Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial

The quality of reporting in randomized controlled trials investigating exercise for individuals with whiplash-associated disorders; a systematic review

BACKGROUND

Whiplash-associated disorders are a common sequela of road traffic accidents. Exercise therapy is considered an effective intervention, and it is recommended for the management of such condition. However, the application of research findings to everyday clinical practice is dependent on sufficient details being reported.

OBJECTIVES

To explore the quality of reporting in studies investigating the effectiveness of exercise for whiplash-associated disorders.

METHODS

A literature search was conducted to identify studies testing the effectiveness of exercise for whiplash-associated disorders. Two reporting checklists were used to evaluate reporting completeness. The median positive scores for each study and overall percentage of positive scores for each item were calculated. Percentage agreement and the Cohen's Kappa coefficient were calculated.

RESULTS

Twenty-one studies were included. According to the Template for Intervention Description and Replication checklist, items were reported appropriately with a median of 29% (range 0-95%, IQR 40.5). The median number of adequately reported items per study was 5 (range 1-10, IQR 3). For the Consensus on Exercise Reporting Template checklist, items were reported appropriately with a median of 29% (range 0-57%, IQR 29). The median number of adequately reported items per study was 4 (range 0-16, IQR 8). Percentage agreement ranged from 57% to 100% while Cohen's Kappa from -0.17 to 1.00.

CONCLUSIONS

The study reveals significant gaps in the quality of reporting in studies investigating exercise for whiplash-associated disorders as both checklists showed a median reporting adequacy of only 29%. Overall, the inter-rater agreement for both checklists was acceptable.

Patients', physiotherapists' and other stakeholders' experiences and perceptions about supported home physiotherapy for people with musculoskeletal conditions: a qualitative study

OBJECTIVES

Exercise, support and advice are the key treatment strategies of musculoskeletal problems. The aims of this study were to determine patients', physiotherapists', and other stakeholders' perspectives about supported home physiotherapy for the management of musculoskeletal problems and to identify the barriers and facilitators to rolling out this model of physiotherapy service delivery.

METHODS

This study was conducted as part of a process evaluation run alongside a large trial designed to determine whether supported home physiotherapy is as good or better than a course of in-person physiotherapy. Forty interviews were conducted with 20 trial participants, 15 physiotherapists, and 5 other stakeholders. The interviews were semi-structured and based on interview guides. Each interview was transcribed and a three-tiered coding tree was developed.

RESULTS

Six key themes were identified. Supported home physiotherapy (i) is convenient for some patients, (ii) does not always align with patients' and therapists' expectations about treatment (iii) is suitable for some but not all, (iv) can reduce personal connection and accountability, (v) has implications for physiotherapists' workloads, and (vi) has barriers and facilitators to future implementation.

CONCLUSIONS

Findings suggest that patients are far more accepting of supported home physiotherapy than physiotherapists assume. This model of service delivery could be rolled out to improve access to physiotherapy and to provide a convenient and effective way of delivering physiotherapy to some patients with musculoskeletal conditions if our trial results indicate that supported home physiotherapy is as good or better than in-person physiotherapy.

CLINICAL TRIAL REGISTRY NUMBER

ACTRN12619000065190 CONTRIBUTIONS OF THIS PAPER.

Neck muscle function improves after neck exercises in individuals with whiplash-associated disorders: a case-control ultrasound study with speckle-tracking analyses

A whiplash injury can alter neck muscle function, which remains years after the injury and may explain why symptoms such as persistent pain and disability occur. There is currently limited knowledge about dynamic neck muscle function in chronic whiplash-associated disorders (WAD), and about the extent to which altered muscle function can improve after rehabilitation. Ultrasound can detect mechanical neck muscle function by measuring real-time deformation and deformation rate in the muscles. This method was used for five dorsal neck muscles in participants with chronic WAD versus matched controls in resistant neck rotation. We obtained real-time, non-invasive ultrasound measurements using speckle tracking, multivariate analyses, and mixed-design ANOVA analyses. The results showed altered deformation in the three deepest neck muscle layers, with less deformation area in the WAD group compared to controls in rotation to the most painful side at baseline. Participants in the WAD group performed three months of neck-specific exercises, resulting in improved deformation in the deep neck muscles in WAD and with a similar deformation pattern to controls, and the significant group differences ceased. We reveal new and important insights into the capability of ultrasound to diagnose altered neck muscle function and evaluate an exercise intervention.

Effect of neck-specific exercises with and without internet support on cervical range of motion and neck muscle endurance in chronic whiplash-associated disorders: analysis of functional outcomes of a randomized controlled trial

OBJECTIVE

To compare the effects of a neck-specific exercise programme with internet support and 4 physiotherapist sessions (NSEIT) and the same neck-specific exercises supervised by a physiotherapist (NSE) on neck muscle endurance and cervical range of motion.

DESIGN

Randomized controlled trial.

PATIENTS

A total of 140 participants with chronic whiplash-associated disorders grade II or grade III were randomly assigned to the NSEIT or NSE groups.

METHODS

Outcomes were changes in active cervical range of motion, cranio-cervical flexion test, neck muscle endurance, and neck pain, at 3- and 15-month follow-ups.

RESULTS

There were no significant differences between the NSEIT and NSE groups. There was a significant group-by-time inter-action effect in active cervical range of motion flexion/extension where the NSEIT group improved to 3-month follow-up, but the NSE group did not. Both groups were significantly improved over time in all other outcomes (p < 0.001) at 3- and 15-month follow-ups, with effect size between 0.64 and 1.35 in active cervical range of motion, cranio-cervical flexion test, dorsal neck muscle endurance, and neck pain, and effect size between 0.22 and 0.42 in ventral neck muscle endurance.

CONCLUSION

Both NSE and NSEIT led to improved neck function. Depending on the patients' needs, either NSE or NSEIT could be used as treatment for patients with chronic whiplash-associated disorders.

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.

High level of post-traumatic stress symptoms in patients with chronic neck pain is associated with poor mental health but does not moderate the outcome of a multimodal physiotherapy programme

INTRODUCTION

Chronic traumatic neck pain has a high prevalence of post-traumatic stress symptoms (PTSS). However, whether PTSS moderates treatment effects is unknown. This study investigated: 1) whether PTSS was associated with patient-reported outcomes and clinical test results at baseline; 2) whether PTSS moderated the effect of a multimodal physiotherapy intervention of exercise therapy and patient education; and 3) whether adherence to the intervention differed across PTSS groups.

METHODS

Secondary data analysis from a randomized controlled trial on chronic neck pain with 12-month follow-up was conducted. Patients were divided into three groups (NT = non-traumatic, LT = traumatic low PTSS, HT = traumatic high PTSS) based on self-reported onset of pain and the Impact of Event Scale. The baseline data were used to analyze the association of PTSS with patient demographics and scores of physical and mental health-related quality of life, depression, neck-related disability, kinesiophobia, and clinical tests. Baseline, 4-month and 12-month follow-up data were analyzed to investigate possible moderating effects on outcomes. Data on adherence were collected at four months.

RESULTS

115 participants were included (NT n = 45; LT n = 46; HT n = 24). The HT group reported lower mental health scores and more depressive symptoms at baseline. PTSS did not significantly moderate the treatment effect on any outcomes. The HT group tended to have lower adherence to the multimodal physiotherapy intervention than the LT group.

CONCLUSION

For patients with traumatic neck pain, high levels of PTSS are associated with poorer psychological outcomes but do not affect the outcomes of multimodal physiotherapy intervention.

Gray Matter Adaptations to Chronic Pain in People with Whiplash-Associated Disorders are Partially Reversed After Treatment: A Voxel-based Morphometry Study

Gray matter (GM) changes are often observed in people with chronic spinal pain, including those with chronic whiplash-associated disorders (CWAD). These GM adaptations may be reversed with treatment, at least partially. Pain neuroscience education combined with exercise (PNE+Exercise) is an effective treatment, but its neural underlying mechanisms still remain unexplored in CWAD. Here, we performed both cross-sectional and longitudinal voxel-based morphometry to 1) identify potential GM alterations in people with CWAD (n = 63) compared to age- and sex-matched pain-free controls (n = 32), and 2) determine whether these GM alterations might be reversed following PNE+Exercise (compared to conventional physiotherapy). The cross-sectional whole-brain analysis revealed that individuals with CWAD had less GM volume in the right and left dorsolateral prefrontal cortex and left inferior temporal gyrus which was, in turn, associated with higher pain vigilance. Fifty individuals with CWAD and 29 pain-free controls were retained in the longitudinal analysis. GM in the right dorsolateral prefrontal cortex increased after treatment in people with CWAD. Moreover, the longitudinal whole-brain analysis revealed that individuals with CWAD had decreases in GM volumes of the left and right central operculum and supramarginal after treatment. These changes were not specific to treatment modality and some were not observed in pain-free controls over time. Herewith, we provide the first evidence on how GM adaptations to CWAD respond to treatment. PERSPECTIVE: This article presents which gray matter adaptations are present in people with chronic pain after whiplash injuries. Then, we examine the treatment effect on these alterations as well as whether other neuroplastic effects on GM following treatment occur.

One and Done? The Effectiveness of a Single Session of Physiotherapy Compared With Multiple Sessions to Reduce Pain and Improve Function and Quality of Life in Patients With a Musculoskeletal Disorder: A Systematic Review With Meta-analyses

OBJECTIVE

To compare single and multiple physiotherapy sessions to improve pain, function, and quality of life (QoL) in patients with musculoskeletal disorders (MSKDs).

DATA SOURCES

AMED, Cinahl, SportsDiscus, Medline, Cochrane Register of Clinical Trials, Physiotherapy Evidence Database, and reference lists.

STUDY SELECTION

Randomized controlled trials (RCTs) comparing single and multiple physiotherapy sessions for MSKDs.

DATA EXTRACTION

Two reviewers extracted data and assessed risk of bias and certainty of evidence using Cochrane Risk of Bias tool 2.0 and Grading of Recommendation Assessment, Development, and Evaluation.

DATA SYNTHESIS

Six RCTs (n=2090) were included (conditions studied: osteoporotic vertebral fracture, neck, knee, and shoulder pain). Meta-analyses with low-certainty evidence showed a significant pain improvement at 6 months in favor of multiple sessions compared with single session interventions (3 RCTs; n=1035; standardized mean difference [SMD]: 0.29; 95% CI: 0.05 to 0.53; P=.02) but this significant difference in pain improvement was not observed at 3 months (4 RCTs; n=1312; SMD: 0.39; 95% CI: -0.11 to 0.89; P=.13) and at 12 months (4 RCTs; n=1266; SMD: -0.05; 95% CI: -0.49 to 0.39; P=.82). Meta-analyses with low-certainty evidence showed no significant differences in function at 3 (4 RCTs; n=1583; SMD: 0.05; 95% CI: -0.11 to 0.21; P=.56), 6 (4 RCTs; n=1538; SMD: 0.06; 95% CI: -0.12 to 0.23; P=.53) and 12 months (4 RCTs; n=1528; SMD: 0.08; 95% CI: -0.08 to 0.25; P=.30) and QoL at 3 (4 RCTs; n=1779; SMD: 0.08; 95% CI: -0.02 to 0.17; P=.12), 6 (3 RCTs; n=1206; SMD: 0.03; 95% CI: -0.08 to 0.14; P=.59), and 12 months (4 RCTs; n=1729; SMD: -0.03; 95% CI: -0.12 to 0.07; P=.58).

CONCLUSIONS

Low certainty meta-analyses found no clinically significant differences in pain, function, and QoL between single and multiple physiotherapy sessions for MSKD management for the conditions studied. Future research should compare the cost-effectiveness of those different models of care.

Longitudinal Changes and Associations Between Quantitative Sensory Testing and Psychological Factors in Whiplash-Associated Disorders: A Systematic Review and Meta-Analyses-Based Data Synthesis

Whiplash-associated disorders (WAD) represent a multifactorial condition often accompanied by altered nociceptive processing and psychological factors. This systematic review on acute and chronic WAD aimed to investigate the relationship between quantitative sensory testing (QST) and psychological factors and quantify whether their trajectories over time follow a similar pattern to disability levels. Eight databases were searched until October 2022. When 2 prospective studies examined the same QST or psychological variable, data synthesis was performed with random-effects meta-analysis by pooling within-group standardized mean differences from baseline to 3-, 6-, and 12-month follow-ups. From 5,754 studies, 49 comprising 3,825 WAD participants were eligible for the review and 14 for the data synthesis. Altered nociceptive processing in acute and chronic WAD, alongside worse scores on psychological factors, were identified. However, correlations between QST and psychological factors were heterogeneous and inconsistent. Furthermore, disability levels, some QST measures, and psychological factors followed general positive improvement over time, although there were differences in magnitude and temporal changes. These results may indicate that altered psychological factors and increased local pain sensitivity could play an important role in both acute and chronic WAD, although this does not exclude the potential influence of factors not explored in this review. PERSPECTIVE: Acute WAD show improvements in levels of disability and psychological factors before significant improvements in nociceptive processing are evident. Facilitated nociceptive processing might not be as important as psychological factors in chronic WAD-related disability, which indicates that chronic and acute WAD should not be considered the same entity although there are similarities. Nonetheless, pressure pain thresholds in the neck might be the most appropriate measure to monitor WAD progression.

Exercise therapy including the cervical extensor muscles in individuals with neck pain: A systematic review

OBJECTIVE

To review the use (dosage parameters and combination with other therapeutic interventions) of cervical extensor muscle exercises and their effect on pain, disability (primary outcomes), range of motion, endurance and strength (secondary outcomes) in people with neck pain.

DATA SOURCES

An extensive literature search was conducted through MEDLINE (Ovid), Scopus (Elsevier) and Physiotherapy Evidence Database (PEDro) up to May 2023. The reference lists of all included studies and relevant reviews were screened for additional studies.

REVIEW METHODS

Randomised controlled trials reporting the use of cervical extensor muscle exercises (alone or combined) applied to adults with idiopathic or traumatic neck pain were included. Study selection, data extraction and critical appraisal (PEDro assessment scale) were performed by two blinded reviewers. Data extraction included dosage parameters, other modalities combined with these exercises and outcomes.

RESULTS

Thirty-five randomised controlled trails (eight of which were complementary analyses) with 2409 participants fulfilled the inclusion criteria. Twenty-six were of moderate to high quality. In most studies, cervical extensor muscle exercises were combined with various other therapeutic modalities and applied at different dosages. Only two studies (one high and one low quality) specifically assessed their effectiveness. The high-quality study showed significant improvements in neck pain and disability, pressure point threshold and neck mobility after both low load and high load training for 6 weeks.

CONCLUSION

The results suggest cervical extensor muscle exercises may reduce neck pain and disability; however firm conclusions cannot be drawn because of the few studies that addressed this question and the heterogeneity of the dosage parameters.

Multiple emergency department encounters for acute musculoskeletal presentation with an existing mental health diagnosis

Reconceptualising acute Musculoskeletal (MSK) injuries with both stress- and tissue- based factors is required to consider prior influences of mental health disorders on acute persistent MSK pain presentations. This report describes repeated emergency presentations of an individual with acute persistent MSK pain in their twenties living with mental health. Their mental health diagnoses included depression, mood disorders, and anorexia nervosa. This person also had mental health related inpatient admissions that were not captured under the retrospective record review for a large district hospital emergency department using the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) classification system. This case report attempts to demonstrate that improving the understanding of preexisting vulnerabilities and mental health diagnoses may assist with informing healthcare design to develop specialised care pathways for acute injury presentations within triage settings.

The effectiveness of aerobic versus strengthening exercise therapy in individuals with chronic whiplash-associated disorder: a randomised single case experimental design study

PURPOSE

Recent RCTs and meta-analyses compare the effectiveness of different types of exercise for chronic whiplash associated disorder (WAD). This study aimed to verify whether the results of these studies translate to statistically significant and clinically meaningful effects in individual participants.

MATERIALS AND METHODS

A series of replicated randomised single case experimental design studies (SCEDs) with A-B design (A: baseline, B: intervention). Eight participants with chronic WAD (8 female, mean [SD] age 47 [10] years) were randomised into one of four baseline durations (5, 8, 11, and 14 days) and to one of two eight-week exercise interventions (aerobic or strengthening). Daily measures of pain intensity, bothersomeness, and interference were collected during the baseline phase and the intervention phase.

RESULTS

Visual analyses indicated that three participants in the aerobic exercise group meaningfully improved. No improvements were found in the strengthening group. Effect sizes favoured the aerobic exercise group, yet randomisation tests of pooled effects did not show a difference in between-intervention effectiveness.

CONCLUSION

Contrary to our expectations, three out of four participants were nearly pain-free at the end of the aerobic exercise intervention, whereas none of the participants in the strengthening group improved meaningfully. This suggests that aerobic exercise may be favourable for WAD.Implications for RehabilitationOur results suggest that aerobic exercises are favourable over strengthening exercises and may be the preferred option for patients with chronic WAD.We found substantial variability in self-reported outcomes within participants, clinicians should be aware of this in the judgement of treatment effectiveness.

The effects of physical exercise on structural, functional, and biochemical brain characteristics in individuals with chronic whiplash-associated disorder: A pilot randomized clinical trial

BACKGROUND

Exercise for people with whiplash associated disorder (WAD) induces hypoalgesic effects in some, but hyperalgesic effects in others. We investigated the exercise-induced neurobiological effects of aerobic and strengthening exercise in individuals with chronic WAD.

METHODS

Sixteen participants (8 WAD, 8 pain-free [CON]) were randomised to either aerobic or strengthening exercise. MRI for brain morphometry, functional MRI for brain connectivity, and magnetic resonance spectroscopy for brain biochemistry, were used at baseline and after the 8-week intervention.

RESULTS

There were no differences in brain changes between exercise groups in either the WAD or CON group, therefore aerobic and strengthening data were combined to optimise sample size. After the exercise intervention, the CON group demonstrated increased cortical thickness (left parahippocampus: mean difference = 0.04, 95% CI = 0.07-0.00, p = 0.032; and left lateral orbital frontal cortex: mean difference = 0.03, 95% CI = 0.00-0.06, p = 0.048). The WAD group demonstrated an increase in prefrontal cortex (right medial orbital frontal) volume (mean difference = 95.57, 95% CI = 2.30-192.84, p = 0.046). Functional changes from baseline to follow-up between the default mode network and the insula, cingulate cortex, temporal lobe, and somatosensory and motor cortices, were found in the CON group, but not in the WAD group. There were no changes post-exercise in brain biochemistry.

CONCLUSION

Aerobic and strengthening exercises did not exert differential effects on brain characteristics, however differences in structural and functional changes were found between WAD and CON groups. This suggests that an altered central pain modulatory response may be responsible for differential effects of exercise in individuals with chronic WAD.

Efficacy of Neck-Specific Exercise With Internet Support Versus Neck-Specific Exercise at a Physiotherapy Clinic in Chronic Whiplash-Associated Disorders: Multicenter Randomized Controlled Noninferiority Trial

BACKGROUND

Neck-specific exercises (NSE) supervised by a physiotherapist twice a week for 12 weeks have shown good results in chronic whiplash-associated disorders (WADs), but the effect of exercise delivered via the internet is unknown.

OBJECTIVE

This study examined whether NSE with internet support (NSEIT) and 4 physiotherapy sessions for 12 weeks were noninferior to the same exercises supervised by a physiotherapist twice a week for 12 weeks (NSE).

METHODS

In this multicenter randomized controlled noninferiority trial with masked assessors, we recruited adults aged 18-63 years with chronic WAD grade II (ie, neck pain and clinical musculoskeletal signs) or III (ie, grade II plus neurological signs). Outcomes were measured at baseline and at 3- and 15-month follow-ups. The primary outcome was change in neck-related disability, measured with the Neck Disability Index (NDI; 0%-100%), with higher percentages indicating greater disability. Secondary outcomes were neck and arm pain intensity (Visual Analog Scale [VAS]), physical function (Whiplash Disability Questionnaire [WDQ] and Patient-Specific Functional Scale [PSFS]), health-related quality of life (EQ-5D-3L and EQ VAS), and self-rated recovery (Global Rating Scale [GRS]). The analyses were conducted on an intention-to-treat basis and with the per-protocol approach as sensitivity analyses.

RESULTS

Between April 6, 2017, and September 15, 2020, 140 participants were randomly assigned to the NSEIT group (n=70) or the NSE group (n=70); 63 (90%) and 64 (91%), respectively, were followed up at 3 months, and 56 (80%) and 58 (83%), respectively, at 15 months. NSEIT demonstrated noninferiority to NSE in the primary outcome NDI, as the 1-sided 95% CI of the mean difference in change did not cross the specified noninferiority margin (7 percentage units). There were no significant between-group differences in change in NDI at the 3- or 15-month follow-up, with a mean difference of 1.4 (95% CI -2.5 to 5.3) and 0.9 (95% CI -3.6 to 5.3), respectively. In both groups, the NDI significantly decreased over time (NSEIT: mean change -10.1, 95% CI -13.7 to -6.5, effect size=1.33; NSE: mean change -9.3, 95% CI -12.8 to -5.7, effect size=1.19 at 15 months; P<.001). NSEIT was noninferior to NSE for most of the secondary outcomes except for neck pain intensity and EQ VAS, but post hoc analyses showed no differences between the groups. Similar results were seen in the per-protocol population. No serious adverse events were reported.

CONCLUSIONS

NSEIT was noninferior to NSE in chronic WAD and required less physiotherapist time. NSEIT could be used as a treatment for patients with chronic WAD grades II and III.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03022812; https://clinicaltrials.gov/ct2/show/NCT03022812.

Cervical facet joint platelet-rich plasma in people with chronic whiplash-associated disorders: A prospective case series of longer term 6- and 12- month outcomes

Objective

To explore the 6- and 12-month effectiveness of a single autologous injection of platelet-rich plasma (PRP) in cervical facet joints of people with chronic WAD and facet-mediated pain.

Design

A prospective case series of people with chronic whiplash-associated disorders and cervical facet joint mediated pain in a community setting.

Interventions

We investigated 44 consecutive people who underwent cervical facet joint PRP ( ​± ​adjunct physiotherapy) between 2019 and 2021, selected for PRP based on 80% relief following single diagnostic medial branch blocks or 50% relief and a significant improvement in performing a previously limited activity of daily living.

Measures

Measures of pain (numerical pain rating scale - NPRS) and disability (Neck Disability Index - NDI) were collected prior to and 3-, 6- and 12- months following cervical facet joint PRP in an electronic registry database. Success was defined as those exceeding the minimal clinically important difference (MCID) for pain (>15%) and disability (>10%). We also calculated the proportion of people with greater than 50% relief of pain. People not reached for follow-up were considered failures for worst-case analysis.

Results

Forty-four people (82% female, mean age ​= ​45.2 (range: 25-71) years) underwent cervical facet joint PRP. Nine people received repeat PRP interventions. Thirty-five people provided 12-month data. There was a significant improvement in pain and disability following PRP (and possibly adjunct physiotherapy) received during this time period. At 12-months, 53% of people exceeded MCID for pain, reporting a mean improvement of 66% (95%CI: 55-77%) on the NPRS. For NDI scores, 69% of people exceeded MCID, reporting a mean improvement of 48% (95%CI: 38-58%). Thirty-seven percent of people reported greater than 50% relief of pain 12-months post-cervical facet joint PRP.

Conclusion

In people with chronic WAD and facet-mediated pain, our long-term data suggests that PRP (and possibly adjunct physiotherapy) is effective. A controlled study is warranted to evaluate the efficacy of PRP.

Improved quality of physiotherapy care in patients with Whiplash-Associated Disorders: Results based on 16 years of routinely collected data

Quality improvement is now a central tenet in physiotherapy care, and quality indicators (QIs), as measurable elements of care, have been applied to analyze and evaluate the quality of physiotherapy care over the past two decades. QIs, based on Donabedian's model of quality of care, provide a foundation for measuring (improvements in) quality of physiotherapy care, providing insight into the many remaining evidentiary gaps concerning diagnostics, prognostics and treatment, as well as patient-related outcome measures. In this overview we provide a synthesis of four recently published articles from our project group on the topic of quantitative measures of quality improvement in physiotherapy care, in this context specifically focused on patients with WAD in primary care physiotherapy. A set of process and outcome QIs (n = 28) was developed for patients with WAD and linked to a database consisting of routinely collected data (RCD) on patients with WAD collected over a 16-year period. The QIs were then embedded per step of the clinical reasoning process: (a) administration (n = 2); (b) history taking (n = 7); (c) objectives of examination (n = 1); (d) clinical examination (n = 5); (e) analysis and conclusion (n = 1); (f) treatment plan (n = 3); (g) treatment (n = 2); (h) evaluation (n = 5); and (i) discharge (n = 2). QIs were expressed as percentages, allowing target performance levels to be defined ≥70% or ≤30%, depending on whether the desired performance required an initially high or low QI score. Using RCD data on primary care patients with WAD (N = 810) and a set of QIs, we found that the quality of physiotherapy care has improved substantially over a 16-year period. This conclusion was based on QIs meeting predetermined performance targets of ≥70% or ≤30%. Twenty-three indicators met the target criterium of ≥70% and three indicators ≤30%. Our recommended set of QIs, embedded in a clinical reasoning process for patients with WAD, can now be used as a basis for the development of a validated QI set that effectively measures quality (improvement) of primary care physiotherapy in patients with WAD.

Comparative Effectiveness and Safety of Concomitant Treatment with Chuna Manual Therapy and Usual Care for Whiplash Injuries: A Multicenter Randomized Controlled Trial

OBJECTIVES

We aimed to compare the effectiveness and safety of Chuna manual therapy combined with usual care to those of usual care alone for treating whiplash injuries.

DESIGN

A two-arm, parallel, assessor-blinded, multicenter pragmatic randomized clinical trial.

SETTING

Three hospitals in Korea.

PARTICIPANTS

Overall, 132 participants between 19 and 70 years of age, involved in traffic accidents and treated at three hospitals in Korea, >2 but <13 weeks prior to enrollment, with neck pain consistent with whiplash-associated disorder grades I and II and a numeric rating scale score ≥5 were included.

INTERVENTIONS

Participants were equally and randomly allocated to the Chuna manual therapy and usual care (n = 66) or usual care (n = 66) groups and underwent corresponding treatment for three weeks.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the number of days to achieve a 50% pain reduction. Secondary outcomes included areas under the 50% numeric rating scale reduction curve: pain, disability, quality of life, and safety.

RESULTS

The Chuna manual therapy + usual care group (23.31 ± 21.36 days; p = 0.01) required significantly fewer days to achieve 50% pain reduction compared to the usual care group (50.41 ± 48.32 days; p = 0.01). Regarding pain severity, functional index, and quality of life index, Chuna manual therapy and usual care were more effective than usual care alone. Safety was acceptable in both groups.

CONCLUSIONS

In patients with subacute whiplash injury, Chuna manual therapy showed a rapid rate of recovery, high effectiveness, and safety.

Protocol for a process evaluation: face-to-face physiotherapy compared with a supported home exercise programme for the management of musculoskeletal conditions: the REFORM trial

INTRODUCTION

The REFORM (REhabilitation FOR Musculoskeletal conditions) trial is a non-inferiority randomised controlled trial (n=210) designed to determine whether a supported home exercise programme is as good or better than a course of face-to-face physiotherapy for the management of some musculoskeletal conditions. The trial is currently being conducted across Sydney government hospitals in Australia. This process evaluation will run alongside the REFORM trial. It combines qualitative and quantitative data to help explain the trial results and determine the feasibility of rolling out supported home exercise programmes in settings similar to the REFORM trial.

METHODS AND ANALYSIS

Two theoretical frameworks underpin our process evaluation methodology: the Realist framework (context, mechanism, outcomes) considers the causal assumptions as to why a supported home exercise programme may be as good or better than face-to-face physiotherapy in terms of the context, mechanisms and outcomes of the trial. The RE-AIM framework describes the Reach, Effectiveness, Adoption, Implementation and Maintenance of the intervention. These two frameworks will be broadly used to guide this process evaluation using a mixed-methods approach. For example, qualitative data will be derived from interviews with patients, healthcare professionals and stakeholders, and quantitative data will be collected to determine the cost and feasibility of providing supported home exercise programmes. These data will be analysed iteratively before the analysis of the trial results and will be triangulated with the results of the primary and secondary outcomes.

ETHICS AND DISSEMINATION

This trial will be conducted in accordance with the National Health and Medical Research Council National Statement on Ethical Conduct in Human Research (2018) and the Note for Good Clinical Practice (CPMP/ICH-135/95). Ethical approval was obtained on 17 March 2017 from the Northern Sydney Local Health District Human Research Ethics Committee (trial number: HREC/16HAWKE/431-RESP/16/287) with an amendment for the process evaluation approved on 4 February 2020. The results of the process evaluation will be disseminated through publications in peer-reviewed journals and presentations at scientific conferences.

TRIAL REGISTRATION NUMBER

ACTRN12619000065190.

Posttraumatic Stress Symptoms and Pain Sensitization After Whiplash Injury: A Longitudinal Cohort Study With Quantitative Sensory Testing

Posttraumatic stress symptoms (PTSS) are common after whiplash injury and are associated with poor recovery. The acute stress response may lead to pain sensitization and widespread pain, thereby compromising recovery. To our knowledge, no longitudinal study has assessed the associations between early PTSS and pain sensitization over time using quantitative sensory testing (QST). The aim of this study was to compare participants with different levels of PTSS, as measured by the impact of event scale (IES; subclinical 0–8, mild 9–25, and clinical ≥ 26) at baseline (<10-day post-injury) and at a follow-up of 1, 3, 6, and 12-month post-injury on pain sensitivity, neck mobility, pain distribution, and pain intensity. In total, 740 participants were recruited from emergency units or general practitioners with acute neck pain after a whiplash injury. The clinical PTSS group showed increased pain sensitivity on all QSTs at all time points compared to the subclinical PTSS group. Also, the clinical PTSS group showed significantly lower neck mobility at all time points except for a 3-month follow-up compared to the subclinical PTSS group. Moreover, the clinical PTSS group showed more widespread pain and self-reported headache and neck pain intensity at all time points compared to the subclinical PTSS group. This study emphasizes that participants with clinical levels of PTSS constitute a high-risk group that is sensitized to pain early after the injury. Hence, screening for PTSS within the 1st week after whiplash injury for those who experience high levels of pain intensity and distress may be an important clinical procedure in the assessment and treatment of whiplash-associated disorders (WAD).

Evaluation of implementation and effectiveness of neck-specific exercise for persistent disability and pain after whiplash injury: study protocol for a randomized controlled study using a hybrid 2 design

Background

Persistent pain and disability in whiplash-associated disorders (WAD) grades II and III are common. In two randomized controlled trials (RCTs) of neck-specific exercises (NSE), we have seen promising results in chronic WAD, with a sustained clinically important reduction in pain and disability. NSE can also be delivered through internet support (NSEIT) and a few visits to a physiotherapist, saving time and cost for both patients and providers. NSE have been shown to have positive effects in other neck pain disorders and we will evaluate the diffusion of the exercises to other patients. The aims of the proposed study are to evaluate an implementation strategy for NSEIT and NSE in primary health care and to evaluate the effectiveness of NSEIT and NSE in clinical practice.

Methods

The proposed study is a prospective cluster-randomized mixed-design study with hybrid 2 trial design. Reg. physiotherapists working in twenty physiotherapy clinics will be included. The primary implementation outcome is proportion of patients with neck pain receiving neck-specific exercise. Secondary outcomes are; physiotherapists attitudes to implementation of evidence-based practice, their self-efficacy and confidence in performing NSEIT/NSE, number of patients visits, and use of additional or other exercises or treatment. To further evaluate the implementation strategy, two qualitative studies will be performed with a sample of the physiotherapists. The primary outcome in the patient effectiveness evaluation is self-reported neck disability according to the Neck Disability Index (NDI). Secondary outcomes are pain intensity in the neck, arm, and head; dizziness; work- and health-related issues; and patient’s improvement or deterioration over time. All measurements will be conducted at baseline and at 3 and 12 months. Physiotherapists´ self-efficacy and confidence in diagnosing and treating patients with neck pain will also be evaluated directly after their instruction in NSEIT/NSE.

Discussion

This trial will evaluate the implementation strategy in terms of adoption of and adherence to NSEIT and NSE in clinical primary health care, and measure diffusion of the method to other patients. In parallel, the effectiveness of the method will be evaluated. The results may guide physiotherapists and health care providers to sustainable and effective implementation of effective exercise programs.

Trial registration

The randomized trial is registered on ClinicalTrials.gov, NCT05198258, initial release date January 20, 2022.

Exercise therapy for whiplash-associated disorders: a systematic review and meta-analysis

OBJECTIVES

Acute as well as chronic pain syndromes are common after whiplash trauma and exercise therapy is proposed as one possible intervention strategy. The aim of the present systematic review was to evaluate the effect of exercise therapy in patients with Whiplash-Associated Disorders for the improvement of neck pain and neck disability, compared with other therapeutic interventions, placebo interventions, no treatment, or waiting list.

CONTENT

The review was registered in Prospero (CRD42017060356) and conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search in PubMed, Scopus and Cochrane from inception until January 13, 2020 was combined with a hand search to identify eligible randomized controlled studies. Abstract screening, full text assessment and risk of bias assessment (Cochrane RoB 2.0) were conducted by two independent reviewers.

SUMMARY

The search identified 4,103 articles. After removal of duplicates, screening of 2,921 abstracts and full text assessment of 100 articles, 27 articles that reported data for 2,127 patients were included. The included articles evaluated the effect of exercise therapy on neck pain, neck disability or other outcome measures and indicated some positive effects from exercise, but many studies lacked control groups not receiving active treatment. Studies on exercise that could be included in the random-effect meta-analysis showed significant short-term effects on neck pain and medium-term effects on neck disability.

OUTLOOK

Despite a large number of articles published in the area of exercise therapy and Whiplash-Associated Disorders, the current evidence base is weak. The results from the present review with meta-analysis suggests that exercise therapy may provide additional effect for improvement of neck pain and disability in patients with Whiplash-Associated Disorders.

Assessment of Neuromuscular and Psychological Function in People with Recurrent Neck Pain during a Period of Remission: Cross-Sectional and Longitudinal Analyses

The aim of this study was to examine for the presence of differences in neuromuscular and psychological function in individuals with recurrent neck pain (RNP) or chronic neck pain (CNP) following a whiplash trauma compared to healthy controls. A secondary aim was to examine whether neuromuscular characteristics together with psychological features in people with RNP were predictive of future painful episodes. Multiple features were assessed including neck disability, kinesiophobia, quality of life, cervical kinematics, proprioception, activity of superficial neck flexor muscles, maximum neck flexion and extension strength, and perceived exertion during submaximal contractions. Overall, those with RNP (n = 22) and CNP (n = 8) presented with higher neck disability, greater kinesiophobia, lower quality of life, slower and irregular neck movements, and less neck strength compared to controls (n = 15). Prediction analysis in the RNP group revealed that a higher number of previous pain episodes within the last 12 months along with lower neck flexion strength were predictors of higher neck disability at a 6-month follow-up. This preliminary study shows that participants with RNP presented with some degree of altered neuromuscular features and poorer psychological function with respect to healthy controls and these features were similar to those with CNP. Neck flexor weakness was predictive of future neck disability.

Systematic review and meta-analysis of the therapeutic management of patients with cervicogenic dizziness

BACKGROUND

Patients with cervicogenic dizziness (CGD) present with dizziness, cervical spine dysfunctions, and postural imbalance, symptoms that can significantly impact their daily functioning.

OBJECTIVES

To provide evidence-based recommendations for the management of patients with CGD.

METHODS

Three databases were searched for randomized controlled trials (RCTs) (last search 15 May 2021). Outcome measures included dizziness, cervical spine, and balance parameters. Cochrane standard methodological procedures were used and included the RoB 2.0 and GRADE. Where possible, RCTs were pooled for meta-analysis.

RESULTS

Thirteen RCTs (n = 898 patients) of high (two RCTs), moderate (five RCTs), and low (six RCTs) methodological quality were analyzed. Six RCTs were included in the meta-analysis. Only three RCTs specified the cause of CGD. They showed inconsistent findings for the effectiveness of exercise therapy in patients with traumatic CGD. Manual therapy and manual therapy combined with exercise therapy may reduce CGD, cervical spine, and balance dysfunctions.

CONCLUSION

There is moderate quality of evidence that manual therapy reduces CGD, cervical spine, and balance symptoms. When manual therapy is combined with exercise therapy, the positive effect on CGD, cervical spine, and balance symptoms is even stronger. However, the quality of the evidence here is very low.

The effect of prolonged experimental neck pain on exercise-induced hypoalgesia

ABSTRACT

Neck pain is a common musculoskeletal problem often accompanied by reduced exercise-induced hypoalgesia (EIH) or hyperalgesia compared to an asymptomatic population. This study investigated EIH in a healthy population during experimental neck pain. Forty participants were randomized into this double-blinded parallel-group study. On four separate test days (Day0, Day2, Day4, Day15), participants completed the Neck Disability Index (NDI) and scored neck pain intensity during head movements on a numerical rating scale (NRS). At the end of Day0 and Day2, Nerve Growth Factor (NGF) or isotonic saline (control) was injected into the right splenius capitis muscle. Pressure pain thresholds (PPTs) were recorded bilaterally over splenius capitis (neck), temporalis (head) and tibialis anterior (leg) muscles on all days. On Day0, Day4 and Day15, PPTs were recorded before and after a hand-bike exercise. EIH was defined as the PPT increase caused by the exercise. Compared with the control-group, the NGF-group demonstrated higher NDI scores at Day2 and Day4 (P<0.001,η2>0.557) and higher NRS scores (P<0.03,η2>0.09) along with reduced neck PPTs (P<0.01,d>0.44) at Day2(Right:95%CI[26.0,54.0];Left:95%CI[6.8,26.9]), Day4(Right:95%CI[40.5, 67.9];Left:95%CI[6.9,28.2]) and Day15(Right:95%CI[5.6,37.2];Left:95%CI[6.9,34.8]). Across days, the EIH-effect was reduced at the neck site in the NGF-group compared to the control-group (P<0.001,η2P=0.367,95%CI[-34.5,-13.7]). At the head and leg sites, the NGF-group showed reduced EIH-effect compared to the control-group (P<0.05,d>0.43) on Day4(Head:95%CI[-61.4,-22.9];Leg:95%CI[-154.7,-72.4]) and Day15(Head:95%CI[-54.3,-7.6];Leg:95%CI[-122.7,-34.4]). These results indicate that a few days of clinically comparable neck pain and hyperalgesia might have a negative impact on EIH-responses and may help explain why some neck pain patients do not experience immediate positive effects of exercise.

Examination of exclusion criteria in total knee arthroplasty rehabilitation trials: influence on the application of evidence in day-to-day practice

OBJECTIVE

Total knee arthroplasty (TKA) rehabilitation trials use exclusion criteria, which may limit their generalizability in practice. We investigated whether patients seen in routine practice who meet common exclusion criteria recover differently from TKA compared to research-eligible patients. We hypothesized that research-ineligible patients would demonstrate poorer average postoperative function and slower rate of functional recovery compared to research-eligible patients.

METHODS

Patient characteristics and exclusion criteria were extracted and summarized from trials included in the three most recent systematic reviews of TKA rehabilitation. Trial participant characteristics were compared to a clinical dataset of patient outcomes collected in routine TKA rehabilitation. Where possible, individual exclusion criterion from the trials were applied to the clinical dataset to determine "eligible" and "ineligible" groups for research participation. Postoperative functional outcomes including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Timed Up and Go (TUG) were compared between "eligible" and "ineligible" groups using mixed effects models.

RESULTS

2,528 participants from 27 trials were compared to 474 patients from the clinical dataset. Research participants were older, with lower Body Mass Index than patients in the clinical dataset. Many patients in the clinical dataset would be "ineligible" for research participation based upon common exclusion criteria from the trials. Differences were observed in average postoperative functioning between some "eligible" and "ineligible" groups in the clinical dataset. However, no differences were observed in functional recovery rate between groups, except for patients with diabetes whose TUG recovered more slowly than their "eligible" counterparts.

CONCLUSIONS

Many patients in the clinical dataset were "ineligible" for research participation based upon common TKA rehabilitation trial exclusion criteria. However, the postoperative recovery rate did not differ between "eligible" and "ineligible" groups based on individual exclusion criterion-except for individuals with diabetes. This suggests that both clinical and research populations may recover similarly from TKA.

Soft-collar use in rehabilitation of whiplash-associated disorders - A systematic review and meta-analysis

BACKGROUND

Active rehabilitation of Whiplash Associated Disorders (WAD) is favoured over passive modalities such as soft-collars. However, the effectiveness of soft-collar use remains unclear.

OBJECTIVE

To investigate the effectiveness of soft-collar use on pain and disability in WAD.

DESIGN

Systematic review.

METHOD

Databases (AMED, CINAHL Complete, Cochrane Library, Embase, Medline, PEDro, PsycINFO, PubMed, SPORTDiscus) were searched for guidelines, reviews and RCTs on soft-collar use as part of WAD treatment. Reference lists of reviews and guidelines were screened for additional RCTs. Study quality was rated using the PEDro-scale and overall quality of evidence with GRADE.

RESULTS

Four RCTs (n = 409) of fair-good quality (PEDro-scores) were included with three using a soft collar in addition to other conservative treatment while one study compared soft-collar use to act-as-usual. All studies found that an active or act-as-usual approach was more effective in reducing pain intensity compared to soft-collar use, confirmed by meta-analysis (two RCTs with data: SMD of -0.80 (-1.20, -0.41)). No studies reported disability outcomes while contrasting results were found between groups regarding total cervical range of motion (two RCTs with data: SMD of 0.16 (-0.21, 0.54)) or rotation (two RCTs with data: SMD of 0.54 (-0.19, 1.27)). Overall quality of the evidence was low to very low.

CONCLUSION

All four RCTs favoured an active approach/act-as-usual over soft-collar treatment. However, due to methodological concerns and low certainty of evidence, future studies investigating soft collar use in combination with an active rehabilitation strategy for acute/subacute WAD are needed.

Changes in Pain Sensitivity and Conditioned Pain Modulation During Recovery From Whiplash-associated Disorders

OBJECTIVE

The objective of this study was to investigate the pain-sensory profile of patients with whiplash-associated disorders (WADs) prior and post 2 weeks of standardized rehabilitation and after a 6-month follow-up.

MATERIALS AND METHODS

Twenty-two WAD participants (grade II; 14 women) and 22 sex-matched and age-matched healthy pain-free controls were enrolled. Pressure pain thresholds (PPTs) were assessed at local and distal muscles. Conditioned pain modulation (CPM) of PPTs was assessed using cuff pressure around the upper arm. Referred area of pain following supra-threshold pressure stimulation of the infraspinatus muscle was recorded on a body chart. Psychometric variables (pain intensity, area of perceived pain, pain catastrophizing, kinesiophobia, sleep problems, and depression level) were assessed. WAD group additionally completed the Neck Disability Index.

RESULTS

The WAD group demonstrated lower local PPTs compared with controls at all time points (P<0.05) and lower distal PPTs at baseline and at 2 weeks when compared with 6 months (within-group) (P<0.05). The WAD group had a reduced CPM response and larger induced referred pain areas compared with controls (P<0.05), while no within-group changes were observed at any time point. The WAD group reported higher pain intensity and perceived area of pain compared with controls at all time points (P<0.05) and a mean Neck Disability Index score of 41% at baseline, 16% at 2 weeks, and 4% at 6 months. Furthermore, the WAD group reported improvements in all other psychometric variables (P<0.05), although only pain catastrophizing levels were comparable to controls at 2 weeks.

DISCUSSION

PPTs but not CPM improved in the WAD group and were comparable to controls following 2 weeks following standardized rehabilitation, indicating that normalization of CPM may not be required to recover from WAD.

Neck-related function and its connection with disability in chronic whiplash-associated disorders: secondary analysis of a randomized controlled study

BACKGROUND

More than 40% of individuals with whiplash injury experience persistent neck pain and disability years later, called whiplash-associated disorders (WAD). A randomized controlled trial evaluated three exercise interventions in WAD and found that neck-specific exercise (NSE) and NSE with a behavioral approach (NSEB) significantly improve disability compared to prescribed physical activity (PPA). However, the relationship between neck-related function and disability is inconclusive and needs to be further investigated.

AIM

The present study compares the effect of NSE, NSEB, and PPA on neck muscle endurance (NME), active cervical range of motion (AROM), grip strength, and pain intensity immediately before and after the physical tests, and neck disability in individuals who are below or above the cut-off for normative reference values regarding NME, AROM, and grip strength.

DESIGN

Follow-up to a multicenter randomized clinical trial.

SETTING

Primary healthcare centers and hospital outpatient services.

POPULATION

The selected population of this study included 216 patients with persistent WAD grades II and III.

METHODS

This is a secondary analysis including 12 months' follow-up. NME, AROM, grip strength, pain, and self-reported disability were recorded at baseline, 3, 6, and 12 months. Linear mixed models were used, and sub-group analyses evaluated by non-parametric tests.

RESULTS

NSE and NSEB resulted in greater improvements compared to PPA (P<0.01) in ventral (only males) and dorsal NME, AROM, and pain intensity during testing. We found no significant between-group differences in grip strength and no significant differences between the NSE and NSEB groups. Improvement in disability was seen at the 12-month follow-up of NSE and/or NSEB for individuals both below and above the cut-off reference values for NME and AROM. Individuals in the PPA group below the reference values for NME and AROM reported increasing disability at 12 months compared to baseline.

CONCLUSIONS

The results suggest that neck-specific exercises (i.e., NSE, NSEB) improve clinical function and decrease disability in chronic WAD compared to PPA, but PPA can increase disability for patients with low neck-related function.

CLINICAL REHABILITATION IMPACT

Higher neck-related function seems to be important for reduced disability in persistent WAD grades II and III. Neck-specific exercises could lead to higher neck-related function.

Experiences of responsiveness to exercise in people with chronic whiplash: A qualitative study

Exercise is recommended in clinical guidelines for the treatment of chronic whiplash associated disorders (WAD). However, randomised controlled trials have shown similar effects for comprehensive exercise programs and advice. To date, there is no clear understanding of why some individuals with WAD appear to respond to exercise whilst others do not. The aim of this study was to explore the experiences and self-reported characteristics of people with chronic whiplash identifying as 'responders' and 'non-responders' to exercise. Semi-structured interviews were conducted with 13 people with chronic whiplash (patients) and seven treating physiotherapists. Patients were asked whether they responded to the exercise program, and what contributed to this. Physiotherapists were asked to share their experiences about the characteristics of people that appear to respond to exercise, and those that do not. An interpretive descriptive approach was selected to facilitate the generation of discipline-specific knowledge. Four themes were generated from patient and physiotherapist interviews, including: (1) the therapeutic relationship, (2) exercise experiences and beliefs, (3) self-efficacy and acceptance, (4) physical and psychological determinants of responsiveness. Responsiveness to exercise is complex and multifaceted. Clinicians may seek to identify the presence of discrete physical impairment(s) (e.g., range of motion restriction), and where present, determine whether targeted exercise results in an immediate and positive response. Clinicians may also focus their efforts on developing aspects of the therapeutic relationship identified as important to patients, such as hope, partnership and rapport.

Trauma-focused cognitive behavioural therapy and exercise for chronic whiplash with comorbid posttraumatic stress disorder: a randomised controlled trial

ABSTRACT

Many people with chronic whiplash-associated disorders (WAD) have also symptoms of posttraumatic stress disorder (PTSD), but this is rarely considered in usual predominantly exercise-based interventions. We aimed to investigate the effectiveness of combined trauma-focused cognitive behavioural therapy (TF-CBT) and exercise compared with supportive therapy (ST) and exercise for people with chronic WAD and PTSD. A randomised controlled multicentre trial with concealed allocation, assessor blinding, and blinded analysis was conducted. One hundred three participants with chronic WAD (>3 months and <5 years, grade II) and PTSD were randomised to TF-CBT and exercise (n = 53) or ST and exercise (n = 50). Both interventions comprised 10 weeks of TF-CBT or ST, followed by 6 weeks of exercise. Outcomes were measured at baseline, 10, 16 weeks, 6, and 12 months after randomisation. Analysis was intention to treat using linear mixed models. There was no difference between the interventions on the primary outcome of neck pain-related disability at any time point. At 16 weeks, the treatment effect on the 0 to 100 Neck Disability Index was 0.59 (95% confidence interval [CI] 5.51 to -4.33), at 6 months 1.18 (95% CI 6.15 to -3.78), and at 12 months 1.85 (95% CI 6.81 to -3.11). In addition, there was no difference between the interventions for most secondary outcomes at any time. Exceptions were in favour of TF-CBT and exercise, where improvements in PTSD symptoms were found at 16 weeks. From 16 weeks onwards, both groups achieved a clinically important improvement in neck pain-related disability. However, both groups remained moderately disabled.

Comparison of the Accuracy of WhipPredict to That of a Modified Version of the Short-Form Örebro Musculoskeletal Pain Screening Questionnaire to Predict Poor Recovery After Whiplash Injury

OBJECTIVE

To compare the accuracy of a whiplash-specific risk screening tool (WhipPredict) with that of the modified generic short-form Örebro Musculoskeletal Pain Screening Questionnaire (SF-ÖMPSQ) for predicting poor recovery in patients following whiplash injury.

STUDY DESIGN

Inception cohort study.

METHODS

Two hundred two participants with acute whiplash completed the WhipPredict and modified SF-ÖMPSQ at baseline. Poor recovery was measured at 6 and 12 months using the Neck Disability Index (greater than 10%), numeric pain-rating scale (greater than 3/10), global perceived recovery (less than +4), and inability to return to preinjury work level. Accuracy statistics were calculated to predict poor recovery.

RESULTS

Seventy-one percent (n = 143) of participants completed the 6-month assessment and 56% (n = 113) completed the 12-month assessment. At baseline, agreement between the WhipPredict and modified SF-ÖMPSQ was fair (prevalence-adjusted and bias-adjusted κ = 0.26; 95% confidence interval: 0.12, 0.39). Depending on the outcome, 20% to 72% of people had not recovered at 6 months and 12% to 71% had not recovered at 12 months. At 6 and 12 months, the WhipPredict tool showed high sensitivity (88%-96%) and low specificity (all outcomes less than 31%) on all 4 separate outcomes. The modified SF-ÖMPSQ showed moderate sensitivity (67%-75%) for the Neck Disability Index, numeric pain-rating scale, and global perceived recovery, high sensitivity for return to work (81%-90%), and moderate specificity (54%-77%) for all 4 outcomes.

CONCLUSION

Both tools showed acceptable accuracy in predicting poor recovery. The WhipPredict tool is recommended to correctly identify patients who will not recover but may falsely classify those who recover well. Using the modified SF-ÖMPSQ will result in fewer patients falsely categorized as being at risk of poor recovery and may result in some people being undertreated. J Orthop Sports Phys Ther 2021;51(5):207-215. Epub 19 Feb 2021. doi:10.2519/jospt.2021.9987.

A contemporary neuroscience approach compared to biomedically focused education combined with symptom-contingent exercise therapy in people with chronic whiplash associated disorders: a randomized controlled trial protocol

BACKGROUND

To address the need for a better treatment of chronic whiplash associated disorders (WAD), a contemporary neuroscience approach can be proposed.

OBJECTIVE

To examine the effectiveness of a contemporary neuroscience approach, comprising pain neuroscience education, stress management, and cognition-targeted exercise therapy versus conventional physical therapy for reducing disability (primary outcome measure) and improving quality of life and reducing pain, central sensitization, and psychological problems (secondary outcome measures) in people with chronic WAD.

METHODS

The study is a multi-center, two-arm randomized, controlled trial with 1-year follow-up and will be performed in two university-based and one regional hospital. People with chronic WAD (n=120) will be recruited. The experimental group will receive pain neuroscience education followed by cognition-targeted exercise therapy, and stress management. The control group will receive biomedically focused education followed by graded and active exercise therapy focusing on muscle endurance, strength, and flexibility, and ergonomic principles. The treatment will have a duration of 16 weeks. Functional status (Neck Disability Index) is the primary outcome measure. Secondary outcome measures include quality of life, pain, central sensitization, and psychological and socio-economic factors. In addition, electroencephalography will measure brain activity at rest and during a conditioned pain modulation paradigm. Assessments will take place at baseline, immediately post-treatment and at 6 and 12 months follow-up.

CONCLUSIONS

This study will examine whether a contemporary neuroscience approach is superior over conventional physical therapy for improving functioning, quality of life, and reducing pain, central sensitization, and psychological problems in people with chronic WAD.

The Role of Cervical Symptoms in Post-concussion Management: A Systematic Review

BACKGROUND

Patients with cervicogenic symptoms following a concussion have shown a disproportionate rate of delayed symptom resolution. However, the prevalence of cervicogenic symptoms in the acute stages following a concussion and the percentage of those patients who continue on to suffer delayed symptom resolution is poorly described in the literature.

OBJECTIVES

To provide a comprehensive report on the clinical prevalence, diagnostic methods, and potential treatment options for cervicogenic symptoms that are elicited during acute and chronic phases following a concussion.

METHODS

Electronic searches were conducted in PubMed, SPORTDiscus, ICL, CINAHL and PEDro, from inception to May 2020, to identify original research articles on concussion involving cervicogenic symptoms. We assessed each included article for risk of bias, methodological quality, level of evidence and evidence quality. The articles were categorized into three topics: (1) prevalence of post-concussion cervicogenic symptoms; (2) diagnostic testing for cervicogenic symptoms, and (3) treatment techniques for cervicogenic symptoms.

RESULTS

The initial review resulted in 1443 abstracts, of which 103 abstracts met the inclusion criteria of our research. After the review of full text, 80 articles were excluded, which resulted in a total of 23 articles for this systematic review. Prevalence of cervicogenic symptoms in the acute stages ranged from 7 to 69% and increased to 90% in patients experiencing persistent post-concussive symptoms. Neck pain at initial evaluation increased risk of developing persistent post-concussive symptoms (PPCS) by 2.58-6.38 times. Patient-reported outcome measures (e.g., Neck Disability Index, Dizziness Handicap Inventory, and Rivermead Post-Concussion Questionnaire) can identify patients with cervicogenic symptoms that should be further differentiated by clinical testing. Lastly, treatment using graded cervical manual therapy has shown to reduce time to symptom resolution and medical clearance.

CONCLUSIONS

Cervicogenic symptoms are prevalent in the acute and chronic stages following concussion, which if not diagnosed appropriately increase the likelihood of PPCS. Several clinical tests are available to help differentiate cervicogenic symptoms; however, lack of awareness and hesitation by practitioners limits their use. More randomized controlled trials are necessary to evaluate the effectiveness of cervical specific treatment programs for PPCS.

How similar are whiplash and mild traumatic brain injury? A systematic review

INTRODUCTION

Mild traumatic brain injury (mTBI) and whiplash are two pathologies which appear in the follow-up of a cranio-cervical trauma. The objective of this study is to review their definitions, to discuss each entity.

METHODS

Whiplash and mTBI were defined. Then, a systematic literature review was carried out using the Pubmed database. Relevant studies after 1995 were selected, with 16 articles describing a link between whiplash and mTBI. 8 articles were analyzed after reading their abstracts.

RESULTS

Whiplash and mTBI have many similarities (symptoms, biomechanics, cognitive disorders, presence of diffuse axonal lesions on functional imaging) and some differences (in posture, more vestibular and balance disorders in whiplash). mTBIs result from linear accelerations between 60- 160g (gravity), studies on whiplash have shown that they can appear from 4.5g, which could explain biomechanically the frequent concomitant appearance. Cervical joint dysfunction can appear in persistent concussive syndrome, with upper cervical pain, less endurance of the cervical flexor muscles, and an increase in cervical stiffness leading to tension headache. This could explain neck pain in mTBI and headache in whiplash. An explanation to vestibular and cochlear disorders is given, and the two pathologies concomitantly could increase the symptoms.

CONCLUSION

To our knowledge, no studies define distinct boundaries between these two pathologies, which overlap on many points. An explanation is their concomitant onset, due to the biomechanics of the trauma and anatomical reasons. Larger-scale studies of rigorous scientific quality are needed to answer the question of the difference between whiplash and mTBI.

Macromolecular changes in spinal cord white matter characterize whiplash outcome at 1-year post motor vehicle collision

Each year, whiplash injuries from motor vehicle collisions (MVC) affect millions worldwide, with no strong evidence of pathology. While the majority recover soon after the injury, the same is not true for roughly 20% reporting higher levels of pain and distress, without diagnostic options. This study used magnetization transfer (MT) imaging to quantify white matter integrity in 78 subjects with varying levels of pain, 1 year after MVC. MT images of the cervical spinal cord were collected parallel to the intervertebral disks. MT ratios (MTR) were calculated in select white matter tracts along with MTR homogeneity (MTRh) at each level. Significant differences were observed between clinical outcome groups in the left and right spinothalamic tracts (p = 0.003 and 0.020) and MTRh (p = 0.009). MTRh was elevated in females with poor recovery versus females reporting recovery (p < 0.001) or milder symptoms (p < 0.001), and in males reporting recovery (p = 0.007) or no recovery (p < 0.001). There was a significant interaction between recovery status and sex (p = 0.015). MT imaging identified tract specific and regional changes in white matter integrity suggesting potential insults to the cord. Additionally, significant MTRh differences between sexes were observed, characterizing the heterogeneity of whiplash recovery and worse outcomes in females.

Effects of specific muscle activation for low back pain on activity limitation, pain, work participation, or recurrence: A systematic review

BACKGROUND

Specific muscle activation (SMA) is a commonly used treatment for people with low back pain (LBP) however there is variability in systematic reviews to date on effectiveness. This may be because of the use of eligibility criteria incongruent with original descriptions of the SMA approach.

PURPOSE

The purpose of this study was to determine the effectiveness of SMA on improving activity limitation, pain, work participation or recurrence for people with LBP.

STUDY DESIGN

Systematic review METHODS: Computer databases were searched for randomised controlled trials (RCTs) published in English up to September 6, 2019. Eligibility criteria were chosen to ensure all clinically relevant RCTs were included and trials of poorly defined or executed SMA excluded. Outcomes for activity limitation, pain, work participation or recurrence were extracted.

RESULTS

Twenty-eight RCTs were included in this review with 18 being considered high quality. GRADE quality assessment revealed low to high quality evidence that SMA was more effective than exercise, conservative medical management, multi-modal physiotherapy, placebo, advice and minimal intervention.

CONCLUSIONS

This systematic review is the first to evaluate the effectiveness of SMA in accordance with the original clinical descriptions. We found significant evidence supporting the effectiveness of SMA for the treatment of LBP. Where significant results were demonstrated, the between-group differences were in many comparisons clinically important based on contemporary definitions and an effect size of 0.5 or more. Practitioners should consider SMA as a treatment component in their patients with LBP.

Overcoming Overuse Part 2: Defining and Quantifying Health Care Overuse for Musculoskeletal Conditions

In this series on "Overcoming Overuse," we explore the issue of health care overuse and how it may be identified in musculoskeletal physical therapy. In part 2, we frame health care overuse as a continuum from overuse to appropriate care, and consider how to measure overuse. We describe how overuse can be defined within a framework of care that is ineffective, inefficient, and misaligned, depending on the perspective of the person delivering or receiving care-the clinician, society, or patient. To ensure that musculoskeletal health care is of high value and sustainable, we encourage physical therapists to reflect on their practice. J Orthop Sports Phys Ther 2020;50(11):588-591. doi:10.2519/jospt.2020.0109.

Central neurobiological effects of physical exercise in individuals with chronic musculoskeletal pain: a systematic review

OBJECTIVE

Primary objectives: to investigate the central neurobiological effects (using MRI) of physical exercise in individuals with chronic pain. Secondary objectives: (1) to investigate the associations between central changes and clinical outcomes and (2) to investigate whether different types and dosages of physical exercise exert different central changes.

DESIGN

Systematic review searching four electronic databases up to September 2018: AMED, CINAHL, Embase and MEDLINE. Two reviewers independently assessed the methodological quality of included studies using the Cochrane Collaboration's Risk of Bias in Non-Randomised Studies-I tool. A standardised extraction table was used for data extraction, which was performed by two reviewers.

INTERVENTIONS

Studies reporting any physical exercise intervention in any chronic musculoskeletal pain condition were included. Eligibility of 4011 records was screened independently by two reviewers, and four studies were included in the review.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome: any brain outcome assessed with any MR technique.

SECONDARY OUTCOMES

any self-reported clinical outcomes, and type and dosage of the exercise intervention.

RESULTS

All four studies had high risk of bias. There was heterogeneity between the brain areas studied and the types of exercise interventions delivered. All studies reported functional MRI changes in various brain areas following an exercise intervention. Insufficient data were available to conduct a meta-analysis or to answer the secondary aims.

CONCLUSIONS

Only a limited number of studies were available and all were at high risk of bias. None of the studies was randomised or included blinded assessment. Exercise may exert effects on brain neurobiology in people with chronic pain. Due to the high risk of bias, future studies should use a randomised study design. Investigation of morphological brain changes could be included.

PROSPERO REGISTRATION NUMBER

CRD42018108179.

Can measuring passive neck muscle stiffness in whiplash injury patients help detect false whiplash claims?

BACKGROUND

Whiplash injury of the cervical spine is the most common injury after a car accident and in 25% of patients it progresses into chronic neck pain.

AIM OF THE STUDY

To investigate the difference in neck muscle stiffness using shear wave ultrasound elastography between subjects who suffered an uncomplicated whiplash injury and a control group. Possible recognition of patients who insist on physical therapy in order to support their false whiplash injury claims.

METHODS

This study included 75 whiplash injury patients and 75 control subjects. Trapezius, splenius capitis and sternocleidomastoid muscles were examined by ultrasound shear wave elastography.

RESULTS

Increased muscle stiffness was noticed in trapezius muscle bilaterally in the whiplash group when compared to the control group (p < 0.001; right 57.47 ± 13.82 kPa vs. 87.84 ± 23.23 kPa; left 54.4 ± 12.68 kPa vs. 87.21 ± 26.47 kPa). Muscle stiffness in splenius capitis and sternocleidomastoid muscles was not suitable for analysis because of asymmetrical data distribution. Patients with less than 76 kPa of muscle stiffness in trapezius muscle are unlikely to belong in whiplash injury group (sensitivity 90% for right and 97% for left trapezius muscle, specificity 72% and 73%, respectively).

CONCLUSION

Patients measuring below 76 kPa of muscle stiffness in the trapezius muscle might have no whiplash injury. Further follow-up of the patients measuring higher than cut-off value might be beneficial for detecting patients with prolonged neck muscle spasm that can lead to chronic cervical pain syndrome.

Relationships Between Context, Process, and Outcome Indicators to Assess Quality of Physiotherapy Care in Patients with Whiplash-Associated Disorders: Applying Donabedian's Model of Care

BACKGROUND

Quality indicators (QIs) are measurable elements of practice performance and may relate to context, process, outcome and structure. A valid set of QIs have been developed, reflecting the clinical reasoning used in primary care physiotherapy for patients with whiplash-associated disorders (WAD). Donabedian's model postulates relationships between the constructs of quality of care, acting in a virtuous circle.

AIM

To explore the relative strengths of the relationships between context, process, and outcome indicators in the assessment of primary care physiotherapy in patients with WAD.

MATERIALS AND METHODS

Data on WAD patients (N=810) were collected over a period of 16 years in primary care physiotherapy practices by means of patients records. This routinely collected dataset (RCD-WAD) was classified in context, process, and outcome variables and analyzed retrospectively. Clinically relevant variables were selected based on expert consensus. Associations were expressed, using zero-order, as Spearman rank correlation coefficients (criterion: rs >0.25 [minimum: fair]; α-value = 0.05).

RESULTS

In round 1, 62 of 85 (72.9%) variables were selected by an expert panel as relevant for clinical reasoning; in round 2, 34 of 62 (54.8%) (context variables 9 of 18 [50.0%]; process variables 18 of 34 [52.9]; outcome variables 8 of 10 [90.0%]) as highly relevant. Associations between the selected context and process variables ranged from 0.27 to 0.53 (p≤0.00), between selected context and outcome variables from 0.26 to 0.55 (p≤0.00), and between selected process and outcome variables from 0.29 to 0.59 (p≤0.00). Moderate associations (rs >0.50; p≤0.00) were found between "pain coping" and "fear avoidance" as process variables, and "pain intensity" and "functioning" as outcome variables.

CONCLUSION

The identified associations between selected context, process, and outcome variables were fair to moderate. Ongoing work may clarify some of these associations and provide guidance to physiotherapists on how best to improve the quality of clinical reasoning in terms of relationships between context, process, and outcome in the management of patients with WAD.

Effectiveness of deep tissue massage therapy, and supervised strengthening and stretching exercises for subacute or persistent disabling neck pain. The Stockholm Neck (STONE) randomized controlled trial

OBJECTIVE

To compare the effectiveness of deep tissue massage, supervised strengthening and stretching exercises, and a combined therapy (exercise followed by massage) (index groups), with advice to stay active (control group).

METHODS

Randomized controlled trial of 619 adults with subacute or persistent neck pain allocated to massage (n = 145), exercise (n = 160), combined therapy (n = 169) or advice (n = 147). Primary outcomes were minimal clinically important improvements in neck pain intensity and pain-related disability based on adapted questions from the Chronic Pain Questionnaire. Secondary outcomes were perceived recovery and sickness absence. Outcomes were measured at seven, 12, 26 and 52 weeks.

RESULTS

We found improvement in pain intensity favouring massage and combined therapy compared to advice; at seven weeks (RR = 1.36; 95%CI:1.04-1.77) and 26 weeks (RR = 1.23; 95%CI:0.97-1.56); and seven (RR = 1.39; 95%CI:1.08-1.81) and 12 weeks (RR = 1.28; 95%CI:1.02-1.60) respectively, but not at later follow-ups. Exercise showed higher improvement of pain intensity at 26 weeks (RR = 1.31; 95%CI:1.04-1.65). Perceived recovery was higher in the index groups than in the advice group at all follow-ups. We found no consistent differences in pain related disability or sickness absence.

CONCLUSIONS

In this study, at 12-months follow-up, none of the index therapies were more effective than advice in terms of pain intensity in the long term or in terms of pain-related disability in the short or long term. However, the index therapies led to higher incidence of improvement in pain intensity in the short term, and higher incidence of favorable perceived recovery in the short and in the long term than advice.

TRIAL REGISTRATION

ISRCTN01453590. Registered 3 July 2014.

Motor vehicle crash reconstruction: Does it relate to the heterogeneity of whiplash recovery?

Whiplash injury is a common consequence of motor vehicle crashes (MVC), yet it is also one of the most poorly understood. While more than 50% of those injured should expect to rapidly recover, others are not as fortunate with approximately 25% of those exposed to and injured in an MVC transitioning from acute to chronic pain and disability. The purpose of this prospective study was to determine if the severity and direction of collisions involving participants enrolled in a longitudinal study of recovery from whiplash are able to differentiate between different recovery groups based on the neck disability index (NDI) percentage scores at 3-months, and if these crash specific parameters are associated with known risk factors for recovery. Here, we examined objective collision data, repair invoices, and characteristics of the crash for 37 acutely injured participants consented and enrolled at their emergency department visit and further assessed at three time points; < 1 week, 2-weeks, and 3-months post MVC. Collision data were used to reconstruct and estimate the severity of the crash and determine if they aligned with the heterogeneity of whiplash injury recovery. Wilcoxon rank sum tests were used to determine if % scores on the Neck Disability Index (NDI) at 3-months post MVC were associated with the following variables: sex, head turned at time of impact, seatbelt use, whether or not airbags deployed, if the vehicle was struck while stopped or while turning, or the principle direction of force (PDOF). Spearman’s correlation coefficients were used to determine if NDI at 3-months post MVC was associated with age, Body Mass Index, pain-related disability at baseline, signs of post-traumatic distress, intrusion/hyperarousal, negative affect, pain intensity, estimated speed change from the impact, and damage estimates (in US$). There was a significant positive association between self-reported neck disability at 3-months post MVC, post-traumatic distress, negative affect and uncontrolled pain. There was no direct effect of participant characteristics, arousal, intrusion/hyperarousal sub-score, damage, PDOF, speed change, or other crash characteristics. Established crash parameters were not associated with the heterogeneity of whiplash injury recovery in a small sample of injured participants.

Evaluation of a novel intervention to improve physical activity for adults with whiplash associated disorders: Protocol for a multiple-baseline, single case experimental study

Half of individuals with a whiplash injury experience ongoing pain and disability. Many are insufficiently active for good health, increasing their risk of preventable morbidity and mortality, and compounding the effects of the whiplash injury. This paper describes a protocol for evaluating the efficacy of a physical activity promotion intervention in adults with whiplash associated disorders. A multiple-baseline, single case experimental design will be used to evaluate the effects of a physical activity (PA) intervention that includes evidence-based behaviour change activities and relapse prevention strategies for six adults with chronic whiplash. A structured visual analysis supplemented with statistical analysis will be used to analyse: accelerometer-measured PA, confidence completing PA in the presence of neck pain, and pain interference.

Personalised treatments for acute whiplash injuries: A pilot study of nested N-of-1 trials in a multiple baseline single-case experimental design

BACKGROUND

Whiplash associated disorder (WAD), a common and disabling condition, incurs huge burden and costs to Australia. Yet, current treatments for whiplash are not very effective; improved outcomes are urgently needed. Clinical guidelines recommend simple analgesia (paracetamol and non-steroidal anti-inflammatory drugs) but there have been no trials of guideline-recommended drugs. This study will investigate the effectiveness of evidence-based advice (EBA), paracetamol, naproxen, and both paracetamol and naproxen, in reducing daily neck pain and preventing chronic neck pain after whiplash injury.

METHODS

This study is a pilot series of multi-cycle, double-blinded, randomised N-of-1 trials, nested in a multiple baseline design. The design will comprise three baselines of 5, 8 or 11 days duration. Post enrolment, participants will be randomly assigned to one of the baselines. Fifteen participants with acute (<2 weeks) Grade II WAD, experiencing at least moderate pain (NRS: ≥ 5/10), and at risk of poor recovery will be recruited from hospitals in Queensland, Australia, and through local physiotherapists. Patients will receive EBA plus a randomised sequence of three cycles of ten day treatment triplets (paracetamol designated as a C phase, naproxen, designated as a D phase, and both paracetamol and naproxen, designated as an E phase).

DISCUSSION

We will test the effects of different treatments on the primary outcome of average neck pain intensity collected daily and at 4 and 7 months post-injury. Secondary outcomes, including disability, depression, post-traumatic stress symptoms, pain catastrophizing, and feasibility of study procedures, will also be evaluated. The results of this study will inform a larger trial aiming to strengthen the evidence on EBA and simple analgesics for WAD.

TRIAL REGISTRATION

Clinical Trials Primary Registry: Australian and New Zealand Clinical Trials Registry.

CLINICAL TRIAL REGISTRATION NUMBER

ACTRN12618001291279.

DATE OF REGISTRATION

31/07/2018.

PRIMARY TRIAL SPONSOR

The University of Queensland, Brisbane QLD 4072 Australia.

FUNDING

The University of Queensland.

Evidence-based care in high- and low-risk groups following whiplash injury: a multi-centre inception cohort study

BACKGROUND

Studies aimed at improving the provision of evidence-based care (EBC) for the management of acute whiplash injuries have been largely successful. However, whether EBC is broadly provided and whether delivery of EBC varies based on risk of non-recovery, is uncertain. Receiving EBC should improve recovery, though this relationship has yet to be established. Further, mitigating the effect of EBC is the relationship with the practitioner, a phenomenon poorly understood in WAD. This study aimed to determine the proportion of individuals with whiplash, at differing baseline risk levels, receiving EBC. This study also aimed to determine whether receiving EBC and the therapeutic relationship were associated with recovery at 3 months post injury.

METHODS

Participants with acute whiplash were recruited from public hospital emergency departments, private physiotherapy practices, and State Insurance Regulatory Authority (SIRA) databases. Participants completed questionnaires at baseline (demographics, risk of non-recovery) and 3-months (treatment received, risk identification, therapeutic relationship) post injury. Primary health care providers (HCPs) treating these participants also completed questionnaires at 3-months. Recovery was defined as neck disability index ≤4/50 and global perceived effect of ≥4/5.

RESULTS

Two-hundred and twenty-eight people with acute whiplash, and 53 primary care practitioners were recruited. The majority of the cohort reported receiving EBC, with correct application of the Canadian C-spine rule (74%), and provision of active treatments (e.g. 89% receiving advice) high. Non-recommended (passive) treatments were also received by a large proportion of the cohort (e.g. 50% receiving massage). The therapeutic relationship was associated with higher odds of recovery, which was potentially clinically significant (OR 1.34, 95% CI 1.18-1.62). EBC was not significantly associated with recovery.

CONCLUSIONS

Guideline-based knowledge and practice has largely been retained from previous implementation strategies. However, recommendations for routine risk identification and tailored management, and reduction in the provision of passive treatment have not. The therapeutic relationship was identified as one of several important predictors of recovery, suggesting that clinicians must develop rapport and understanding with their patients to improve the likelihood of recovery.