High-dose methylprednisolone prevents extensive sick leave after whiplash injury. A prospective, randomized, double-blind study

Effectiveness of Interventions on Work Outcomes After Road Traffic Crash-Related Musculoskeletal Injuries: A Systematic Review and Meta-analysis

BACKGROUND

Musculoskeletal injuries are common after road traffic crash (RTC) and can lead to poor work-related outcomes. This review evaluated the impact of interventions on work-related (e.g. sick leave), health, and functional outcomes in individuals with a RTC-related musculoskeletal injury, and explored what factors were associated with work-related outcomes.

METHODS

Searches of seven databases were conducted up until 9/03/2023. Eligible interventions included adults with RTC-related musculoskeletal injuries, a comparison group, and a work-related outcome, and were in English. Meta-analyses were conducted using RevMan and meta-regressions in Stata.

RESULTS

Studies (n = 27) were predominantly conducted in countries with third-party liability schemes (n = 26), by physiotherapists (n = 17), and in participants with whiplash injuries (94%). Pooled effects in favour of the intervention group were seen overall (SMD = - 0.14, 95% CI: - 0.29, 0.00), for time to return to work (- 17.84 days, 95% CI: - 24.94, - 10.74), likelihood of returning to full duties vs. partial duties (RR = 1.17, 95% CI: 1.01, 1.36), decreased pain intensity (- 6.17 units, 95% CI: - 11.96, - 0.39, 100-point scale), and neck disability (- 1.77 units, 95% CI: - 3.24, - 0.30, 50-point scale).

DISCUSSION

Interventions after RTC can reduce time to return to work and increase the likelihood of returning to normal duties, but the results for these outcomes were based on a small number of studies with low-quality evidence. Further research is needed to evaluate a broader range of interventions, musculoskeletal injury types, and to include better quality work-related outcomes.

A 13-Year Long-Term Follow-Up of a Case Report With Continued Improvement in Severe Chronic Neck and Head Pain Alleviated With Chiropractic BioPhysics® Spinal Rehabilitation Protocols

Alleviation of headaches (HAs), neck pain (NP), and disability is a desirable clinical outcome for the billions globally who suffer from these conditions. Chiropractic BioPhysics® (CBP®) methods may provide an option for head and neck-injured patients. A 62-year-old female historically injured multiple times including two motor vehicle collisions (MVC), and a strike to the face with a hockey puck; all resulting in chronic pain and suffering. The subject sought and received successful treatment in 2016 using this conservative protocol at a facility in the USA. The resolution of symptoms following 36 treatments was previously reported. Following 13 years without treatment beyond home exercises, the subject was re-evaluated and found to be stable in the long term for pain, structural and functional assessment. Thirty-six treatments over 12 weeks in 2016 led to an improvement in numerical pain rating scale (NPRS) for NP (5/10 to 1/10), and HA (9+/10 to 0/10), resolution of NP disability (6/100 to 0/100) as well as normalization of ROM without pain and resumption of all activities of daily living including high-level athletics without pain and disability. A 13-year follow-up found continued stability objectively and subjectively. We provide a case of successful conservative treatment using specific traction, exercises, and spine manipulation procedures. CBP® provides an option to treat pain and this case adds to growing evidence.

The safety of pulse corticosteroid therapy- Systematic review and meta-analysis

OBJECTIVE

To amass all available evidence from randomized controlled trials regarding the safety of pulse corticosteroids therapy, in order to establish its safety.

PATIENTS AND METHODS

All electronic databases from 1/1966 up to 02/2019 were reviewed to find all randomized controlled trials comparing pulse corticosteroids to oral corticosteroids or to placebo/no treatment. Two reviewers independently extracted and recorded data regarding type of corticosteroid treatment, dosages, length of treatment and follow-up. Risk ratios (RR) with 95% (CI) for differences between pulse corticosteroids and comparator were pooled using a fixed effect meta-analysis. The primary outcome was occurrence of severe adverse events (SAEs). Secondary outcomes included any adverse events (AEs), AEs requiring discontinuation, AEs per system involved and all-cause mortality.

RESULTS

A total of 64 trials were included: 18 trials which compared pulse corticosteroids to oral corticosteroids and 46 trials which compared pulse corticosteroids to placebo/no intervention. Pulse corticosteroids was not associated with increased risk for SAEs for both comparators: RR 0.77 (95% CI 0.52-1.14), and RR 0.99 (95% CI 0.93-1.06), respectively. Sensitivity analysis based on adequate allocation concealment and use of a valid AE grading did not alter the results. Subgroup analysis revealed no increased risk of specific SAEs or AEs with pulse corticosteroids compared to oral corticosteroids.

CONCLUSION

Pulse corticosteroids was not associated with an increase risk of SAEs and should be regarded as safe.

The effect of steroid treatment on whiplash associated syndrome: a controlled randomized prospective trial

PURPOSE

There is significant evidence in the literature that low or relatively low cortisol concentrations near the time of an accident are associated with more severe forms of whiplash-associated disorders. We hypothesized that treating patients that were involved in a motor vehicle accident with hydrocortisone would alleviate the incidence and severity of these disabling disorders.

METHODS

A prospective, randomized, double-blind, placebo-controlled clinical trial. Blunt trauma patients that underwent a motor vehicle crash were allocated into a study group that received a single bolus of hydrocortisone and a control group that received saline. The patients were followed for 1 month. The incidence and severity of whiplash associated disorder, functional disturbances, and post-traumatic stress disorder were compared between the two groups. The analyses were repeated for sub-divisions into groups of high and low admission cortisol.

RESULTS

The more severe forms of whiplash-associated disorders on the day of accident were associated with low cortisol levels; mean cortisol concentration of the lower grade of whiplash patients (13.09 ± 7.35 µg%) was higher than that of whiplash syndrome of the severe forms (8.33 ± 3.45 µg), p = 0.001. There were no differences between study and control groups regarding whiplash-associated disorders, functional tests, and severity of stress disorder 1 month after the accident. Significant differences were evident between high and low cortisol sub-groups. Those who had low cortisol level on admission and received hydrocortisone had worse outcomes.

CONCLUSION

Steroid treatment of patients with whiplash might be harmful to those who present with low cortisol concentrations (< 9.5 μg/dL).

TRIAL REGISTRATION

Clinical Trials: Association between low cortisol levels and whiplash syndrome. Date of registration: March 18, 2014. Date the first participant was enrolled: May 10, 2014.

TRIAL REGISTRATION NUMBER

NCT02090309. URL: https://clinicaltrials.gov/ct2/show/NCT02090309 .

Methylprednisolone in the management of spinal cord injuries: Lessons from randomized, controlled trials

The efficacy of glucocorticoid for treatment of acute spinal cord injuries remains a controversial topic. Differing medical societies have issued conflicting recommendations in this regard. Here we review the available randomized, controlled trial (RCT) data on this subject and offer a synthesis of these data sets.

Persistent Pain Among Older Adults Discharged Home From the Emergency Department After Motor Vehicle Crash: A Prospective Cohort Study

STUDY OBJECTIVE

Motor vehicle crashes are the second most common form of trauma among older adults. We seek to describe the incidence, risk factors, and consequences of persistent pain among older adults evaluated in the emergency department (ED) after a motor vehicle crash.

METHODS

We conducted a prospective longitudinal study of patients aged 65 years or older who presented to one of 8 EDs after motor vehicle crash between June 2011 and June 2014 and were discharged home after evaluation. ED evaluation was done through in-person interview; follow-up data were obtained through mail-in survey or telephone call. Pain severity (0 to 10 scale) overall and for 15 parts of the body were assessed at each follow-up point. Principal component analysis was used to assess the dimensionality of the locations of pain data. Participants reporting pain severity greater than or equal to 4 attributed to the motor vehicle crash at 6 months were defined as having persistent pain.

RESULTS

Of the 161 participants, 72% reported moderate to severe pain at the ED evaluation. At 6 months, 26% of participants reported moderate to severe motor vehicle crash-related pain. ED characteristics associated with persistent pain included acute pain severity; pain located in the head, neck, and jaw or lower back and legs; poor self-rated health; less formal education; pre-motor vehicle crash depressive symptoms; and patient's expected time to physical recovery more than 30 days. Compared with individuals without persistent pain, those with persistent pain were substantially more likely at 6-month follow-up to have also experienced a decline in their capacity for physical function (73% versus 36%; difference=37%; 95% confidence interval [CI] 19% to 52%), a new difficulty with activities of daily living (42% versus 17%; difference=26%; 95% CI 10% to 43%), a 1-point or more reduction in overall self-rated health on a 5-point scale (54% versus 30%; difference=24%; 95% CI 6% to 41%), and a change in their living situation to obtain additional help (23% versus 8%; difference=15%; 95% CI 2% to 31%).

CONCLUSION

Among older adults discharged home from the ED post-evaluation after a motor vehicle crash, persistent pain is common and frequently associated with functional decline and disability.

WITHDRAWN: Botulinum toxin for subacute/chronic neck pain

Withdrawn due to non‐compliance with The Cochrane Collaboration’s Commercial Sponsorship Policy

The editorial group responsible for this previously published document have withdrawn it from publication.

WITHDRAWN: Medicinal and injection therapies for mechanical neck disorders

Withdrawn due to non‐compliance with The Cochrane Collaboration’s Commercial Sponsorship Policy

The editorial group responsible for this previously published document have withdrawn it from publication.

The effectiveness of infrared thermography in patients with whiplash injury

Objective

This study aims to visualize the subjective symptoms before and after the treatment of whiplash injury using infrared (IR) thermography.

Methods

IR thermography was performed for 42 patients who were diagnosed with whiplash injury. There were 19 male and 23 female patients. The mean age was 43.12 years. Thermal differences (ΔT) in the neck and shoulder and changes in the thermal differences (ΔdT) before and after treatment were analyzed. Pain after injury was evaluated using visual analogue scale (VAS) before and after treatment (ΔVAS). The correlations between ΔdT and ΔVAS results before and after the treatment were examined. We used Digital Infrared Thermal Imaging equipment of Dorex company for IR thermography.

Results

The skin temperature of the neck and shoulder immediately after injury showed 1-2℃ hyperthermia than normal. After two weeks, the skin temperature was normal range. ΔT after immediately injuy was higher than normal value, but it was gradually near the normal value after two weeks. ΔdT before and after treatment were statistically significant (p<0.05). VAS of the neck and shoulder significantly reduced after 2 week (p=0.001). Also, there was significant correlation between ΔdT and reduced ΔVAS (the neck; r=0.412, p<0.007) (the shoulder; r=0.648, p<0.000).

Conclusion

The skin temperature of sites with whiplash injury is immediately hyperthermia and gradually decreased after two weeks, finally it got close to normal temperature. These were highly correlated with reduced VAS. IR thermography can be a reliable tool to visualize the symptoms of whiplash injury and the effectiveness of treatment in clinical settings.

Physician-delivered injection therapies for mechanical neck disorders: a systematic review update (non-oral, non-intravenous pharmacological interventions for neck pain)

Background:

Controversy persists regarding medicinal injections for mechanical neck disorders (MNDs).

Objectives:

To determine the effectiveness of physician-delivered injections on pain, function/disability, quality of life, global perceived effect and patient satisfaction for adults with MNDs.

Search Methods:

We updated our previous searches of CENTRAL, MEDLINE and EMBASE from December 2006 through to March 2012.

Selection Criteria:

We included randomized controlled trials of adults with neck disorders treated by physician-delivered injection therapies.

Data Collection and Analysis:

Two authors independently selected articles, abstracted data and assessed methodological quality. When clinical heterogeneity was absent, we combined studies using random-effects models.

Results:

We included 12 trials (667 participants). No high or moderate quality studies were found with evidence of benefit over control. Moderate quality evidence suggests little or no difference in pain or function/disability between nerve block injection of steroid and bupivacaine vs bupivacaine alone at short, intermediate and long-term for chronic neck pain. We found limited very low quality evidence of an effect on pain with intramuscular lidocaine vs control for chronic myofascial neck pain. Two low quality studies showed an effect on pain with anaesthetic nerve block vs saline immediately post treatment and in the short-term. All other studies were of low or very low quality with no evidence of benefit over controls.

Authors' Conclusions:

Current evidence does not confirm the effectiveness of IM-lidocaine injection for chronic mechanical neck pain nor anaesthetic nerve block for cervicogenic headache. There is moderate evidence of no benefit for steroid blocks vs controls for mechanical neck pain.

Pharmacological Interventions Including Medical Injections for Neck Pain: An Overview as Part of the ICON Project

OBJECTIVES

To conduct an overview (review-of-reviews) on pharmacological interventions for neck pain.

SEARCH STRATEGY

Computerized databases and grey literature were searched from 2006 to 2012.

SELECTION CRITERIA

Systematic reviews of randomized controlled trials (RCT) in adults with acute to chronic neck pain reporting effects of pharmacological interventions including injections on pain, function/disability, global perceived effect, quality of life and patient satisfaction.

DATA COLLECTION & ANALYSIS

Two independent authors selected articles, assessed risk of bias and extracted data The GRADE tool was used to evaluate the body of evidence and an external panel provided critical review.

MAIN RESULTS

We found 26 reviews reporting on 47 RCTs. Most pharmacological interventions had low to very low quality methodologic evidence with three exceptions. For chronic neck pain, there was evidence of: a small immediate benefit for eperison hydrochloride (moderate GRADE, 1 trial, 157 participants);no short-term pain relieving benefit for botulinum toxin-A compared to saline (strong GRADE; 5 trial meta-analysis, 258 participants) nor for subacute/chronic whiplash (moderate GRADE; 4 trial meta-analysis, 183 participants) including reduced pain, disability or global perceived effect; andno long-term benefit for medial branch block of facet joints with steroids (moderate GRADE; 1 trial, 120 participants) over placebo to reduce pain or disability;

REVIEWERS' CONCLUSIONS

While in general there is a lack of evidence for most pharmacological interventions, current evidence is against botulinum toxin-A for chronic neck pain or subacute/chronic whiplash; against medial branch block with steroids for chronic facet joint pain; but in favour of the muscle relaxant eperison hydrochloride for chronic neck pain.

High power laser therapy treatment compared to simple segmental physical rehabilitation in whiplash injuries (1° and 2° grade of the Quebec Task Force classification) involving muscles and ligaments

INTRODUCTION

whiplash is a frequent post traumatic pathology caused by muscle, tendon and capsular elements over stretching. The authors conducted a short term prospective randomised study to test the effectiveness of a multi wave High Power Laser Therapy (HPLT) versus conventional simple segmental physical rehabilitation (PT) included in Italian tariff nomenclature performance physiotherapy Study Design: prospective randomised study (Level II).

MATERIAL AND METHODS

the authors identified 135 homogeneous patients with whiplash grade 1 - 2 of the Quebec Task Force classification (QTFC). INAIL, the Italian National Workers Insurance, based in Milan, was reliable source for identifying patients. All patients with whiplash injuries grade 1 or 2 QTFC, were eligible for the study, starting from April 28 2010 to September 30 2010. Patients referred to a Coordinator (C.M.) who applied the inclusion and exclusion criteria. Patients who agreed to participate were randomly assigned to one of the two treatment groups. Dates for initial treatment session were arranged, including cervical spine X-ray, and assessment. Each patient gave informed consent for participation and agreed to adopt only the study treatment for 6 weeks. Group A (84 patients) was treated with High Power Laser Therapy (HPLT), Group B (51 patients) received conventional simple segmental physical rehabilitation (PT). During the treatment period, no other electro-medical therapy, analgesics or anti-inflammatory drugs were allowed. All patients were assessed at baseline (T0) and at the end of the treatment period (T1) using a Visual Analogical Scale (VAS), (T2) the date of return to work was registered afterwards.

RESULTS

there was a reduction in VAS pain scores at T1. Group A (VAS = 20) Group B (VAS = 34,8) (p =0.0048). Laser treatment allowed quick recovery and return to work (T2). Group A after 48 days against 66 days of Group B (p=0.0005).

CONCLUSIONS

results suggest that High Power Laser Therapy - is an effective treatment in patients with whiplash injury, compared to conventional simple segmental physical rehabilitation.

Steroids for acute spinal cord injury

BACKGROUND

Acute spinal cord injury is a devastating condition typically affecting young people, mostly males. Steroid treatment in the early hours after the injury is aimed at reducing the extent of permanent paralysis during the rest of the patient's life.

OBJECTIVES

To review randomized trials of steroids for human acute spinal cord injury.

SEARCH METHODS

We searched the Cochrane Injuries Group Specialised Register (searched 02 Aug 2011), The Cochrane Central Register of Controlled Trials 2011, issue 3 (The Cochrane Library), MEDLINE (Ovid) 1948 to July Week 3 2011, EMBASE (Ovid) 1974 to 2011 week 17, ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED) 1970 to Aug 2011, ISI Web of Science: Conference Proceedings Citation Index- Science (CPCI-S) 1990 to Aug 2011 and PubMed [www.ncbi.nlm.nih.gov/sites/entrez/] (searched 04 Aug 2011) for records added to PubMed in the last 90 days). Files of the National Acute Spinal Cord Injury Study (NASCIS) were reviewed (NASCIS was founded in 1977 and has tracked trials in this area since that date). We also searched the reference lists of relevant studies and previously published reviews.

SELECTION CRITERIA

All randomized controlled trials of steroid treatment for acute spinal cord injury in any language.

DATA COLLECTION AND ANALYSIS

One review author extracted data from trial reports. Japanese and French studies were found through NASCIS and additional data (e.g. SDs) were obtained from the original study authors.

MAIN RESULTS

Eight trials are included in this review, seven used methylprednisolone. Methylprednisolone sodium succinate has been shown to improve neurologic outcome up to one year post-injury if administered within eight hours of injury and in a dose regimen of: bolus 30mg/kg over 15 minutes, with maintenance infusion of 5.4 mg/kg per hour infused for 23 hours. The initial North American trial results were replicated in a Japanese trial but not in the one from France. Data was obtained from the latter studies to permit appropriate meta-analysis of all three trials. This indicated significant recovery in motor function after methylprednisolone therapy, when administration commenced within eight hours of injury. A more recent trial indicates that, if methylprednisolone therapy is given for an additional 24 hours (a total of 48 hours), additional improvement in motor neurologic function and functional status are observed. This is particularly observed if treatment cannot be started until between three to eight hours after injury. The same methylprednisolone therapy has been found effective in whiplash injuries. A modified regimen was found to improve recovery after surgery for lumbar disc disease. The risk of bias was low in the largest methyprednisolne trials. Overall, there was no evidence of significantly increased complications or mortality from the 23 or 48 hour therapy.

AUTHORS' CONCLUSIONS

High-dose methylprednisolone steroid therapy is the only pharmacologic therapy shown to have efficacy in a phase three randomized trial when administered within eight hours of injury. One trial indicates additional benefit by extending the maintenance dose from 24 to 48 hours, if start of treatment must be delayed to between three and eight hours after injury. There is an urgent need for more randomized trials of pharmacologic therapy for acute spinal cord injury.

Toward optimal early management after whiplash injury to lessen the rate of transition to chronicity: discussion paper 5

STUDY DESIGN

Expert debate and synthesis of research to inform future management approaches for acute whiplash disorders.

OBJECTIVE

To identify a research agenda toward improving outcomes for acute whiplash-injured individuals to lessen the incidence of transition to chronicity.

SUMMARY OF BACKGROUND DATA

International figures are concordant, estimating that 50% of individuals recover from pain and disability within 3 to 6 months of a whiplash injury. The remainder report continuing symptoms up to 1 to 2 years or longer postinjury. As no management approach to date has improved recovery rates, new clinical/research directions are required for early management of whiplash-injured patients.

METHODS

A group of multidisciplinary researchers critically debated evidence and current research concerning whiplash from biological, psychological, and social perspectives toward informing future research directions for management of acute whiplash.

RESULTS

It was recognized that effective treatments for acute whiplash are constrained by a limited understanding of causes of whiplash-associated disorders. Acute whiplash presentations are heterogeneous leading to the proposal that a research priority was development of a triage system based on modifiable prognostic indicators and clinical features to better inform individualized early management decisions. Other priorities identified included researching effective early pain management for individuals presenting with moderate to high levels of pain; development of best education/information for acute whiplash; testing the efficacy of stratified and individualized rehabilitation, researching modes of delivery considering psychosocial modulators of pain and disability; and the timing, nature, and mode of delivery of cognitive-behavioral therapies. Directions were highlighted for future biomechanical research into injury prevention.

CONCLUSION

The burden of whiplash injuries, the high rate of transition to chronicity, and evidence of limited effects of current management on transition rates demand new directions in evaluation and management. Several directions have been proposed for future research, which reflect the potential multifaceted dimensions of an acute whiplash disorder.

Botulinum toxin for subacute/chronic neck pain

BACKGROUND

Neck disorders are common, disabling and costly. Botulinum toxin (BoNT) intramuscular injections are often used with the intention of treating neck pain.

OBJECTIVES

To systematically evaluate the literature on the treatment effectiveness of BoNT for neck pain, disability, global perceived effect and quality of life in adults with neck pain with or without associated cervicogenic headache, but excluding cervical radiculopathy and whiplash associated disorder.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE, AMED, Index to Chiropractic Literature, CINAHL, LILACS, and EMBASE from their origin to 20 September 2010.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials in which BoNT injections were used to treat subacute or chronic neck pain.

DATA COLLECTION AND ANALYSIS

A minimum of two review authors independently selected articles, abstracted data, and assessed risk of bias, using the Cochrane Back Review Group criteria. In the absence of clinical heterogeneity, we calculated standardized mean differences (SMD) and relative risks, and performed meta-analyses using a random-effects model. The quality of the evidence and the strength of recommendations were assigned an overall grade for each outcome.

MAIN RESULTS

We included nine trials (503 participants). Only BoNT type A (BoNT-A) was used in these studies.High quality evidence suggests there was little or no difference in pain between BoNT-A and saline injections at four weeks (five trials; 252 participants; SMD pooled -0.07 (95% confidence intervals (CI) -0.36 to 0.21)) and six months for chronic neck pain. Very low quality evidence indicated little or no difference in pain between BoNT-A combined with physiotherapeutic exercise and analgesics and saline injection with physiotherapeutic exercise and analgesics for patients with chronic neck pain at four weeks (two trials; 95 participants; SMD pooled 0.09 (95% CI -0.55 to 0.73)) and six months (one trial; 24 participants; SMD -0.56 (95% CI -1.39 to 0.27)). Very low quality evidence from one trial (32 participants) showed little or no difference between BoNT-A and placebo at four weeks (SMD 0.16 (95% CI -0.53 to 0.86)) and six months (SMD 0.00 (95% CI -0.69 to 0.69)) for chronic cervicogenic headache. Very low quality evidence from one trial (31 participants), showed a difference in global perceived effect favouring BoNT-A in chronic neck pain at four weeks (SMD -1.12 (95% CI: -1.89 to -0.36)).

AUTHORS' CONCLUSIONS

Current evidence fails to confirm either a clinically important or a statistically significant benefit of BoNT-A injection for chronic neck pain associated with or without associated cervicogenic headache. Likewise, there was no benefit seen for disability and quality of life at four week and six months.

A research synthesis of therapeutic interventions for whiplash-associated disorder: part 1 - overview and summary

Whiplash-associated disorder (WAD) represents a significant public health problem, resulting in a substantial socioeconomic burden throughout the industrialized world, wherever costs are documented. While many treatments have been advocated for patients with WAD, scientific evidence of their effectiveness is often lacking. A systematic review was conducted to evaluate the strength of evidence supporting various WAD therapies. Multiple databases (including Web of Science, EMBASE and PubMed) were searched to identify all studies published from January 1980 through March 2009 that evaluated the effectiveness of any clearly defined treatment for acute (less than two weeks), subacute (two to 12 weeks) or chronic (longer than 12 weeks) WAD. The present article, the first in a five-part series, provides an overview of the review methodology as well as a summary and discussion of the review's main findings. Eighty-three studies met the inclusion criteria, 40 of which were randomized controlled trials. The majority of studies (n=47) evaluated treatments initiated in the chronic stage of the disorder, while 23 evaluated treatments for acute WAD and 13 assessed therapies for subacute WAD. Exercise and mobilization programs for acute and chronic WAD had the strongest supporting evidence, although many questions remain regarding the relative effectiveness of various protocols. At present, there is insufficient evidence to support any treatment for subacute WAD. For patients with chronic WAD who do not respond to conventional treatments, it appears that radiofrequency neurotomy may be the most effective treatment option. The present review found a relatively weak but growing research base on which one could make recommendations for patients at any stage of the WAD continuum. Further research is needed to determine which treatments are most effective at reducing the disabling symptoms associated with WAD.

A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): part 2 - interventions for acute WAD

Whiplash-associated disorder (WAD) represents a significant public health problem, resulting in substantial social and economic costs throughout the industrialized world. While many treatments have been advocated for patients with WAD, scientific evidence supporting their effectiveness is often lacking. A systematic review was conducted to evaluate the strength of evidence associated with various WAD therapies. Multiple databases (including Web of Science, EMBASE and PubMed) were searched to identify all studies published from January 1980 through March 2009 that evaluated the effectiveness of any clearly defined treatment for acute (less than two weeks), subacute (two to 12 weeks) or chronic (more than 12 weeks) WAD. The present article, the second in a five-part series, evaluates the evidence for interventions initiated during the acute phase of WAD. Twenty-three studies that met the inclusion criteria were identified, 16 of which were randomized controlled trials with 'fair' overall methodological quality (median Physiotherapy Evidence Database score of 5.5). For the treatment of acute WAD, there was strong evidence to suggest that not only is immobilization with a soft collar ineffective, but it may actually impede recovery. Conversely, although exercise programs, active mobilization and advice to act as usual all appeared to improve recovery, it is not clear which of these interventions was the most effective. While there was also evidence supporting the use of pulsed electromagnetic field therapy and methylprednisolone infusion, the evidence was insufficient to establish the effectiveness of either of these treatments. Based on current evidence, activation-based therapy is recommended for the treatment of acute WAD; however, additional research is required to determine the relative effectiveness of various exercise⁄mobilization programs.

Whiplash: diagnosis, treatment, and associated injuries

Study design Focused review of the current literature. Objective To identify and synthesize the most current data pertaining to the diagnosis and treatment of whiplash and whiplash-associated disorders (WAD), and to report on whiplash-related injuries. Methods A search of OVID Medline (1996–January 2007) and the Cochrane database of systematic reviews was performed using the keywords whiplash and WAD. Articles under subheadings for pathology, diagnosis, treatment, and epidemiology were chosen for review after identification by the authors. Results A total of 485 articles in the English language literature were identified. Thirty-six articles pertained to the diagnosis, treatment, epidemiology of whiplash, and WAD, and were eligible for focused review. From these, 21 primary and 15 secondary sources were identified for full review. In addition, five articles were found that focused on whiplash associated cervical injuries. These five articles were also primary sources. Conclusions Whiplash is a common injury associated most often with motor vehicle accidents. It may present with a variety of clinical manifestations, collectively termed WAD. Whiplash is an important cause of chronic disability. Many controversies exist regarding the diagnosis and treatment of whiplash injuries. The multifactorial etiology, believed to underly whiplash injuries, make management highly variable between patients. Radiographic evidence of injury often cannot be identified in the acute phase. Recent studies suggest early mobilization may lead to improved outcomes. Ligamentous and bony injuries may go undetected at initial presentation leading to delayed diagnosis and inappropriate therapies.

Whiplash injury

This review discusses the causes, outcome and prevention of whiplash injury, which costs the economy of the United Kingdom approximately £3.64 billion per annum. Most cases occur as the result of rear-end vehicle collisions at speeds of less than 14 mph. Patients present with neck pain and stiffness, occipital headache, thoracolumbar back pain and upper-limb pain and paraesthesia. Over 66% make a full recovery and 2% are permanently disabled. The outcome can be predicted in 70% after three months.

Knowledge to action: a challenge for neck pain treatment

SYNOPSIS

For clinicians, systematic reviews can enhance incorporation into practice of the large volumes of information emerging from research on effectiveness and risks. But we believe that these reviews are most useful with simplified tools to facilitate translation of this knowledge into practice. We provide a "Neck Care Tool Kit" that gives a diagrammatic approach to prioritizing intervention. The evidence from a series of 11 systematic reviews by the Cervical Overview Group is depicted in decision flow-charts and tables to enhance clinical interpretation of the overview findings. On simple visual inspection of symbols in a table, the reader can establish where there is evidence of benefit or no benefit, the strength of the recommendation, and if these data represent short- or long-term findings. Where possible, we guide clinicians to dosage of specific treatment methods. There is no consensus as to which outcome measures to prioritize among the large number in use. This clinical commentary guides clinicians to view the evidence in enough detail to integrate it into their clinical practice environment. We conclude by delineating research gaps and proposing future research directions.

LEVEL OF EVIDENCE

Therapy, level 5.

The analgesic effect of botulinum-toxin A on postwhiplash neck pain

BACKGROUND

The effectiveness of botulinum neurotoxin type A (BTXA) injections in relieving the neck pain and reduced motion that evolve after whiplash injury (WI) has been controversial.

AIM OF STUDY

To test the long-term efficacy of a tender point injection of BTXA in relieving neck pain in patients with WI.

METHODS

Twenty patients with cervical myofascial pain, 2 to 48 weeks after WI, were randomly assigned to receive either 200 U of BTXA or placebo at 4 tender points and were seen during the follow-ups 3, 6, 9, 12, and 24 weeks after the injections. Outcome measures included the intensity of pain as evaluated by a 10-cm Visual Analog Scale (VAS) and a 5-point Verbal Rating Scale (VRS), quality of life as evaluated by the SF-36 questionnaire, treatment efficacy as per the global assessment of the physician and patient, intensity of pain in response to mechanical pressure, range of cervical motion, and use of other therapies and their adverse effects.

RESULTS

A time-dependent improvement in all the parameters was found in both groups, which was consistently larger in the BTXA-treated group, but mostly not at a significant level. Significant differences between the groups were found only in the percentages of patients who achieved 50% or more of reduction in intensity (VAS and average VRS) at 24 weeks (50% vs. 0%, P>0.05 and 70% vs. 11%, P>0.05, respectively). Systemic adverse effects tended to be more common in the BTXA-treated group (40% vs. 0%, P=0.07).

CONCLUSIONS

Study results suggest that BTXA treatment has some efficacy when administered within 1 year of the WI. However, a large, well-designed clinical trial is needed to draw final conclusions.

Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders

STUDY DESIGN

Best evidence synthesis.

OBJECTIVE

To identify, critically appraise, and synthesize literature from 1980 through 2006 on noninvasive interventions for neck pain and its associated disorders.

SUMMARY OF BACKGROUND DATA

No comprehensive systematic literature reviews have been published on interventions for neck pain and its associated disorders in the past decade.

METHODS

We systematically searched Medline and screened for relevance literature published from 1980 through 2006 on the use, effectiveness, and safety of noninvasive interventions for neck pain and associated disorders. Consensus decisions were made about the scientific merit of each article; those judged to have adequate internal validity were included in our best evidence synthesis.

RESULTS

Of the 359 invasive and noninvasive intervention articles deemed relevant, 170 (47%) were accepted as scientifically admissible, and 139 of these related to noninvasive interventions (including health care utilization, costs, and safety). For whiplash-associated disorders, there is evidence that educational videos, mobilization, and exercises appear more beneficial than usual care or physical modalities. For other neck pain, the evidence suggests that manual and supervised exercise interventions, low-level laser therapy, and perhaps acupuncture are more effective than no treatment, sham, or alternative interventions; however, none of the active treatments was clearly superior to any other in either the short- or long-term. For both whiplash-associated disorders and other neck pain without radicular symptoms, interventions that focused on regaining function as soon as possible are relatively more effective than interventions that do not have such a focus.

CONCLUSION

Our best evidence synthesis suggests that therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain; this was also true of therapies which include educational interventions addressing self-efficacy. Future efforts should focus on the study of noninvasive interventions for patients with radicular symptoms and on the design and evaluation of neck pain prevention strategies.

Medicinal and injection therapies for mechanical neck disorders

BACKGROUND

Controversy persists regarding medicinal therapies and injections.

OBJECTIVES

To determine the effects of medication and injections on primary outcomes (e.g. pain) for adults with mechanical neck disorders and whiplash.

SEARCH STRATEGY

We searched CENTRAL, MANTIS, CINAHL from their start to May 2006; MEDLINE and EMBASE to December 2006. We scrutinised reference lists for other trials.

SELECTION CRITERIA

We included randomised controlled trials with adults with neck disorders, with or without associated headache or radicular findings. We considered medicinal and injection therapies, regardless of route of administration.

DATA COLLECTION AND ANALYSIS

Two authors independently selected articles, abstracted data and assessed methodological quality. When clinical heterogeneity was absent, we combined studies using random-effects models.

MAIN RESULTS

We found 36 trials that examined the effects of oral NSAIDs, psychotropic agents, steroid injections, and anaesthetic agents. Trials had a mean of 3.1 on the Jadad Scale for methodological quality; 70% were high quality. For acute whiplash, administering intravenous methylprednisolone within eight hours of injury reduced pain at one week (SMD -0.90, 95% CI -1.57 to -0.24), and sick leave but not pain at six months compared to placebo in one trial. For chronic neck disorders at short-term follow-up, intramuscular injection of lidocaine was superior to placebo (SMD -1.36, 95% CI -1.93 to -0.80); NNT 3, treatment advantage 45% and dry needling, but similar to ultrasound in one trial each. In chronic neck disorders with radicular findings, epidural methylprednisolone and lidocaine reduced neck pain and improved function more than when given by intramuscular route at one-year follow-up, in one trial. In subacute and chronic neck disorders, muscle relaxants, analgesics and NSAIDs had limited evidence and unclear benefits. In participants with chronic neck disorders with or without radicular findings or headache, there was moderate evidence from five high quality trials that Botulinum toxin A intramuscular injections had similar effects to saline in improving pain (pooled SMD: -0.39, 95%CI -1.25 to 0.47), disability or global perceived effect.

AUTHORS' CONCLUSIONS

The major limitations are the lack of replication of the findings and sufficiently large trials. There is moderate evidence for the benefit of intravenous methylprednisolone given within eight hours of acute whiplash, from a single trial. Lidocaine injection into myofascial trigger points appears effective in two trials. There is moderate evidence that Botulinum toxin A is not superior to saline injection for chronic MND. Muscle relaxants, analgesics and NSAIDs had limited evidence and unclear benefits.

Fracture dislocations of the cervical spine: a review of 106 conservatively and operatively treated patients

We compared clinical outcomes following conservative treatment of subaxial fracture dislocations of the cervical spine and posterior fusion using bone grafts and interspinous Roger's wiring (Bohlman modification). We reviewed 106 patients: 51 were treated primarily surgically, and 55 treated conservatively served as historical controls. Those patients who neurologically recovered at least one Frankel grade had on average less displacement on discharge (1.3 mm vs 3.1 mm, p=0.04). Although anatomical outcomes were better in the operatively treated group (1.6 mm vs 2.9 mm displacement at end of follow-up, p=0.001), there was no difference in neurological recovery. Late neck pain correlated with residual displacement ( p=0.04) and was more common in the conservatively treated patients ( p=0.01). Time in hospital was shorter in the group with posterior fusions, and complication rates were similar to those found after conservative treatment. A significant number of the conservatively treated patients developed kyphotic deformity, and 29% needed later surgery because of chronic instability or unacceptable anatomical results.

A review of treatment interventions in whiplash-associated disorders

In recent years, there has been much debate on the treatment of whiplash-associated disorders (WAD). It is not clear if the treatments commonly employed are effective, and concerns have been raised on the available scientific evidence of many of these treatments. The aim of this study was to review the literature systematically to analyze the evidence basis of many commonly used treatments for patients suffering from WAD, both in the acute and the chronic state. A computer-assisted search of the databases Medline (from 1962 to May 2003), CINAHL (1960-2003), Embase (1976-2003), and Psychinfo (1960-2003) was conducted as well as a check of the reference lists of relevant studies. All randomized controlled trials (RCTs) were retrieved and systematically analyzed with three common instruments of measurement of methodological quality. A qualitative analysis ("best-evidence synthesis") was performed. The methodological quality of 26 RCTs was analyzed. The median quality scores for all three instruments were poor. Based on the degrees of evidence and the practical obstacles, the following treatments can be recommended: Early physical activity in acute WAD, radiofrequency neurotomy, combination of cognitive behavioral therapy with physical therapy interventions, and coordination exercise therapy in chronic WAD. High-quality RCTs are not common in the field of WAD. More research is needed, particularly on the treatment of chronic WAD.

Spinal canal narrowing during simulated whiplash

STUDY DESIGN

A biofidelic whole cervical spine model with muscle force replication was used to evaluate spinal canal pinch diameter (CPD) narrowing during simulated whiplash.

OBJECTIVES

To quantify CPD narrowing during simulated whiplash and to determine if whiplash resulted in a narrower post-whiplash CPD.

SUMMARY OF BACKGROUND DATA

Spinal cord injuries are uncommon in whiplash patients, although such injuries have been reported in those with narrow canals. It has been hypothesized that increased cerebral spinal fluid pressure during whiplash could injure neural tissues.

METHODS

The biofidelic model and a bench-top whiplash apparatus were used to simulate whiplash at 3.5, 5, 6.5, and 8 g accelerations of the T1 vertebra. The CPD was measured in the intact specimen in the neutral posture (neutral posture CPD) and under a 1.5 Nm static extension load (pre-whiplash CPD), during simulated whiplash (dynamic whiplash CPD), and again under a 1.5 Nm extension load following each whiplash simulation (post-whiplash CPD).

RESULTS

The average dynamic whiplash CPDs were significantly narrower (P < 0.05) than the corresponding pre-whiplash CPDs at accelerations of 3.5 g and above. The narrowest CPD was observed at C5-C6 during the 6.5 g simulation and was 3.5 mm narrower than the neutral posture CPD. In general, the average post-whiplash CPDs were not significantly narrower than the corresponding pre-whiplash CPDs.

CONCLUSIONS

Spinal cord injury during whiplash is unlikely in patients with average normal canal diameters. Cord compression following whiplash due to physiologic extension loading is not likely. Previous clinical studies have found that whiplash patients with narrow canals may be at risk of injury, and our results do not disprove it.

Whiplash: Pathophysiology, diagnosis, treatment, and prognosis

We have reviewed the literature relevant to pathophysiology, diagnosis, treatment, and prognosis of whiplash-associated disorder (WAD) since 1995 and provided a brief summary of literature pertaining to forces action on the head and neck during a motor vehicle accident. The scope of the current review is confined to the Quebec guidelines for WAD grades 1-3 but excludes grade 4 (neck complaints and fracture or dislocation). After excluding papers without scientific data and single case reports or case series with fewer than 20 patients, articles were reviewed for methodological quality. The diagnosis remains clinical. No imaging, physiological, or psychological study provides specific diagnostic criteria. In the acute period up to 2 weeks, soft collars or rest and work-leave do not shorten the duration of neck pain. Sick leave is reduced by high-dose methylprednisolone given within 8 h of injury, but confirmatory studies examining the cost-benefit relationship are needed. In the first 6 months, active as opposed to passive treatment results in improved outcomes. Specific exercise strategies have not been studied. For those with symptoms lasting more than 6 months, percutaneous radio-frequency neurotomy can provide pain relief for many months in those responding to blind local anesthetic facet blocks. Intra-articular corticosteroids are ineffective. Uncontrolled trials suggest that multimodal rehabilitation programs result in improved overall function. The overall prognosis for recovery has varied considerably across studies. Such variability is likely due to differences in case identification methods and whether outcome is assessed in terms of symptoms or the receipt of financial compensation for injury. The impact on prognosis of both collision- and patient-related factors is also reviewed.

Pharmacologic therapies for neck pain

A variety of drug types are available for the treatment of pain. Significant relief of acute neck pain is usually achievable. Treatment of chronic neck pain requires a more comprehensive rehabilitation approach combined with judicious use of medications. Research on the development of analgesics that affect other neurotransmitter systems and that have fewer side effects is currently underway.

[Whiplash injury of the neck from concepts to facts]

OBJECTIVES

To focus on a topic of traumatology and rehabilitation becoming recently a much debated public health problem.

METHOD

A references search from Medline database with whiplash as keyword was carried out. Were selected articles with abstracts in french or english and focusing on accidentology, biomechanics, demonstrated lesions, epidemiology and treatments.

RESULTS

From 1664 references found, 232 were reviewed. The usual mechanism of crash is a rear-end collision inducing in the occupants of the bumped vehicle a sudden lower cervical spine extension with upper flexion followed by a global flexion. In nearly 50% of the cases, the stress occurring in the collision is comparable to that observed in bumper cars. The velocity changes are seldom up to 15 km/h. A headrest at the level of the center of gravity of the head restrict significantly the extension of the neck. Every structure of the cervical spine could be damaged and mainly the facet joints but the lesions were only demonstrated in severes traumatisms. The discrepancies in incidence among the different countries could be related to their medicolegal system. Although subjectives, the early symptoms are rather similar among patients suggesting true anatomical or functional disorders but the chronicity seems to be mainly related to social and psychological factors. The association of: no posterior midline cervical tenderness, no intoxication, normal alertness, no focal neurological deficit and no painful distracting injuries has a good predictive value of the lack of osteo-articular lesion on X-rays. Except the grade IV of the Quebec task Force (0, no symptom; 1, pain and stiffness; 2, neck complaint and physical signs; 3, neck complaint and neurological signs; 4, fracture or dislocation) the use of a collar should be avoided and the cervical spine should be mobilized.

CONCLUSION

In most whiplash injuries, the mildness should be early stated, mobilization encouraged, and procedures of compensation shortened.

Eye motility and auditory brainstem response dysfunction after whiplash injury

The aim of this study was to identify the prevalence of brain/brainstem dysfunction after acute whiplash trauma (grades II and III according to the Quebec Task Force Classification on whiplash-associated disorders) and to investigate a possible correlation between the development of chronic symptoms and objective findings from auditory brainstem response (ABR) and eye motility tests. We used ABR and oculomotor tests and a thorough clinical, subjective and psychological evaluation in a sample of prospective whiplash trauma patients who were followed up for 2 years after the trauma. The initial test results did not reveal any prognostic clinical signs for the tested group as a whole, but we could discriminate some patients with clinical symptoms and signs paired with pathologic test results. Over time, some patients normalized clinically and their test results improved while others deteriorated clinically and their test results were worse at the 2-year investigation. Our findings of moderate derangements in the tests could be the effects of pain and/or changed cervical afferent activity at the brain/brainstem level, while eye motility dysfunction, in addition to pathological neuro-otological findings in a small proportion of the patients with severe symptoms, could be explained by lesions to the brain/brainstem.

Steroids for acute spinal cord injury

BACKGROUND

Acute spinal cord injury is a devastating condition typically affecting young people with a preponderance being male. Steroid treatment in the early hours of the injury is aimed at reducing the extent of permanent paralysis during the rest of the patient's life.

OBJECTIVES

To review randomized trials of steroids for acute spinal cord injury.

SEARCH STRATEGY

The review draws on the search strategy developed by the Cochrane Injuries Group. In addition, files of the National Acute Spinal Cord Injury Study have been reviewed and a Medline search conducted.

SELECTION CRITERIA

All published or unpublished randomized controlled trials of steroid treatment for acute spinal cord injury in any language.

DATA COLLECTION AND ANALYSIS

Data have been abstracted from original trial reports. For the NASCIS, Japanese and French trials, additional data (e.g. SDs) have been obtained from the original authors.

MAIN RESULTS

There are few trials in this area of medical care. Only one steroid has been extensively studied, methylprednisolone sodium succinate, which has been shown to improve neurologic outcome up to one year post injury if administered within eight hours of injury and in a dose regimen of: bolus 30mg/kg administered over 15 minutes with a maintenance infusion of 5.4 mg/kg per hour infused for 23 hours. The initial North American trial was replicated in a Japanese trial but not in the one from France. Data has been obtained from the latter studies to permit appropriate meta-analysis of all three trials. This analysis indicates significant recovery in motor function after methylprednisolone therapy when administration commences within eight hours of injury. A more recent trial indicates that if methylprednisolone therapy is given for an additional 24 hours (for a total of 48 hours), additional improvement in motor neurologic function and functional status is observed. This is particularly observed if treatment cannot be started until between three to eight hours after injury. The same methylprednisolone therapy has been found effective in whiplash injuries and a modified regimen found to improve recovery after surgery for lumbar disc disease.

REVIEWER'S CONCLUSIONS

High dose methylprednisolone steroid therapy is the only pharmacological therapy shown to have efficacy in a Phase Three randomized trial when it can be administered within eight hours of injury. A recent trial indicates additional benefit by extending the maintenance dose from 24 to 48 hours if start of treatment must be delayed to between three and eight hours after injury. There is an urgent need for more randomized trials of pharmacological therapy for acute spinal cord injury.

Methylprednisolone and acute spinal cord injury: an update of the randomized evidence

OBJECTIVES

Randomized trials are widely recognized as providing the most reliable evidence for assessing efficacy and safety of therapeutic interventions. This evidence base is used to evaluate the current status of methylprednisolone (MPSS) in the early treatment of acute spinal cord injury.

METHODS

Medline, CINAHL, and other specified databases were searched for MeSH headings "methylprednisolone and acute spinal cord injury." The Cochrane Library and an existing systematic review on the topic were also searched.

RESULTS

Five randomized controlled trials were identified that evaluated high-dose MPSS for acute spinal cord injury. Three trials by the NASCIS group were of high methodologic quality, and a Japanese and French trial of moderate to low, methodologic quality. Meta-analysis of the final result of three trials comparing 24-hour high-dose MPSS with placebo or no therapy indicates an average unilateral 4.1 motor function score improvement (95% confidence interval 0.6-7.6, P = 0.02) in patients treated with MPSS. This neurologic recovery is likely to be correlated with improved functional recovery in some patients. The safety of this regimen of MPSS is evident from the spinal cord injury trials and a systematic review of 51 surgical trials of high-dose MPSS.

CONCLUSION

High-dose MPSS given within 8 hours of acute spinal cord injury is a safe and modestly effective therapy that may result in important clinical recovery for some patients. Further trials are needed to identify superior pharmacologic therapies and to test drugs that may sequentially influence the postinjury cascade.

Whiplash: a review of a commonly misunderstood injury

Whiplash injury is a relatively common occurrence, but its mechanism and optimal treatment remain poorly understood. It is estimated that the incidence of whiplash injury is approximately 4 per 1,000 persons. The most common radiographic findings include either preexisting degenerative changes or a slight flattening of the normal lordotic curvature of the cervical spine. Computed tomography and magnetic resonance imaging are generally reserved for cases of neurologic deficit, suspected disc or spinal cord damage, fracture, or ligamentous damage. Biomechanics studies have determined that after rear impact C6 is rotated back into extension before movement of the upper cervical vertebrae. Thus, the lower cervical vertebrae were in extension while the upper vertebrae were in a position of relative flexion, producing an S shape in the cervical spine. It is believed that this abnormal motion pattern might play a role in the development of whiplash injuries. Historically, a soft cervical collar has been used early after the injury in an attempt to restrict cervical range of motion and limit the chances of further injury. More recent studies report rest and restriction of motion to be detrimental and to slow the healing process.

Risks and benefits of preoperative high dose methylprednisolone in surgical patients: a systematic review

BACKGROUND

A single preoperative high dose of methylprednisolone (15 to 30 mg/kg) has been advocated in surgery, because it may inhibit the surgical stress response and thereby improve postoperative outcome and convalescence. However, these potential clinical benefits must be weighed against possible adverse effects.

OBJECTIVE

To conduct a risk-benefit analysis using a meta-analysis, to compare complication rates and clinical advantages associated with the use of high dose methylprednisolone in surgical patients.

METHODS

Randomised controlled trials of high dose methylprednisolone in elective and trauma surgery were systematically searched for in various literature databases. Outcome data on adverse effects, postoperative pain and hospital stay were extracted and statistically pooled in fixed-effects meta-analyses.

RESULTS

We located 51 studies in elective cardiac and noncardiac surgery, as well as traumatology. Pooled data failed to show any significant increase in complication rates. In patients treated with corticosteroids, nonsignificantly more gastrointestinal bleeding and wound complications were observed; the 95% confidence interval boundaries of the numbers-needed-to-harm were 59 and 38, respectively. The only significant finding was a reduction of pulmonary complications (risk difference -3.5%; 95% confidence interval -1.0 to -6.1), mainly in trauma patients.

CONCLUSION

For patients undergoing surgical procedures, a perioperative single-shot administration of high dose methylprednisolone is not associated with a significant increase in the incidence of adverse effects. In patients with multiple fractures, limited evidence suggests promising benefits of glucocorticoids on pulmonary complications.

Whiplash Injuries

The term "whiplash" is not a medical diagnosis, but is the result of soft-tissue trauma to the neck. A whiplash injury occurs as a result of a sudden acceleration or deceleration of the head and neck with respect to the body. This article recommends that patient treatment be individualized.

Clinical measurement, statistical analysis, and risk-benefit: controversies from trials of spinal injury

BACKGROUND

The National Acute Spinal Cord Injury Studies have been a series of trials assessing the role of pharmacologic agents in the prevention of secondary neuronal damage after acute spinal cord injury.

METHODS

The trials were multicenter randomized, controlled studies.

RESULTS

Two trials have demonstrated the efficacy of high-dose methylprednisolone in improving neurologic and functional recovery and have shown a reassuring safety profile.

CONCLUSION

This study responds to a recent commentary on these trials and examines in particular the roles of clinical measurement, statistical analysis, and risk benefit in assembling evidence for or against innovative therapies.

Emergency department evaluation and treatment of the neck and cervical spine injuries

In the United States, nearly 5 million patients per year require spinal immobilization. The emergency physician (EP) must be able to efficiently and effectively manage these patients. To do so, the EP must have an understanding of cervical spine anatomy, spinal immobilization techniques, specific injury patterns, optimal imaging studies, and associated injuries and treatment modalities. This article addresses these important issues and discusses other challenges in the management of cervical spine injuries.

Musculoskeletal rehabilitation and sports medicine. 1. Head and spine injuries

This self-directed learning module focuses on head, neck, and spine injuries that are frequent occurrences in sporting activity. It is part of the chapter on musculoskeletal rehabilitation and sports medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. The physiatrist must be able to recognize not only the cause of the acute injury but also the functional consequences of the impairment. This article will discuss some of the more common head, neck, and spine injuries in patients engaged in sports activity and will suggest typical management options for these patients.