A new stratified risk assessment tool for whiplash injuries developed from a prospective observational study

Same patient but different worlds: A state-of-the-art review translating best practice psychosocial care from musculoskeletal care to the orthopaedic context

BACKGROUND

Individuals with chronic musculoskeletal conditions experience persistent pain and disability that has deleterious impacts on physical function, psychological health, social engagement, relationships, and work participation. This impact is greater in people with psychosocial risk factors, and best practice musculoskeletal care recommends a biopsychosocial approach to management. Orthopaedic surgery is often an effective management approach for chronic musculoskeletal conditions, but research has only recently explored the links between differing patient outcomes after orthopaedic surgery and psychosocial risk factors. Implementing biopsychosocial approaches to musculoskeletal care has taken great strides in the primary care setting however, implementation of the biopsychosocial approach in orthopaedic surgery brings complexity as the context changes from primary care to hospital based secondary care. The aim of this review therefore is to explore implementation of psychosocial care in the elective orthopaedic surgery context, informed by evidence in musculoskeletal care.

ASSESSMENT AND MANAGEMENT OF PSYCHOSOCIAL FACTORS

Several composite screening tools for psychosocial factors or 'yellow flags' are recommended for use in primary care for musculoskeletal conditions alongside a comprehensive patient interview. However, in the orthopaedic surgery context, composite measures have focused on discharge destination, and there is not a universal approach to comprehensive patient interview incorporating a biopsychosocial approach. A range of biopsychosocial approaches to musculoskeletal conditions have been developed for the primary care setting, yet few have been explored in the context of orthopaedic surgery.

IMPLEMENTATION OF PSYCHOSOCIAL CARE

Implementing best practice psychosocial care into the orthopaedic context has enormous potential for all stakeholders, but several barriers exist at the level of the individual patient and practitioner, workforce, health service and society. We have discussed key considerations for implementation including workforce composition, patient-centred care and shared decision making, health literacy, continuity of care, and consideration of preferences for women and culturally diverse communities.

CONCLUSION

This review considers current literature exploring implementation of psychosocial care into the orthopaedic surgery context, informed by current research in musculoskeletal care. This presents a critical opportunity for orthopaedic surgery to provide optimised, equitable, high-value, patient-centred care.

Imaging in Whiplash-Associated Disorders

"Whiplash," a term describing the severe acceleration and deceleration forces applied to the head, craniocervical junction (CCJ), and cervical spine during trauma, is one of the most frequent mechanisms of injury to the CCJ. The CCJ is a complex region at the transition of the cranium and the cervical spine, essential for maintaining craniocervical stability. In whiplash injuries, the CCJ may be compromised due to underlying ligamentous or, less frequently, osseous, intravertebral disk and/or muscular lesions. Imaging is crucial in detecting acute lesions but may also play a role in the follow-up of chronic pathology because soft tissue lesions and progressive disk pathology could contribute to a whiplash-associated disorder.

Do expectations of recovery improve risk assessment for people with whiplash-associated disorders? Secondary analysis of a prospective cohort study

Background

WhipPredict, which includes prognostic factors of pain-related disability, age and hyperarousal symptoms, was developed and validated for prediction of outcome in people with whiplash associated disorders (WAD). Patient expectations of recovery was not an included factor, though is known to mediate outcomes. The aim of this study was to determine whether the addition of expectations of recovery could improve the accuracy of WhipPredict.

Methods

Two hundred twenty-eight participants with acute WAD completed questionnaires (WhipPredict and expectations of recovery) at baseline. Health outcomes (neck disability index (NDI) and Global Perceived Recovery (GPR)) were assessed at 6- and 12-months post injury. Cut-off points for expectations of recovery predictive of both full recovery (NDI ≤10 % , GPR ≥ 4) and poor outcome (NDI ≥30 % , GPR ≤  − 3) were determined, and multivariate logistic regression analyses were used to compare models with and without this variable.

Results

Expectations of recovery improved or maintained the accuracy of predictions of poor outcome (6-months: sensitivity 78 to 83%, specificity maintained at 79.5%; 12-months: sensitivity maintained at 80%, specificity 69 to 73%). The sensitivity of predictions of full recovery improved (6-months: 68 to 76%; 12-months: 57 to 81%), though specificity did not change appreciably at 6 months (80 to 81%) and declined at 12 (83 to 76%). ROC curves indicated a larger and more consistent improvement in model performance when expectations of recovery were added to the pathway predictive of full recovery.

Conclusions

The addition of expectations of recovery may improve the accuracy of WhipPredict, though further validation is required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05242-8.

Advanced magnetic resonance imaging of chronic whiplash patients: a clinical practice-based feasibility study

BACKGROUND

Whiplash injury is common following road traffic crashes affecting millions worldwide, with up to 50% of the injured developing chronic symptoms and 15% having a reduced working capability due to ongoing disability. Many of these patients receive treatment in primary care settings based upon clinical and diagnostic imaging findings. Despite the identification of different types of injuries in the whiplash patients, clinically significant relationships between injuries and chronic symptoms remains to be fully established. This study investigated the feasibility of magnetic resonance imaging (MRI) techniques including quantitative diffusion weighted imaging and measurements of cerebrospinal fluid (CSF) flow as novel non-invasive biomarkers in a population of healthy volunteers and chronic whiplash patients recruited from a chiropractic clinic for the purpose of improving our understanding of whiplash injury.

METHODS

Twenty chronic whiplash patients and 18 healthy age- and gender matched control subjects were included [mean age ± SD (sex ratio; females/males), case group: 37.8 years ± 9.1 (1.22), control group: 35.1 years ± 9.2 (1.25)]. Data was collected from May 2019 to July 2020. Data from questionnaires pertaining to the car crash, acute and current symptoms were retrieved and findings from clinical examination and MRI including morphologic, diffusion weighted and phase-contrast images were recorded. The apparent diffusion coefficient and fractional anisotropy were calculated, and measurement and analysis of CSF flow was conducted. Statistical analyses included Fisher's exact test, Mann Whitney U test and analysis of variance between groups.

RESULTS

The studied population was described in detail using readily available clinical tools. No statistically significant differences were found between the groups on MRI.

CONCLUSIONS

This study did not show that MRI-based measures of morphology, spinal cord and nerve root diffusion or cerebrospinal fluid flow are sensitive biomarkers to distinguish between chronic whiplash patients and healthy controls. The detailed description of the chronic whiplash patients using readily available clinical tools may be of great relevance to the clinician. In the context of feasibility, clinical practice-based advanced imaging studies with a technical setup similar to the presented can be expected to have a high likelihood of successful completion.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

DISCUSSION

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

Revisiting Risk-stratified Whiplash-exposed Patients 12 to 14 Years After Injury

OBJECTIVE

The objective of this study was to evaluate the long-term predictive value of the Danish Whiplash Group Risk Assessment Score (DWGRAS) with 7 risk strata.

DESIGN

E-questionnaire-based follow-up study (n=927) combining 2 cohorts of whiplash-injured patients, 1 observational (n=187) and 1 interventional randomized controlled trial (n=740).

METHODS

Nine hundred twenty-seven previously healthy persons exposed to acute whiplash injury during motor vehicle collision were sent letter by postal service asking the addressee if they would respond to an E-questionnaire. Outcome measures were: whiplash-related disability, pain, use of medication/nonmedical treatment, work capacity.

RESULTS

The response rate was 37%. Fifty-five percent reported whiplash-related disability. Fourteen percent reported daily symptoms. A strong relationship was found between risk strata and impact of event and between risk strata and disabling symptoms.

CONCLUSIONS

Internal and long-term validation of DWGRAS was performed, but a low response rate indicates that results should be interpreted with caution. Furthermore, external validation needs to be done in long-term studies. An receiver operating characteristics curve of 0.73 (95% confidence interval 0.67; 0.79) predicting daily or weekly whiplash-related disability after 12 to 14 years was found using the DWGRAS risk score.

Clinical Characteristics and Patient-Reported Outcomes of Primary Care Physiotherapy in Patients with Whiplash-Associated Disorders: A Longitudinal Observational Study

BACKGROUND

Whiplash-associated disorders (WADs) constitute a state of health characterized by a wide diversity of symptoms as a result of impairments of functions, activity limitations, and participation restrictions. Patient-reported outcome measurements (PROMs) and patient-reported outcomes (PROs) seem appropriate when describing and evaluating the health status of patients with WAD.

AIM

To measure the use of PROMs and PROs as quality indicators in clinical reasoning, and to analyze and evaluate pre- and post-treatment 'pain intensity' and 'functioning', and for 'perceived improvement' in patients with WAD in primary care physiotherapy practice by year of referral, with the phase after accident and prognostic health profile embedded in the clinical reasoning process.

MATERIALS AND METHODS

Data were collected over a period of 10 years. Pain intensity, functioning, and perceived improvement were measured using the Visual Analogue Scale for Pain (VAS-P), the Neck Disability Index (NDI) and the Global Perceived Effect scale (GPE). Pre- and post-treatment mean differences were tested for statistical significance and compared to minimal clinically important differences (MCID). Effect sizes were expressed as Cohen's d. Multivariable regression analysis was performed to explore independent associations of year of referral, phase after the accident, and the patient's prognostic health profile with post-treatment pain intensity and functioning.

RESULTS

A consecutive sample of 523 patients was included. Pre- and post-treatment mean differences on VAS-P and NDI were statistically significant (P<0.000) and clinically relevant, with 'large' effect sizes for pain intensity and functioning. MCIDs were achieved by 80% for VAS-P and for 60% for NDI. Year of referral and phase after the accident were independently associated with worse post-treatment functioning. About half of the patients (n=241 [46.1%]) perceived themselves as improved.

CONCLUSION

The PROMs and PROs pain intensity, functioning and perceived improvement were integrated as quality indicators in the physiotherapy clinical reasoning process for patients with WAD. Significant differences in pain intensity and functioning were found but were unrelated to year of referral, phase after whiplash-related injury or prognostic health profile. The MCID VAS-P scores did not differ depending on experienced pain.

Does Overall Cervical Spine Pathology Relate to the Clinical Heterogeneity of Chronic Whiplash?

BACKGROUND AND PURPOSE

There remains limited evidence for the clinical importance of most imaging findings in whiplash. However, it is possible the type and number of findings on Computed Tomography (CT) may contribute to prognostic recovery models. The purpose is to interpret cervical spine pathologies in the context of known factors influencing recovery.

MATERIALS AND METHODS

This is a secondary analysis from a database of 97 acutely injured participants enrolled in a prospective inception cohort study. Thirty-eight participants underwent standard of care cervical spine CT in the emergency medicine department. All 38 participants were assessed at <1-week, 2-weeks, and 3-months post-injury and classified using percentage scores on the Neck Disability Index (recovered/mild (NDI of 0-28%) or moderate/severe (NDI ≥ 30%)). Between-group comparison of categorical variables (gender (male/female), presence of at least one CT finding (yes/no), and presence of ≥3 pathologies on CT (yes/no)) was conducted using 2-tailed Fisher's exact test.

RESULTS

Participants from both groups demonstrated at least one observable pathology. The group with persistent moderate/severe symptoms presented with significantly more pathology at baseline than those who later reported recovery or milder symptoms at 3-months post injury (p = 0.02).

CONCLUSIONS

This preliminary study, which needs replication in a larger cohort, provides foundation that the number of degenerative pathologies seen on initial post MVC CT may be associated with the subsequent clinical course of whiplash.

Development of an Internet-delivered educational video for acute whiplash injuries

Objective

To describe the development of a preventive educational video for patients exposed to whiplash trauma following motor vehicle accidents.

Methods

The development followed a systematic approach and was theory-driven supplemented with available empirical knowledge. The specific content was developed by a multidisciplinary group involving health professionals and visual production specialists.

Results

A 14-min educational video was created. The video content focuses on stimulating adaptive recovery expectations and preventing maladaptive illness beliefs. The video presents a multifactorial model for pain incorporating physiological and cognitive-behavioural aspects, advice on pain relief, and exercises. Subjects interviewed for a qualitative evaluation found the video reassuring and that it aligned well with verbal information received in the hospital.

Conclusions

The development of the visual educational intervention benefitted from a systematic development approach entailing both theoretical and research-based knowledge. The sparse evidence on educational information for acute whiplash trauma posed a challenge for creating content. Further knowledge is required regarding what assists recovery in the early stages of whiplash injuries in order to improve the development of educational interventions.

Minor Head Injury Symptoms and Recovery From Whiplash Injury: A 1-Year Prospective Study

Aim:

To examine concussion-related disability in neck injuries, the Rivermead Head Injury Follow-Up Questionnaire (RHFUQ) was applied. Furthermore, we wanted to investigate symptoms found in post-concussion syndrome (PCS) and global pain, neck pain intensities obtained from acute whiplash patients within 1 week and at 6 months after injury in a prospective study on 1-year work disability.

Methods:

A total of 143 consecutive acute whiplash-injured patients were admitted to the study from the Emergency Unit (Aarhus University Hospital). Patients with direct head trauma or reported retro- or anterograde amnesia were excluded from the study. Average neck pain and global pain intensity were measured on a Visual Analogue Scale (VAS 0-10). The RHFUQ (10 items, score from 0 to 4, total score from 0 to 40) was fulfilled after 1 week and 6 months. Patients underwent neurological examination within 1 week after injury. Recovery (return to work) was assessed 1 year post-injury.

Results:

In total, 97% completed the study, and 9% (12/138) did not recover. Non-recovered patients reported more neck pain and global pain after 1 week (P < .003) and 6 months (P < .008) and higher PCS symptom score after 1 week (P < .001) and 6 months (P < .002). Using the RHFUQ total score as a predictive test, a receiver-operating characteristic curve (ROC) area of 0.77 (0.61-0.92) and a cut-off at 10 points revealed a sensitivity of 75% and a specificity of 67.2%. At 1 week, 8 of 10 items reached higher scores among non-recovered and 10 of 10 items after 6 months post-injury.

Conclusions:

RHFUQ is useful in acute whiplash patients for predicting 1-year work disability. PCS-related symptoms along with neck pain and global pain are more burdensome in the non-recovered group. This emphasizes that post-concussion symptoms are not a sign of brain injury alone, but are found in other types of mishaps like whiplash injuries.

Development of the circumduction metric for identification of cervical motion impairment

INTRODUCTION

Chronic neck pain results in considerable personal, clinical, and societal burden. It consistently ranks among the top three pain-related reasons for seeking healthcare. Despite its prevalence, neck pain is difficult to both assess and treat. Quantitative approaches are required since diagnostic imaging techniques rarely provide information on movement-related neck pain, and most common clinical assessment tools are limited to single plane motion measurement.

METHODS

In this study, the ability of an inertial measurement unit to document the cervical motion characteristics of 28 people with chronic neck pain and 23 healthy controls was assessed. A total of six circumduction metrics and one neck circumduction trajectory model were proposed as identification metrics.

RESULTS

Five metrics demonstrated significant differences between the two groups. The neck circumduction trajectory model successfully distinguished between the two groups.

DISCUSSION

The evaluation of the proposed metrics provides proof of concept that novel metrics can be captured with relative ease in the clinical setting using an inexpensive wearable sensor headband. The derivation of the proposed model may open new lines of inquiry into the clinical utility of assessing the multiplanar movement of cervical circumduction. The results obtained from this study also provide additional insight for the development of a sensitive, quantifiable and real-world neck evaluation strategies.

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

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

Recovery Pathways and Prognosis After Whiplash Injury

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

Are People With Whiplash-Associated Neck Pain Different From People With Nonspecific Neck Pain?

Study Design Secondary analysis of a prospective cohort study with cross-sectional and longitudinal analyses. Background The clinical importance of a history of whiplash-associated disorder (WAD) in people with neck pain remains uncertain. Objective To compare people with WAD to people with nonspecific neck pain, in terms of their baseline characteristics and pain and disability outcomes over 1 year. Methods Consecutive patients with neck pain who presented to a secondary-care spine center answered a comprehensive self-report questionnaire and underwent a physical examination. Patients were classified into a group of either those with WAD or those with nonspecific neck pain. We compared the outcomes of baseline characteristics of the 2 groups, as well as pain intensity and activity limitation at follow-ups of 6 and 12 months. Results A total of 2578 participants were included in the study. Of these, 488 (19%) were classified as having WAD. At presentation, patients with WAD were statistically different from patients without WAD for almost all characteristics investigated. While most differences were small (1.1 points on an 11-point pain-rating scale and 11 percentage points on the Neck Disability Index), others, including the presence of dizziness and memory difficulties, were substantial. The between-group differences in pain and disability increased significantly (P<.001) over 12 months. At 12-month follow-up, the patients with WAD had on average approximately 2 points more pain and 17 percentage points more disability than those with nonspecific neck pain. Conclusion People referred to secondary care with WAD typically had more self-reported pain and disability and experienced worse outcomes than those with nonspecific neck pain. Caution is required when interpreting the longitudinal outcomes due to lower-than-optimal follow-up rates. Level of Evidence Prognosis, level 2. J Orthop Sports Phys Ther 2016;46(10):894-901. Epub 3 Sep 2016. doi:10.2519/jospt.2016.6588.

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.

External validation of a clinical prediction rule to predict full recovery and ongoing moderate/severe disability following acute whiplash injury

STUDY DESIGN

Retrospective secondary analysis of data.

OBJECTIVES

To investigate the external validity of the whiplash clinical prediction rule (CPR).

BACKGROUND

We recently derived a whiplash CPR to consolidate previously established prognostic factors for poor recovery from a whiplash injury and predicted 2 recovery pathways. Prognostic factors for full recovery were being less than 35 years of age and having an initial Neck Disability Index (NDI) score of 32% or less. Prognostic factors for ongoing moderate/severe pain and disability were being 35 years of age or older, having an initial NDI score of 40% or more, and the presence of hyperarousal symptoms. Validation is required to confirm the reproducibility and accuracy of this CPR. Clinician feedback on the usefulness of the CPR is also important to gauge acceptability.

METHODS

A secondary analysis of data from 101 individuals with acute whiplash-associated disorder who had previously participated in either a randomized controlled clinical trial or prospective cohort study was performed using accuracy statistics. Full recovery was defined as NDI score at 6 months of 10% or less, and ongoing moderate/severe pain and disability were defined as an NDI score at 6 months of 30% or greater. In addition, a small sample of physical therapists completed an anonymous survey on the clinical acceptability and usability of the tool. Results The positive predictive value of ongoing moderate/severe pain and disability was 90.9% in the validation cohort, and the positive predictive value of full recovery was 80.0%. Surveyed physical therapists reported that the whiplash CPR was simple, understandable, would be easy to use, and was an acceptable prognostic tool.

CONCLUSION

External validation of the whiplash CPR confirmed the reproducibility and accuracy of this dual-pathway tool for individuals with acute whiplash-associated disorder. Further research is needed to assess prospective validation, the impact of inclusion on practice, and to examine the efficacy of linking treatment strategies with predicted prognosis.

LEVEL OF EVIDENCE

Prognosis, level 1b.

The return-to-work process of individuals sick-listed because of whiplash-associated disorder: a three-year follow-up study in a Danish cohort of long-term sickness absentees

Background

The chronic course of whiplash-associated disorder (WAD) has implications for both the individual and society. It has been shown that up to 50% of patients have not yet returned to work six months after a whiplash injury. We wanted to study the return-to-work (RTW) process in individuals sick-listed for more than eight weeks in six Danish municipalities. RTW in individuals sick-listed due to WAD was compared to that in those sick-listed for other musculoskeletal disorders (MSD).

Methods

Information about long-term sick-listed individuals in six Danish municipalities was retrieved from an existing database. Data on public transfer income were collected and the RTW process was followed on a weekly basis. Multivariate logistic regression analysis of RTW was done four times during the first three years after the start of sick-listing.

Results

One hundred and four individuals were sick-listed due to WAD and 3,204 individuals were sick-listed due to other MSDs. After 6 months, the RTW was significantly lower in the WAD group. OR for RTW in the WAD group was 0.29 (0.18–0.49) compared to the MSD group. The RTW process for both groups stabilised after two years of follow-up; 44% returned to work in the WAD group as compared to 58% in the MSD group.

Conclusion

Sick-listed individuals with whiplash-associated disorder are less likely to return to work than individuals who are sick-listed because of other musculoskeletal disorders. In both groups, RTW stabilised after two years of follow-up.