The possibility to use simple validated questionnaires to predict long-term health problems after whiplash injury

Validation of Neck Disability Index Severity among Patients Receiving One or Two-Level Anterior Cervical Surgery

STUDY DESIGN

Retrospective cohort.

PURPOSE

To evaluate the validity of established severity thresholds for Neck Disability Index (NDI) among patients undergoing anterior cervical discectomy and fusion (ACDF) or cervical disc arthroplasty (CDA).

OVERVIEW OF LITERATURE

Few studies have examined the validity of established NDI threshold values among patients undergoing ACDF or CDA.

METHODS

A surgical database was reviewed to identify patients undergoing cervical spine procedures. Demographics, operative characteristics, comorbidities, NDI, Visual Analog Scale (VAS), and 12-item Short Form (SF-12) physical and mental composite scores (PCS and MCS) were recorded. NDI severity was categorized using previously established threshold values. Improvement from preoperative scores at each postoperative timepoint and convergent validity of NDI was evaluated. Discriminant validity of NDI was evaluated against VAS neck and arm and SF-12 PCS and MCS.

RESULTS

All 290 patients included in the study demonstrated significant improvements from baseline values for all patient-reported outcome measures (PROMs) at all postoperative timepoints (p<0.001) except SF-12 MCS at 2 years (p =0.393). NDI showed a moderate- to-strong correlation (r≥0.419) at most timepoints for VAS neck, VAS arm, SF-12 PCS, and SF-12 MCS (p<0.001, all). NDI severity categories demonstrated significant differences in mean VAS neck, VAS arm, SF-12 PCS, and SF-12 MCS at all timepoints (p<0.001, all). Differences between NDI severity groups were not uniform for all PROMs. VAS neck values demonstrated significant intergroup differences at most timepoints, whereas SF-12 MCS showed significantly different values between most severity groups.

CONCLUSIONS

Neck disability is strongly correlated with neck and arm pain, physical function, and mental health and demonstrates worse outcomes with increasing severity. Previously established severity categories may be more applicable to pain than physical function or mental health and may be more uniformly applied preoperatively for cervical spine patients.

Comparison of hospital based and home based exercise on quality of life, and neck and shoulder function in patients with spinal accessary nerve injury after head and neck cancer surgery

OBJECTIVES

The purpose of this study was to compare the effects of hospital-based and home-based exercise programs on quality of life (QOL) and neck and shoulder function of patients who underwent head and neck cancer (HNC) surgery.

METHODS

This clinical trial included 40 patients with neck and shoulder dysfunction after HNC. The exercise program included range of motion (ROM) exercises, massage, stretching, and strengthening exercises. Twenty patients who were assigned to the hospital-based exercise group performed physical therapy for 40 min three times a week for four weeks, and the remaining 20 patients were assigned to the home-based group. The European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30), the EORTC Head and Neck Questionnaire (EORTC QLQ-H&N), the Neck and Shoulder Disability Index (NDI), ROM, and numeric rating scale (NRS) were assessed before and after the exercise program. The program consisted of a 10-minute ROM to the neck and shoulder, a 10-minute massage, and 15 min of progressive resistance exercises, followed by a five-minute stretching exercise.

RESULTS

There were statistically significant differences in the changes of neck and shoulder disability index (p < .05). Additionally, there were significant differences in neck extension and rotation ROM and NRS in the hospital-based group compared with the home-based group (p < .05). QOL was not significantly different between the two groups.

CONCLUSIONS

Home-based exercise was effective for improving QOL, shoulder function, and pain relief. Hospital-based exercise had better effects on physical function of the neck and shoulder and reduced pain.

Correlation between Short-Form 36 Scores and Neck Disability Index in Patients Undergoing Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Case control study.

PURPOSE

To determine how the Neck Disability Index (NDI), a cervical spine-specific outcome, reflects health-related quality-of-life, and if NDI is correlated to the 36-item Short-Form Health Survey (SF-36) scores.

OVERVIEW OF LITERATURE

NDI is a useful tool for assessing health-related quality of life in patients with neck pain.

METHODS

We used the Pearson product-moment correlation coefficient to assess the validity of all items under NDI and SF-36, and the Pearson's correlation coefficient to assess the correlation between NDI and total SF-36 scores. The primary outcome measures were spine-specific health status- and general health status-measures after spine surgery, and these were evaluated every year for 2 years, using both NDI and SF-36 scores.

RESULTS

NDI had a strong linear correlation with SF-36 and its two scales, the Physical Component Score (PCS) and the Mental Component Score (MCS), attesting to the validity of these two instruments. Among the eight subscales of SF-36, there was a strong linear correlation between NDI and PCS-physical functioning, PCS-bodily pain, and MCS-role emotional. Further, a moderate linear correlation was observed between NDI and subscales of PCS-role physical, PCS-general health, and MCS-social functioning, and between NDI and MCS-vitality and MCS-mental health.

CONCLUSIONS

Our findings suggest that the NDI adequately reflects the patient's physical and mental quality of life, implying that the use of NDI to assess functional outcomes can also be ultimately used to evaluate the patient's quality of life.

The qualitative grading of muscle fat infiltration in whiplash using fat and water magnetic resonance imaging

BACKGROUND CONTEXT

The development of muscle fat infiltration (MFI) in the neck muscles is associated with poor functional recovery following whiplash injury. Custom software and time-consuming manual segmentation of magnetic resonance imaging (MRI) is required for quantitative analysis and presents as a barrier for clinical translation.

PURPOSE

The purpose of this work was to establish a qualitative MRI measure for MFI and evaluate its ability to differentiate between individuals with severe whiplash-associated disorder (WAD), mild or moderate WAD, and healthy controls.

STUDY DESIGN/SETTING

This is a cross-sectional study.

PATIENT SAMPLE

Thirty-one subjects with WAD and 31 age- and sex-matched controls were recruited from an ongoing randomized controlled trial.

OUTCOME MEASURES

The cervical multifidus was visually identified and segmented into eighths in the axial fat/water images (C4-C7). Muscle fat infiltration was assessed on a visual scale: 0 for no or marginal MFI, 1 for light MFI, and 2 for distinct MFI. The participants with WAD were divided in two groups: mild or moderate and severe based on Neck Disability Index % scores.

METHODS

The mean regional MFI was compared between the healthy controls and each of the WAD groups using the Mann-Whitney U test. Receiver operator characteristic (ROC) analyses were carried out to evaluate the validity of the qualitative method.

RESULTS

Twenty (65%) patients had mild or moderate disability and 11 (35%) were considered severe. Inter- and intra-rater reliability was excellent when grading was averaged by level or when frequency of grade II was considered. Statistically significant differences (p<.05) in regional MFI were particularly notable between the severe WAD group and healthy controls. The ROC curve, based on detection of distinct MFI, showed an area-under-the curve of 0.768 (95% confidence interval 0.59-0.94) for discrimination of WAD participants.

CONCLUSIONS

These preliminary results suggest a qualitative MRI measure for MFI is reliable and valid, and may prove useful toward the classification of WAD in radiology practice.

An Investigation of Fat Infiltration of the Multifidus Muscle in Patients With Severe Neck Symptoms Associated With Chronic Whiplash-Associated Disorder

Study Design Cross-sectional study. Background Findings of fat infiltration in cervical spine multifidus, as a sign of degenerative morphometric changes due to whiplash injury, need to be verified. Objectives To develop a method using water/fat magnetic resonance imaging (MRI) to investigate fat infiltration and cross-sectional area of multifidus muscle in individuals with whiplash-associated disorders (WADs) compared to healthy controls. Methods Fat infiltration and cross-sectional area in the multifidus muscles spanning the C4 to C7 segmental levels were investigated by manual segmentation using water/fat-separated MRI in 31 participants with WAD and 31 controls, matched for age and sex. Results Based on average values for data spanning C4 to C7, participants with severe disability related to WAD had 38% greater muscular fat infiltration compared to healthy controls (P = .03) and 45% greater fat infiltration compared to those with mild to moderate disability related to WAD (P = .02). There were no significant differences between those with mild to moderate disability and healthy controls. No significant differences between groups were found for multifidus cross-sectional area. Significant differences were observed for both cross-sectional area and fat infiltration between segmental levels. Conclusion Participants with severe disability after a whiplash injury had higher fat infiltration in the multifidus compared to controls and to those with mild/moderate disability secondary to WAD. Earlier reported findings using T1-weighted MRI were reproduced using refined imaging technology. The results of the study also indicate a risk when segmenting single cross-sectional slices, as both cross-sectional area and fat infiltration differ between cervical levels. J Orthop Sports Phys Ther 2016;46(10):886-893. Epub 2 Sep 2016. doi:10.2519/jospt.2016.6553.

The Qualification of Outcome after Cervical Spine Surgery by Patients Compared to the Neck Disability Index

Objective

The Neck Disability Index (NDI) is a patient self-assessed outcome measurement tool to assess disability, and that is frequently used to evaluate the effects of the treatment of neck-related problems. In individualized medicine it is mandatory that patients can interpret data in order to choose a treatment. A change of NDI or an absolute NDI is generally meaningless to a patient. Therefore, a correlation between the qualification of the clinical situation rated by the patient and the NDI score was evaluated.

Methods

Patients who completed an NDI after anterior surgery because of symptomatic single level degenerative cervical disc disease were asked one month after completion of the NDI to qualify their clinical situation of a 5-item Likert scale varying from excellent to bad. Since a clear distinction between the categories was not possible based on the total NDI score, a ROC-curve was built, and the AUC computed in order to estimate best dichotomization in qualification of the clinical situation. The best corresponding cut-off point for the NDI total score was found by studying sensitivity and specificity for all possible cut-off points.

Results

102 patients were included. The highest AUC was obtained by dichotomizing the qualification into a group with good outcome and less-good outcome. The highest sensitivity and specificity for the dichotomized qualification as good outcome corresponded to a NDI ≤ 7. Sensitivity was 81.08% and specificity was 78.57%.

Conclusion

This is the first study that correlated the qualification of the situation by the patients themselves and NDI. An NDI ≤ 7 corresponded to a good outcome according to the patients. This is valuable information to inform patients in their decision for any treatment.

Classifying Whiplash Recovery Status Using the Neck Disability Index: Optimized Cutoff Points Derived From Receiver Operating Characteristic

OBJECTIVE

Researchers often use Neck Disability Index (NDI) scores to classify recovery status in whiplash patients. The purpose of this study was to investigate the optimal cutoff point score for the NDI as a mechanism for differentiating recovery from nonrecovery after whiplash.

METHODS

Subjects (N = 123) who had previously sustained whiplash injuries were recruited from 12 clinics. Subjects rated themselves as being recovered (36%) or nonrecovered (64%). This state variable was compared with their NDI score as test variable using the receiver operating characteristic statistic. The area under the receiver operating characteristic curve and optimized cutoff points were computed for the whole group and also dichotomized for sex and age.

RESULTS

The mean NDI score for the recovered group was 7.8. It was 27.1 for the nonrecovered group. The cutoff point that optimized sensitivity and specificity for the whole group was an NDI score of 15. For women, it was 19; for older persons, it was 21.

CONCLUSION

The optimal NDI score cutoff point for differentiating the recovery state after whiplash is 15. Misclassification errors are likely when using lower values.

Confirmatory Factor Analysis and Multiple Linear Regression of the Neck Disability Index: Assessment If Subscales Are Equally Relevant in Whiplash and Nonspecific Neck Pain

OBJECTIVE

Because of previously published recommendations to modify the Neck Disability Index (NDI), we evaluated the responsiveness and dimensionality of the NDI within a population of adult whiplash-injured subjects. The purpose of the present study was to evaluate the responsiveness and dimensionality of the NDI within a population of adult whiplash-injured subjects.

METHODS

Subjects who had sustained whiplash injuries of grade 2 or higher completed an NDI questionnaire. There were 123 subjects (55% female, of which 36% had recovered and 64% had chronic symptoms. NDI subscales were analyzed using confirmatory factor analysis, considering only the subscales and, secondly, using sex as an 11th variable. The subscales were also tested with multiple linear regression modeling using the total score as a target variable.

RESULTS

When considering only the 10 NDI subscales, only a single factor emerged, with an eigenvalue of 5.4, explaining 53.7% of the total variance. Strong correlation (> .55) (P < .0001) between all variables was found. Multiple linear regression modeling revealed high internal consistency with all coefficients reaching significance (P < .0001). The 4 NDI subscales exerting the greatest effect were, in decreasing order, Sleeping, Lifting, Headaches, and Pain Intensity.

CONCLUSION

A 2-factor model of the NDI is not justified based on our results, and in this population of whiplash subjects, the NDI was unidimensional, demonstrating high internal consistency and supporting the original validation study of Vernon and Mior.

Upper cervical and upper thoracic manipulation versus mobilization and exercise in patients with cervicogenic headache: a multi-center randomized clinical trial

Background

Although commonly utilized interventions, no studies have directly compared the effectiveness of cervical and thoracic manipulation to mobilization and exercise in individuals with cervicogenic headache (CH). The purpose of this study was to compare the effects of manipulation to mobilization and exercise in individuals with CH.

Methods

One hundred and ten participants (n = 110) with CH were randomized to receive both cervical and thoracic manipulation (n = 58) or mobilization and exercise (n = 52). The primary outcome was headache intensity as measured by the Numeric Pain Rating Scale (NPRS). Secondary outcomes included headache frequency, headache duration, disability as measured by the Neck Disability Index (NDI), medication intake, and the Global Rating of Change (GRC). The treatment period was 4 weeks with follow-up assessment at 1 week, 4 weeks, and 3 months after initial treatment session. The primary aim was examined with a 2-way mixed-model analysis of variance (ANOVA), with treatment group (manipulation versus mobilization and exercise) as the between subjects variable and time (baseline, 1 week, 4 weeks and 3 months) as the within subjects variable.

Results

The 2X4 ANOVA demonstrated that individuals with CH who received both cervical and thoracic manipulation experienced significantly greater reductions in headache intensity (p < 0.001) and disability (p < 0.001) than those who received mobilization and exercise at a 3-month follow-up. Individuals in the upper cervical and upper thoracic manipulation group also experienced less frequent headaches and shorter duration of headaches at each follow-up period (p < 0.001 for all). Additionally, patient perceived improvement was significantly greater at 1 and 4-week follow-up periods in favor of the manipulation group (p < 0.001).

Conclusions

Six to eight sessions of upper cervical and upper thoracic manipulation were shown to be more effective than mobilization and exercise in patients with CH, and the effects were maintained at 3 months.

Trial registration

NCT01580280 April 16, 2012.

The Effectiveness of Conservative Management for Acute Whiplash Associated Disorder (WAD) II: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

OBJECTIVE

To evaluate the effectiveness of conservative management (except drug therapy) for acute Whiplash Associated Disorder (WAD) II.

DESIGN

Systematic review and meta-analysis of Randomised Controlled Trials (RCTs) using a pre-defined protocol. Two independent reviewers searched information sources, decided eligibility of studies, and assessed risk of bias (RoB) of included trials. Data were extracted by one reviewer and checked by the other. A third reviewer mediated any disagreements throughout. Qualitative trial and RoB data were summarised descriptively. Quantitative syntheses were conducted across trials for comparable interventions, outcome measures and assessment points. Meta-analyses compared effect sizes with random effects, using STATA version 12.

DATA SOURCES

PEDro, Medline, Embase, AMED, CINAHL, PsycINFO, and Cochrane Library with manual searching in key journals, reference lists, British National Bibliography for Report Literature, Center for International Rehabilitation Research Information & Exchange, and National Technical Information Service were searched from inception to 15th April 2015. Active researchers in the field were contacted to determine relevant studies.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

RCTs evaluating acute (<4 weeks) WADII, any conservative intervention, with outcome measures important to the International Classification of Function, Disability and Health.

RESULTS

Fifteen RCTs all assessed as high RoB (n=1676 participants) across 9 countries were included. Meta-analyses enabled 4 intervention comparisons: conservative versus standard/control, active versus passive, behavioural versus standard/control, and early versus late. Conservative intervention was more effective for pain reduction at 6 months (95%CI: -20.14 to -3.38) and 1-3 years (-25.44 to -3.19), and improvement in cervical mobility in the horizontal plane at <3 months (0.43 to 5.60) compared with standard/control intervention. Active intervention was effective for pain alleviation at 6 months (-17.19 to -3.23) and 1-3 years (-26.39 to -10.08) compared with passive intervention. Behavioural intervention was more effective than standard/control intervention for pain reduction at 6 months (-15.37 to -1.55), and improvement in cervical movement in the coronal (0.93 to 4.38) and horizontal planes at 3-6 months (0.43 to 5.46). For early (<4 days) versus late (>10 days) interventions, there were no statistically significant differences in all outcome measures between interventions at any time.

CONCLUSIONS

Conservative and active interventions may be useful for pain reduction in patients with acute WADII. Additionally, cervical horizontal mobility could be improved by conservative intervention. The employment of a behavioural intervention (e.g. act-as-usual, education and self-care including regularly exercise) could have benefits for pain reduction and improvement in cervical movement in the coronal and horizontal planes. The evidence was evaluated as low/very low level according to the Grading of Recommendations Assessment, Development and Evaluation system.

Normative score and cut-off value of the Neck Disability Index

BACKGROUND

Neck pain is a common health problem that restricts activities of daily living. The Neck Disability Index (NDI) was developed to assess disability in patients with neck pain. The normative score and the cut-off value are mandatory to assess an individual patient or a certain patient group for clinically important neck pain with disability, by distinguishing it from nonsignificant pain. The objective of the present study was to determine the normative score and the cut-off value of the NDI.

METHODS

A total of 1,200 participants who registered with an internet research company were interviewed on the website about their episodes of neck pain during the previous 4 weeks, and completed the online NDI questionnaire. If the participants reported neck pain, they were also asked about the disability in activity of daily living it caused, and the presence of associated symptoms in upper limbs. Disability was defined according to the consensus study on the standardization of back pain definitions. The normative score was determined by calculating the mean in the participants, and the cut-off value was determined by the receiver-operating characteristic curve analysis.

RESULTS

The prevalence of neck pain was 37.8 %. Demographic data of the participants also indicated that they were representative of the normal population in Japan. The mean score was 6.98, and the median was 2. The NDI score was higher in middle age, and at its peak in the 50s age group (50-59 years of age). The female mean was significantly higher. The NDI score was higher in those with upper limb symptoms. We have determined the cut-off value of the NDI to detect neck pain associated with disability to be 15.

CONCLUSIONS

The normative score and the cut-off value of the NDI were determined. Our cut-off value is potentially useful in evaluating the therapeutic effectiveness of various interventions for neck pain.

Evaluation of the injury impairment scale, a tool to predict road crash sequelae, in a French cohort of road crash survivors

OBJECTIVE

The objective of the present study was to validate sequelae prediction by the Maximal Injury Impairment Score (M-IIS) in comparison with the Functional Independence Measure (FIM) assessed at 1-year follow-up of severe road crash victims.

METHODS

The study population came from "the Etude et Suivi d'une Population d'Accidentés de la Route dans le Rhône" (ESPARR; Rhône Area Road Crash Victim Follow-up Study) cohort: 178 victims (with Maximal Abbreviated Injury Scale ≥ 3) of road crashes in the Rhône administrative department of France, aged ≥ 16 years and with medical examination including FIM scoring 1 year postaccident. Two thresholds were tested for both scores. Firstly, the relation between FIM and M-IIS was assessed on logistic regression models adjusted on age and presence of complications at 1 year postaccident. The predictive capacity of M-IIS was expressed as its negative and positive predictive values and was considered good when 80 percent or better.

RESULTS

Sixty-three of the 178 adult subjects (mean age = 37.7 years; range = 16.1-82.9 years) showed postaccident complications. One-year sequelae prediction on M-IIS was greater in head, spine, and limb lesions but limited to slight impairments (M-IIS = 1). There was a significant correlation between FIM and M-IIS, although age and medical complications were confounding factors on certain multivariate models. The predictive capacity of M-IIS was low for all types of sequelae.

CONCLUSIONS

M-IIS, in this severely injured population, failed to predict sequelae at 1 year as measured by the FIM, despite a good correlation between the two. Complications are to be taken into account in assessing the M-IIS's capacity to predict sequelae. Further evaluation will be needed on larger series or assessment of other indicators and measures of sequelae at 1 year to obtain a robust tool to predict road crash sequelae.

Prosthetic total disk replacement--can we learn from total hip replacement?

Total lumbar disk replacement has become a routine procedure in many countries. However, discussions regarding its use are ongoing. Issues focus on patient selection, technical limitations, and avoidance or management of complications or long-term outcomes. A review of the development of this technology, since the development of the first successful implantation of a total lumbar disk prosthesis in 1984, shows an amazing analogy to the history of total hip replacement. This article is a one-to-one comparison of the evolution of total hip and total lumbar disk replacement from "skunk works" to scientific evidence.

Cross-cultural adaptation and validation of the Korean version of the neck disability index

STUDY DESIGN

Validation of a translated, culturally adapted questionnaire.

OBJECTIVE

The purpose of this study is to translate and culturally adapt the Neck Disability Index (NDI) and to validate the use of the derived version in Korean patient.

SUMMARY OF BACKGROUND DATA

Although several valid measures exist for measurement of neck pain and functional impairment, these measures have yet been validated in Korean version.

METHODS

The NDI was linguistically translated into Korean, and prefinal version was assessed and modified by a pilot study. The reliability and validity of the derived Korean version was examined in 78 patients with degenerative cervical spine disease. Test-retest reliability, internal consistency, and construct validity were investigated by comparing Visual Analogue Scale (VAS) and Short Form Health Survey (SF-36) scores.

RESULTS

Factor analysis of Korean NDI extracted 2 factors with eigenvalues >1. The intraclass-correlation coefficient of test-retest reliability was 0.93. Reliability, estimated by internal consistency, had a Cronbach alpha value of 0.82. The correlation between NDI and VAS scores was r = 0.49, and the correlation between NDI and SF-36 scores was r = -0.44. The physical health component score of SF-36 was highly correlated with NDI, and the correlation between VAS scores and the mental health component scores of SF-36 was high.

CONCLUSION

The derived Korean version of the NDI was found to be a reliable and valid instrument for measuring disability in Korean patients with cervical problems. The authors recommend its use in future Korean clinical studies.

Multimodal group rehabilitation compared to usual care for patients with chronic neck pain: a pilot study

The aim of this pilot randomised controlled trial (RCT) was to compare multimodal group rehabilitation to usual care physiotherapy for patients with chronic neck pain (CNP). Participants (n=14) were randomly assigned to one of two interventions, multimodal group rehabilitation or usual care physiotherapy. Multimodal group rehabilitation involved stability, strengthening and proprioceptive exercises along with an educational programme. Patients attended for 1h, once a week for six weeks. The usual care group was treated as deemed appropriate by their physiotherapist. A blinded assessor recorded baseline and post-intervention scores of disability and pain using the neck disability index (NDI) and the 0-10 pain numerical rating scale (NRS), respectively. One participant from each group dropped out before receiving any intervention. Post-intervention both groups significantly improved in both function and pain scores (p ≤ 0.01). The mean change in the NDI scores for the multimodal group versus the usual care group were 12.3 ± 5.3% and 7.4 ± 4.8%, and pain NRS score changes were 4.6 ± 2.3 and 4.5 ± 2.2, respectively. There was no significant difference in improvements in disability (p = 0.84) or pain (p = 0.67) between groups. These results warrant further investigation of multimodal group rehabilitation for CNP, and provide data to inform an appropriately powered full-scale RCT with long-term follow-up.

Five years post whiplash injury: Symptoms and psychological factors in recovered versus non-recovered

Background

Few studies have focused on the differences between persons who are recovered after whiplash injury and those who suffer from persistent disability. The primary aim of this study was therefore to examine differences in symptoms, psychological factors and life satisfaction between subjects classified as recovered and those with persistent disability five years after whiplash injury based on the Neck Disability Index (NDI).

Methods

A set of questionnaires was answered by 158 persons (75 men, 83 women) to assess disability (NDI), pain intensity (VAS), whiplash-related symptoms (Rivermead Post-Concussion Symptoms Questionnaire, RPQ), post-traumatic stress (Impact of Event Scale, IES), depression (Beck's depression inventory, BDI) and life satisfaction (LiSat-11).

The participants were divided into three groups based on the results of the NDI: recovered (34.8%), mild disability (37.3%) and moderate/severe disability (27.3%).

Results

The moderate/severe group reported significantly higher VAS, BDI and IES scores and lower level of physical health and psychological health compared to the mild and the recovered groups. Less significant differences were reported between the mild and the recovered groups.

Conclusions

The group with the highest disability score reported most health problems with pain, symptoms, depression, post-traumatic stress and decreased life satisfaction. These findings indicate that classifying these subjects into subgroups based on disability levels makes it possible to optimize the management and treatment after whiplash injury.

Dynamics of improvement following total lumbar disc replacement: is the outcome predictable?

STUDY DESIGN

Prospective clinical study of total lumbar disc replacement (TDR) with ProDisc II (Synthes, Paoli, PA).

OBJECTIVES

To examine whether baseline variables VAS (Visual Analogue Scale) and ODI (Oswestry Disability Index) correspond with late and final postoperative outcome parameters and to identify early predictors of late outcome following total lumbar disc replacement (TDR).

SUMMARY OF BACKGROUND DATA

Previously published TDR studies reported on the pooled data averages collected from various cohort sizes. The individual patient's prognosis as well as prognostic factors of postoperative improvement remain unestablished.

METHODS

Data were accumulated prospectively and included VAS and ODI scores. The subjective outcome evaluation was based on a 3-scale grading system ("highly satisfied," "satisfied," "not satisfied"). An analysis was performed to ascertain whether the late and final outcome following TDR can be predicted based on preoperative and early postoperative data from the 3 and 6 month follow-up (FU).

RESULTS

The overall results from 161 patients with an average FU of 4 years (mean: 45.5 months, range: 24.1-94.4 months) revealed a significant and maintained improvement of VAS and ODI scores (P < 0.0001). The most pronounced changes occurred within the early postoperative period (P < 0.0001) with no significant changes thereafter (P > 0.05).Baseline ODI levels were significantly correlated with VAS/ODI scores and patient satisfaction rates at the final FU (P < 0.0001).After surgery, early and late ODI levels were highly significantly correlated with each other (r = 0.84, P < 0.0001). Similar associations were observed between early and late VAS scores and patient satisfaction rates (P < 0.006).The individual patient's subjective outcome evaluation revealed stable postoperative results. An improvement or a deterioration by 2 classes on a 3-scale grading system was only observed in 3.1% (n = 5/161) of all cases overall. Patients with an early "highly satisfactory" result (n = 83) maintained either a satisfactory (15.7%, n = 13/83) or a highly satisfactory outcome (79.5%, n = 66/83) in 95.2% of all cases (n = 79/83).Conversely, the probability that patients with an "unsatisfactory" outcome would still achieve a "highly satisfactory" result after the early postoperative period was 5.0%.

CONCLUSION

Baseline ODI and early postoperative outcome parameters (< or =6 months) revealed significant and strong associations with the final results following TDR. While the vast majority of patients with an early highly satisfactory outcome maintained satisfactory results at later FU stages, any significant improvement considered as "highly satisfied" is unlikely in a group of patients which reported early unsatisfactory results. In summary, any clinically relevant changes are unlikely to occur after the early postoperative period.The current findings offer a foundation for weighing both the patients and the spine surgeons expectations against possible realistic achievements. Although the data show that the midterm outcome at a FU of 4 years (mean: 45.5 months, range: 24.1-94.4 months) is predictable following TDR, the long-term results of lumbar disc replacements still need to be established.

A review of the definitions of 'recovery' used in prognostic studies on whiplash using an ICF framework

PURPOSE

The purpose of this article is to review the various definitions of recovery used in the prognostic whiplash literature to date, and to evaluate them from the framework of the International Classification of Functioning, Disability and Health (ICF).

METHODS

Reference lists of previous systematic reviews and meta-analyses on the topic were reviewed and citations were retrieved. An updated Medline search was performed. Recovery rates and the method for operationalising recovery were extracted and evaluated for their fit within the ICF model of health. Descriptive statistics were calculated and presented.

RESULTS

Thirty-one independent cohorts were identified. In total, 30 different primary methods for defining recovery were described in the sample of literature. Eighty-three percent of the primary outcomes fit within the body structure and function domain of the ICF. Restricted participation was the second most common domain represented, followed by activity limitations. Even within each domain, there is wide variability in the cut-off values for dichotomising a group as recovered or not.

CONCLUSIONS

The wide range of recovery rates reported in the literature can be at least partly accounted for by the lack of a standardised definition of recovery after acute whiplash. The emphasis on symptoms in the current literature neglects other important aspects of health as described by the ICF.

Vestibular evoked myogenic potentials (VEMPs) in whiplash injury: a prospective study

CONCLUSIONS

Patients affected by whiplash-associated disorder presented alterations of vestibular evoked myogenic potentials (VEMPs). VEMP testing may be an important 'forensic' diagnostic tool in the assessment of cervical spine injury.

OBJECTIVES

The purpose of this prospective study was to evaluate changes in VEMPs in the assessment of whiplash injuries.

PATIENTS AND METHODS

Fourteen patients complaining of whiplash injury were examined and compared with 15 controls. All patients underwent VEMP testing within 7 days from the injury and 90 days after whiplash injury. Beside VEMPs, standard investigation consisted of pure-tone and speech audiometry, impedance audiometry and evaluation of the vestibular system.

RESULTS

All subjects presented normal hearing, normal impedence audiometry findings, and normal vestibular function. VEMPs were present both in patients affected by whiplash injury and in the control group at time 0. At 90 days VEMPs were absent in two cases (14.3%). Statistical analysis showed that at time 0 and at time 90 days p1 latency was significantly higher in whiplash patients compared with healthy subjects on both sides (p < 0.002). The amplitude of p1-n1 was significantly lower in whiplash patients at time 0 (p = 0.003 on the right and p = 0.018 on the left), but not at 90 days.

Measurement properties of the neck disability index: a systematic review

STUDY DESIGN

Systematic review of clinical measurement.

OBJECTIVE

To find and synthesize evidence on the psychometric properties and usefulness of the neck disability index (NDI).

BACKGROUND

The NDI is the most commonly used outcome measure for neck pain, and a synthesis of knowledge should provide a deeper understanding of its use and limitations.

METHODS AND MEASURES

Using a standard search strategy (1966 to September 2008) and 4 databases (Medline, CINAHL, Embase, and PsychInfo), a structured search was conducted and supplemented by web and hand searching. In total, 37 published primary studies, 3 reviews, and 1 in-press paper were analyzed. Pairs of raters conducted data extraction and critical appraisal using structured tools. Ranking of quality and descriptive synthesis were performed.

RESULTS

Horizon estimation suggested the potential for 1 missed paper. The agreement between raters on quality assessments was high(kappa = 0.82). Half of the studies reached a quality level greater than 70%. Failures to report clear psychometric objectives/hypotheses or to rationalize the sample size were the most common design flaws. Studies often focused on less clinically applicable properties, like construct validity or group reliability, than transferable data, like known group differences or absolute reliability (standard error of measurement [SEM] or minimum detectable change [MDC]). Most studies suggest that the NDI has acceptable reliability, although intraclass correlation coefficients (ICCs) range from 0.50 to 0.98. Longer test intervals and the definition of stable can influence reliability estimates. A number of high-quality published (Korean, Dutch, Spanish, French, Brazilian Portuguese) and commercially supported translations are available. The NDI is considered a 1-dimensional measure that can be interpreted as an interval scale. Some studies question these assumptions. The MDC is around 5/50 for uncomplicated neck pain and up to 10/50 for cervical radiculopathy. The reported clinically important difference (CID) is inconsistent across different studies ranging from 5/50 to 19/50. The NDI is strongly correlated (>0.70) to a number of similar indices and moderately related to both physical and mental aspects of general health.

CONCLUSION

The NDI has sufficient support and usefulness to retain its current status as the most commonly used self-report measure for neck pain. More studies of CID in different clinical populations and the relationship to subjective/work/function categories are required.

Psychosocial and socio-demographic factors associated with outcomes for patients undergoing rehabilitation for chronic whiplash associated disorders: a pilot study

PURPOSE

Identify psychosocial and socio-demographic factors (measured prior to treatment) that were associated with post-treatment self-perceived pain and disability and two secondary outcomes: psychological distress, and return to work in patients undergoing multidisciplinary rehabilitation for chronic whiplash associated disorders (WAD).

METHOD

Interviews were conducted with 28 patients with chronic WAD at entry to and completion of an intensive rehabilitation program, and a telephone interview was carried out three months later. Participants completed pain and disability, and psychological distress questionnaires, at baseline and at both follow-ups. They also completed psychosocial questionnaires and provided socio-demographic information. The effect of each of the independent variables on the outcomes was first evaluated by simple regressions, and then subsequently by multiple regression analysis.

RESULTS

Higher baseline pain and disability predicted higher pain and disability at both follow-ups (p < 0.001), and higher psychological distress at program completion (p = 0.003). Younger age (p = 0.028) and higher baseline psychological distress (p = 0.002) were associated with higher psychological distress three months post-rehabilitation. Greater social support at work was prognostic of return to work at program completion (p = 0.04).

CONCLUSIONS

Baseline pain and disability was the only factor that affected pain and disability post-rehabilitation. Psychosocial factors played a role in the prognosis of psychological distress and return to work.

The Neck Disability Index: state-of-the-art, 1991-2008

BACKGROUND

Published in 1991, the Neck Disability Index (NDI) was the first instrument designed to assess self-rated disability in patients with neck pain. This article reviews the history of the NDI and the current state of the research into its psychometric properties--reliability, validity, and responsiveness--as well as its translations. Focused reviews are presented into its use in studies of the prognosis of whiplash-injured patients as well as its use in clinical trials of conservative therapies for neck pain.

SPECIAL FEATURES

The NDI is a relatively short, paper-pencil instrument that is easy to apply in both clinical and research settings. It has strong psychometric characteristics and has proven to be highly responsive in clinical trials. As of late 2007, it has been used in approximately 300 publications; it has been translated into 22 languages, and it is endorsed for use by a number of clinical guidelines.

SUMMARY

The NDI is the most widely used and most strongly validated instrument for assessing self-rated disability in patients with neck pain. It has been used effectively in both clinical and research settings in the treatment of this very common problem.

Impact of motor vehicle accidents on neck pain and disability in general practice

BACKGROUND

High levels of continuous neck pain after a motor vehicle accident (MVA) are reported in cross-sectional studies. Knowledge of this association in general practice is limited.

AIM

To compare the differences in perceived pain and disability in patients with acute neck pain due to an MVA versus other self-reported causes. The secondary aim was to identify prognostic factors for continuous neck pain.

DESIGN OF STUDY

Prospective cohort study with 1-year follow-up.

SETTING

General practices in Rotterdam and its suburban region.

METHOD

Patients with non-specific acute neck pain were invited to participate. Questionnaires were collected at baseline and after 6, 12, 26, and 52 weeks. The numerical pain-rating scale (NRS) and the neck disability index (NDI) were measured. Regression analysis was used to identify prognostic factors for continuous neck pain.

RESULTS

A total of 187 patients were included. The MVA subgroup (n = 42) was significantly younger (P = 0.007), reported more sick leave (P = 0.037), higher levels of headache (P<0.001) and higher NDI scores at baseline (P = 0.018) but lower scores for previous neck pain (P = 0.015) compared to the remaining cohort. At follow-up the MVA subgroup had higher scores for continuous neck pain (63% versus 40%) and at the NDI (11.0 versus 7.1). After multivariate analysis 'pain in the upper part of the neck' (odds ratio [OR] = 1.6), 'duration of complaints at baseline longer than 2 weeks' (OR = 5.3), and an 'MVA' (OR = 5.3) were significantly correlated with outcome.

CONCLUSION

Individuals exposed to MVAs constitute a relevant subgroup of patients with neck pain. An MVA and a longer duration of complaints are prognostic factors for continuous neck pain.

The effect of pre-injury physical fitness on the initial severity and recovery from whiplash injury, at six-month follow-up

OBJECTIVE

To evaluate the effect of pre-injury physical fitness on the initial severity and recovery of motor vehicle-induced neck injury (whiplash injury).

DESIGN

A quantitative experimental design using both retrospective and prospective data.

SETTING

Metropolitan Police physiotherapy and rehabilitation department in the UK.

SUBJECTS

One-hundred and two patients with neck pain following whiplash injury.

INTERVENTIONS

Patients were divided into three groups based on pre-injury physical fitness (low, medium and high). Recovery was compared between the three groups initially then again at three and six months.

MAIN MEASURES

Three measurement scales were used: the Neck Disability Index, the Problem Percentage, and the Physical Activity Scale.

RESULTS

Pre-injury physical fitness had a marked effect on recovery at three and six months, with the medium and high fitness groups having significantly better recovery than the low fitness group. At three months the Neck Disability Index score for the low fitness group was 12 compared with 7 and 7.5 for the medium and high fitness groups respectively (P = 0.009). At six months the Neck Disability Index score was 9 for the low fitness group compared with 0 and 3 for the medium and high fitness groups (P = 0.002). In addition, the return to work rate was almost twice as high for individuals with medium/high fitness.

CONCLUSION

Early recovery from whiplash injury was significantly more likely for individuals with medium to high levels of pre-injury physical fitness than for individuals with low levels of pre-injury physical fitness.

A systematic literature review of psychological factors and the development of late whiplash syndrome

This systematic literature review aims to assess the prognostic value of psychological factors in the development of late whiplash syndrome (LWS). We included prospective cohort studies that provided a baseline measure of at least one psychological variable and used outcome measures relating to LWS (i.e. pain or disability persisting 6 months post injury). A search of electronic databases (Pubmed, Medline, Cinahl, Embase and Psychinfo) up to August 2006 was done using a predetermined search strategy. Methodological quality was assessed independently by two assessors. Data extraction were carried out using a standardised data extraction form. Twenty-five articles representing data from 17 cohorts were included. Fourteen articles were rated as low quality with 11 rated as adequate quality. Meta-analysis was not undertaken due to the heterogeneity of prognostic factors, outcome measures and methods used. Results were tabulated and predefined criterion applied to rate the overall strength of evidence for associations between psychological factors and LWS. Data on 21 possible psychological risk factors were included. The majority of findings were inconclusive. Limited evidence was found to support an association between lower self-efficacy and greater post-traumatic stress with the development of LWS. No association was found between the development of LWS and personality traits, general psychological distress, wellbeing, social support, life control and psychosocial work factors. The lack of conclusive findings and poor methodological quality of the studies reviewed highlights the need for better quality research. Self-efficacy and post-traumatic distress may be associated with the development of LWS but this needs further investigation.

Legislative change is associated with improved health status in people with whiplash

STUDY DESIGN

Interrupted time series.

OBJECTIVE

To assess whether a change in legislation improved health status and quality of life for people with whiplash.

SUMMARY OF BACKGROUND DATA

Whiplash was the most prevalent injury in a compulsory, fault based, third party motor vehicle insurance scheme in New South Wales, Australia. Legislative change removed financial compensation for "pain and suffering" for whiplash, introduced clinical practice guidelines for its treatment; and changed regulations to permit earlier acceptance of compensation claims, and earlier access to treatment, for all types of injury.

METHODS

Three independent groups of people with whiplash were identified from insurance data (before legislative change--the 1999 group and, after legislative change--the 2001 and 2003 groups). Health status was assessed 2 years after injury by a telephone interviewer blinded to the study hypotheses. The main outcome measure was disability, as assessed by the Functional Rating Index (FRI). Pain and health-related quality of life was also assessed.

RESULTS

The mean FRI at 2 years after injury was 38.0% (SE, 1.9) for the 1999 group, 31.8% (SE, 2.1) for the 2001 group, and 30.1% (SE, 1.8) for the 2003 group (F = 5.0, P = 0.007). Improvement in secondary outcomes, including pain, also occurred.

CONCLUSION

Health status of people with whiplash improved after legislative change. Design of compensation schemes should be undertaken with the understanding that the scheme structure may have substantial effects on the long-term health of injured people.

A systematic literature review of physical prognostic factors for the development of Late Whiplash Syndrome

STUDY DESIGN

Systematic Review.

OBJECTIVE

To summarize evidence concerning physical prognostic factors for development of Late Whiplash Syndrome (LWS).

SUMMARY OF BACKGROUND DATA

There have been 3 previous systematic reviews of prognosis of whiplash with conflicting findings. The Quebec Task Force concluded that high priority should be given to determining prognostic factors. Subsequently their review was updated by Cote et al (Spine 2001;26:E445-58) and most recently by Scholten-Peeters et al (Pain 2003;104:303-22).

METHODS

We searched electronic databases from their inception to August 2006 using a prespecified search strategy. We included prospective cohort and case control studies that studied physical prognostic factors at baseline. Two independent reviewers selected articles, extracted data, and assessed quality. Meta-analysis was not performed due to the heterogeneity between studies. Instead, levels of evidence were generated by grouping similar findings from cohorts.

RESULTS

Thirty-eight articles from 26 cohorts were reviewed. The majority of articles (25 of 38) were rated as low quality. No studies were rated as high quality. Only a minority of studies used validated prognostic measures and/or outcome measures. High initial neck pain intensity, neck pain related disability, and cold hyperalgesia all had moderate evidence for an association with the development of LWS. No factor was rated as having strong evidence.

CONCLUSION

Pain has a central role to play as a prognostic factor for the development of LWS. Other physical factors commonly used in the clinical setting showed inconclusive evidence for their influence on prognosis. There is a need for improved quality of studies with consistent use of validated measures of all categories of prognostic factors and outcome. This may then provide a clearer understanding of prognosis of Whiplash Associated Disorders and therefore facilitate effective management of this costly problem.

Evaluation of the core outcome measure in whiplash

STUDY DESIGN

Reanalysis of data derived from longitudinal cohort studies.

OBJECTIVE

To comprehensively evaluate the psychometric properties of a 5-item version of the Core Outcome Measure in people with whiplash.

SUMMARY OF BACKGROUND DATA

The 7-item Core Outcome Measure was initially proposed as a brief health outcome measure for use in low back pain. To date, this measure has not been comprehensively assessed in a whiplash population. METHOD.: Data were sourced from 3 separate whiplash cohorts (total 481) encompassing acute, early chronic, and late-chronic whiplash among primary care and insurance populations. Subjects completed a 5-item version of the Core Outcome Measure for whiplash (Core Whiplash Outcome Measure [CWOM]), the Functional Rating Index, Neck Disability Index, SF-36, and perceived recovery questionnaires at baseline and short and long-term follow-up periods. Psychometric evaluation of the CWOM included assessing questionnaire responses, internal consistency, construct validity, and internal and external responsiveness.

RESULTS

Internal consistency was excellent at all stages of whiplash (Cronbach alpha = 0.76 in the acute stage and 0.83 in the late-chronic stage). Convergent validity was observed between the CWOM and Functional Rating Index (Pearson r = 0.81), Neck Disability Index (Pearson r = 0.76), and SF-36 physical health summary measure (Pearson r = -0.65). Divergent validity was observed between the CWOM and SF-36 mental health summary measure (Pearson r = -0.45). The internal and external responsiveness of the CWOM was similar to other neck-specific outcome measures.

CONCLUSIONS

We recommend the 5-item CWOM as a brief clinical measure for whiplash because it is quick to administer and score, and has excellent measurement properties. The CWOM may need to be supplemented with other questionnaires (e.g., when assessment of psychological or emotional health is required).

Prognostic factors for chronic neck pain in persons with minor or moderate injuries in traffic accidents

Prognostic factors for chronic neck pain were identified in a prospective Norwegian insurance cohort comprising 636 persons with minor or moderate traffic injuries. One questionnaire was used at baseline and another at 3 years post-injury. Daily severe or very severe neck pain at three years follow up was defined as chronic neck pain. Eight significant independent prognostic factors for chronic neck pain were identified: (1) rear-end or frontal and rear-end collision, odds ratio (OR): 4.10 (95% confidence interval (CI): 1.72-10.82); (2) neck and/or shoulder pain before the accident, OR: 2.38 (95% CI: 1.07-5.37); (3) post-accident (a) memory and concentration problems, OR: 4.62 (95% CI: 1.99-11.20), (b) bodily tension, OR: 3.43 (95% CI: 1.49-8.42), (c) difficulties to climb stairs, OR: 5.03 (95% CI: 1.77-14.95), (d) difficulties to bend forward, OR: 4.85 (95% CI: 2.06-11.79), (e) difficulties to do heavy labour, OR: 3.70 (95% CI: 1.24-11.64); (4) beliefs in future work disability, OR: 2.64 (95% CI: 1.11-6.48). The results indicate that development of chronic neck pain is influenced by pre-accident neck and/or shoulder pain, the impact of the collision, as well as post-accident symptoms, perceived impaired function and pessimism for the future ability to work.

A prospective cohort study of health outcomes following whiplash associated disorders in an Australian population

OBJECTIVE

To define health outcomes of whiplash associated disorders (WAD) at three months, six months, and two years after injury and to examine predictors of these outcomes.

DESIGN

Prospective cohort study.

SETTING

New South Wales, Australia.

SUBJECTS

People with compensable motor crash injuries who reported whiplash as one of their injuries.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Functional Rating Index (FRI), Short Form 36 (SF-36) at three months, six months, and two years after injury, ascertained by telephone interview.

RESULTS

At three months, 33.6% of the cohort was recovered (as defined by FRI<or=25), increasing marginally at six months (38.9% recovered), but more significantly at two years (51.7% recovered, p = 0.001). The mean physical component score of the SF-36 improved at each time point (p = 0.002), while the mean mental component score did not (p = 0.59). Predictors of recovery at two years (as defined by global perceived effect) included a lower FRI index at baseline (p = 0.001) and closure of the claim at two years (p = 0.02).

CONCLUSION

Whiplash injury had a large effect on the health of this Australian cohort of whiplash sufferers, with only 50% of the cohort recovered at two years. Physical measures of health appear to improve over time, whereas mental measures of health did not. Despite this, this cohort is largely able to participate in activities and work at two years. Prevention of chronic disability may lie with concentration of resources to those who score highly on the FRI at baseline. In addition, chronic psychological ill health may be prevented by directing treatment to those with poor scores on sensitive measures of psychological ill health at baseline.

Reliability and responsiveness of the Dutch version of the Neck Disability Index in patients with acute neck pain in general practice

A prospective cohort study with a 1 week follow-up. To examine the reliability and responsiveness of the Dutch version of the Neck Disability Index (NDI) in patients with acute neck pain in general practice. An increasing number of studies on treatment options is published in which the NDI is used. Reports of the ability of the NDI to detect change over time, often called responsiveness, however have not yet been published. At baseline 187 patients (119 women, 68 men) were included. They completed a questionnaire on demographic variables, self-reported cause of their complaints and the NDI. After 1 week, 86 patients were sent the NDI again together with the perceived recovery scale which was used as our external criterion. The scale ranged from 1 (complete recovery) to 7 (complaints are worse than ever). Response rate was 93%. Test-retest scores on reliability were good (ICC = 0.90). A Bland and Altman plot and a graph of total sum score differences showed no visible tendency towards unequal spreading of the data. For patients that reported on the perceived recovery scale that they were "stable" we found a responsiveness ratio of 1.82. The standard error of measurement (SEM) was 0.60 what resulted in a minimal detectable change (MDC) of 1.66. The NDI has shown to be a reliable and responsive instrument in patients with acute neck pain in general practice.