural Physiotherapy Intervention (ABPI) was developed through combining empirical (modified Delphi study) and theoretical (social cognitive theory focusing on self-efficacy) evidence. This pilot and feasibility trial has been designed to inform the design of an adequately powered definitive randomised controlled trial.

METHODS AND ANALYSIS

Two parallel phases. (1) An external pilot and feasibility cluster randomised double-blind (assessor and participants), parallel two-arm (ABPI vs standard physiotherapy) clinical trial to evaluate procedures and feasibility. Six UK private physiotherapy clinics will be recruited and cluster randomised by a computer-generated randomisation sequence. Sixty participants (30 each arm) will be assessed at recruitment (baseline) and at 3 months postbaseline. The planned primary outcome measure is the neck disability index. (2) An embedded exploratory qualitative study using semistructured indepth interviews (n=3-4 physiotherapists) and a focus group (n=6-8 patients) and entailing the recruitment of purposive samples will explore perceptions of the ABPI. Quantitative data will be analysed descriptively. Qualitative data will be coded and analysed deductively (identify themes) and inductively (identify additional themes).

ETHICS AND DISSEMINATION

This trial is approved by the University of Birmingham Ethics Committee (ERN_15-0542).

TRIAL REGISTRATION NUMBER

ISRCTN84528320.

Importance of psychological factors for the recovery from a first episode of acute non-specific neck pain - a longitudinal observational study

Background

The influence of psychological factors on acute neck pain is sparsely studied. In a secondary analysis of prospectively collected data, this study investigated how several psychological factors develop in the first three months of acute neck pain and how these factors influence self-perceived recovery.

Methods

Patients were recruited in various chiropractic practices throughout Switzerland between 2010 and 2014. The follow-up telephone interviews were conducted for all patients by research assistants in the coordinating university hospital following a standardized procedure. The population of this study consisted of 103 patients (68 female; mean age = 38.3 ± 13.8 years) with a first episode of acute (<4 weeks) neck pain. Prior to the first treatment, the patients filled in the Bournemouth Questionnaire (BQ). One week and 1 and 3 months later, they completed the BQ again along with the Patient Global Impression of Change (PGIC). The temporal development (repeated measure ANOVA) of the BQ questions 4 (anxiety), 5 (depression), 6 (fear-avoidance) and 7 (pain locus of control) as well as the influence of these scores on the PGIC were investigated (binary logistic regression analyses, receiver operating curves (ROC)).

Results

All psychological parameters showed significant reduction within the first month. The parameter ‘anxiety’ was associated with outcome at 1 and 3 months (p = 0.013, R² = 0.40 and p = 0.039, R² = 0.63, respectively). Baseline depression (p = 0.037, R² = 0.21), but not baseline anxiety, was a predictor for poor outcome. A high reduction in anxiety within the first month was a significant predictor for favorable outcome after 1 month (p < 0.001; R² = 0.57).

Conclusions

Psychological factors emerged from this study as relevant in the early phase of acute neck pain. Particularly persistent anxiety and depression at baseline might be risk factors for a transition to chronic pain that should be addressed in the early management of neck pain patients.

Thoracic dysfunction in whiplash-associated disorders: a systematic review and meta-analysis protocol

BACKGROUND

Whiplash-associated disorder (WAD) research has largely focused on the neck, yet symptoms often include other areas. The prevalence of acute thoracic spine pain is reported ~66 %, which is perhaps unsurprising given the mechanism of injury involves a forceful loading/eccentric contraction of posterior thoracic structures such as the trapezius. Many individuals with WAD experience disability and pain beyond normal tissue healing time, termed chronic WAD. With the thoracic spine contributing to neck mobility, and 23 % of individuals complaining of thoracic pain 1 year post injury, it is time to look beyond the neck to fully understand the anatomical dysfunction in WAD.

METHODS/DESIGN

A systematic review protocol has been designed and will be reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P). A sensitive topic-based search strategy is planned from inception to the current date. Databases, grey literature and registers will be searched using terms and keywords derived from a scoping search. Two reviewers will independently search information sources, assess studies for inclusion and extract data. A third reviewer will check for accuracy. Data to be extracted include summary data: sample size and characteristics, timescales to reflect disorder state, patient-reported or performance-based measure and findings. Risk of bias within studies will be assessed using the Newcastle-Ottawa Scale. Quantitative meta-analysis approach will be used for homogenous data and where appropriate presented using subgroups. All other results will be presented using narrative summaries. Subgroups will, where possible, be based on patient-reported or performance-based measure of dysfunction and/or stage of condition (acute/sub-acute or chronic). Strength of the overall body of evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE).

DISCUSSION

This is the first study to bring together evidence of thoracic dysfunction post whiplash and provide new insights into the scope and nature of thoracic dysfunction in WAD. With current management options being largely focused to a primary neck complaint and many patients going to become chronic in their presentations, this review may stimulate research and clinical interest in a largely under investigated, yet anatomically and kinematically related, spinal region.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015026983.

Five years after the accident, whiplash casualties still have poorer quality of life in the physical domain than other mildly injured casualties: analysis of the ESPARR cohort

Background

This study aims to compare health status and quality of life five years after a road accident between casualties with whiplash versus other mild injuries, to compare evolution of quality of life at 1 and 5 years after the accident, and to explore the relation between initial injury (whiplash vs. other) and quality of life.

Methods

The study used data from the ESPARR cohort (a representative cohort of road accident casualties) and included 167 casualties with “pure” whiplash and a population of 185 casualties with other mild injuries (MAIS-1). All subjects with lesions classified as cervical contusion (AIS code 310402) or neck sprain (AIS code 640278) were considered as whiplash casualties. Diagnosis was made by physicians, at the outset of hospital care, based on interview, clinical findings and X-ray. Whiplash injuries were then classified following the Quebec classification (grades 1 and 2). Quality of life was assessed on the WHOQoL-Bref questionnaire. Correlations between explanatory variables and quality of life were explored by Poisson regression and variance analysis.

Results

Between 1 and 5 years, global QoL improved for both whiplash and non-whiplash casualties; but, considering the two whiplash groups separately, improvement in grade 2 was much less than in grade 1. At 5 years, grade-2 whiplash casualties were more dissatisfied with their health (39.4 %; p < 0.05) than non-whiplash (24.3 %) or grade-1 whiplash casualties (27.0 %). Deteriorated quality of life in the mental, social and environmental domains was mainly related to psychological and socioeconomic factors for both whiplash and other mildly injured road-accident casualties. While PTSD was a major factor for the physical domain, whiplash remained a predictive factor after adjustment on PTSD; unsatisfactory health at 5 years, with deteriorated quality of life in the physical domain, was observed specifically in the whiplash group, pain playing a predominant intermediate role.

Conclusions

Deteriorated quality of life in the physical domain remained 5 years after the accident, specifically in the grade-2 whiplash group, pain playing a predominant intermediate role, which may be in line with the hypothesis of neuropathic pain.

Initial healthcare and coping preferences are associated with outcome 1 year after whiplash trauma: a multicentre 1-year follow-up study

OBJECTIVE

Individuals exposed to whiplash collisions have to cope with the stressful event as well as early physical symptoms. As in other chronic pain conditions, coping has been associated with outcome after whiplash. In this study, our aim was to examine whether initial coping preferences were associated with the development of chronic whiplash.

DESIGN

Prospective study.

SETTING

Primary care.

METHODS

740 acute whiplash patients were recruited from emergency units and general practitioners after car collisions in Denmark. Within 10 days postinjury, participants were asked what they believed could help them get better. At 12-month follow-up, the level of neck pain and capability to work was obtained. Whether coping preferences (baseline) were associated with outcome was investigated using multiple regression analyses.

RESULTS

Persistent neck pain was most strongly associated with preferring medications (mean difference=1.24 (95% CI 0.67 to 1.82)) and sickness absence (mean difference=1.18 (95% CI 0.53 to 1.82)). Reduced work capability was most strongly associated with preferring medications (OR=3.53 (95% CI 2.13 to 5.86)), sickness absence (OR=3.05 (95% CI 1.80 to 5.17)) and being referred to a physiotherapist/chiropractor (OR=3.03 (95% CI 1.33 to 6.91)). Active coping was associated with better outcomes: Participants preferring to change their lifestyle were protected against reduced work capability (OR=0.11 (95% CI 0.01 to 0.78)). Individuals who wanted to keep living as usual only (no other preference reported) were protected against neck pain (mean difference -1.62 (95% CI -2.39 to -0.84)) and reduced work capability (OR=0.09 (95% CI 0.01 to 0.64)).

CONCLUSIONS

A simple nine-item measure of coping preferences is associated with the development of chronic neck pain and reduced capability to work following whiplash trauma and may be used to identify individuals at risk of poor recovery.