An Overview of Systematic Reviews on Prognostic Factors in Neck Pain: Results from the International Collaboration on Neck Pain (ICON) Project

Prognostic factors of pain, disability, and poor outcomes in persons with neck pain - an umbrella review

OBJECTIVE

The aim of this study was to identify prognostic factors pertaining to neck pain from systematic reviews.

DATA SOURCES

A search on PubMed, Scopus, and CINAHL was performed on June 27, 2024. Additional grey literature searches were performed.

REVIEW METHODS

We conducted an umbrella review and included systematic reviews reporting the prognostic factors associated with non-specific or trauma-related neck pain and cervical radiculopathy. Prognostic factors were sorted according to the outcome predicted, the direction of the predicted outcome (worse, better, inconsistent), and the grade of evidence (Oxford Center of Evidence). The predicted outcomes were regrouped into five categories: pain, disability, work-related outcomes, quality of life, and poor outcomes (as "recovery"). Risk of bias analysis was performed with the ROBIS tool.

RESULTS

We retrieved 884 citations from three databases, read 39 full texts, and included 16 studies that met all selection criteria. From these studies, we extracted 44 prognostic factors restricted to non-specific neck pain, 47 for trauma-related neck pain, and one for cervical radiculopathy. We observed that among the prognostic factors, most were associated with characteristics of the condition, cognitive-emotional factors, or socio-environmental and lifestyle factors.

CONCLUSION

This study identified over 40 prognostic factors associated mainly with non-specific neck pain or trauma-related neck pain. We found that a majority were associated with worse outcomes and pertained to domains mainly involving cognitive-emotional factors, socio-environmental and lifestyle factors, and the characteristics of the condition to predict outcomes and potentially guide clinicians to tailor their interventions for people living with neck pain.

Development and internal validation of a multivariable prognostic model to predict chronic pain after a new episode of non-specific idiopathic, non-traumatic neck pain in physiotherapy primary care practice

OBJECTIVE

To develop and internally validate a prognostic model to predict chronic pain after a new episode of acute or subacute non-specific idiopathic, non-traumatic neck pain in patients presenting to physiotherapy primary care, emphasising modifiable biomedical, psychological and social factors.

DESIGN

A prospective cohort study with a 6-month follow-up between January 2020 and March 2023.

SETTING

30 physiotherapy primary care practices.

PARTICIPANTS

Patients with a new presentation of non-specific idiopathic, non-traumatic neck pain, with a duration lasting no longer than 12 weeks from onset.

BASELINE MEASURES

Candidate prognostic variables collected from participants included age and sex, neck pain symptoms, work-related factors, general factors, psychological and behavioural factors and the remaining factors: therapeutic relation and healthcare provider attitude.

OUTCOME MEASURES

Pain intensity at 6 weeks, 3 months and 6 months on a Numeric Pain Rating Scale (NPRS) after inclusion. An NPRS score of ≥3 at each time point was used to define chronic neck pain.

RESULTS

62 (10%) of the 603 participants developed chronic neck pain. The prognostic factors in the final model were sex, pain intensity, reported pain in different body regions, headache since and before the neck pain, posture during work, employment status, illness beliefs about pain identity and recovery, treatment beliefs, distress and self-efficacy. The model demonstrated an optimism-corrected area under the curve of 0.83 and a corrected R2 of 0.24. Calibration was deemed acceptable to good, as indicated by the calibration curve. The Hosmer-Lemeshow test yielded a p-value of 0.7167, indicating a good model fit.

CONCLUSION

This model has the potential to obtain a valid prognosis for developing chronic pain after a new episode of acute and subacute non-specific idiopathic, non-traumatic neck pain. It includes mostly potentially modifiable factors for physiotherapy practice. External validation of this model is recommended.

Systemic Inflammation, Sleep, and Psychological Factors Determine Recovery Trajectories for People With Neck Pain: An Exploratory Study

We conducted an explorative prospective cohort study with 6 months follow-up to 1) identify different pain and disability trajectories following an episode of acute neck pain, and 2) assess whether neuroimmune/endocrine, psychological, behavioral, nociceptive processing, clinical outcome, demographic and management-related factors differ between these trajectories. Fifty people with acute neck pain (ie, within 2 weeks of onset) were included. At baseline, and at 2, 4, 6, 12, and 26 weeks follow-up, various neuroimmune/endocrine (eg, inflammatory cytokines and endocrine factors), psychological (eg, stress symptoms), behavioral (eg, sleep disturbances), nociceptive processing (eg, condition pain modulation), clinical outcome (eg, trauma), demographic factors (eg, age), and management-related factors (eg, treatment received) were assessed. Latent class models were performed to identify outcome trajectories for neck pain and disability. Linear mixed models or the Pearson chi-square test were used to evaluate differences in these factors between the trajectories at baseline and at each follow-up assessment and over the entire 6 months period. For pain, 3 trajectories were identified. The majority of patients were assigned to the "Moderate pain - Favourable recovery" trajectory (n = 25; 50%) with smaller proportions assigned to the "Severe pain - Favourable recovery" (n = 16; 32%) and the "Severe pain - Unfavourable recovery" (n = 9; 18%) trajectories. For disability, 2 trajectories were identified: "Mild disability - Favourable recovery" (n = 43; 82%) and "Severe disability - Unfavourable recovery" (n = 7; 18%). Ongoing systemic inflammation (increased high-sensitive C-reactive protein), sleep disturbances, and elevated psychological factors (such as depression, stress and anxiety symptoms) were mainly present in the unfavorable outcome trajectories compared to the favorable outcome trajectories. PERSPECTIVE: Using exploratory analyses, different recovery trajectories for acute neck pain were identified based on disability and pain intensity. These trajectories were influenced by systemic inflammation, sleep disturbances, and psychological factors.

Cortisol as a Marker of Pain and Distress After Acute Musculoskeletal Trauma

OBJECTIVES

The best available predictors of chronic pain development broadly encompass baseline metrics of cognition (ie, beliefs/expectations) about the trauma and resulting symptoms. In the context of musculoskeletal trauma, we have previously shown the Traumatic Injuries Distress Scale (TIDS) capable of risk-stratifying cohorts for chronic pain development. Here, we explore whether the physiological marker cortisol shows meaningful associations with cognitions predictive of pain outcomes.

METHODS

Data for these cross-sectional analyses were drawn from an observational study that recruited 130 participants presenting to the hospital with pain related to a recent noncatastrophic Musculoskeletal trauma. Cortisol was measured from the participant's hair, saliva, and blood. In addition to pain and distress questionnaires, metadata such as age, sex, body mass index (BMI), adverse childhood events, pretrauma stress levels, and pre-existing physical/psychological comorbidities were collected.

RESULTS

We found no significant associations between cortisol levels and pain or distress in isolation. When stratified by person-level variables, associations were revealed with distress (TIDS) in young age and low pretrauma stress subgroups (hair cortisol) and low BMI (blood cortisol). Through hierarchical regression analysis, we found the "cortisol X age" or "cortisol X stress" interaction terms significantly improved TIDS prediction beyond either variable in isolation (Age: ∆ R2 =15.1%; pretrauma stress: ∆ R2 =9.1%).

DISCUSSION

Our findings suggest that while linear correlations between pain-related distress and cortisol may be overly simplistic, certain person-level variables such as age, pretrauma stress, and BMI are worthy of consideration for experimental design or confounder characterization in future studies of pain and distress following musculoskeletal injuries especially when "trait" (hair) cortisol is the predictor variable.

Prognostic Factors for Postoperative Chronic Pain after Knee or Hip Replacement in Patients with Knee or Hip Osteoarthritis: An Umbrella Review

Knee and hip osteoarthritis are highly prevalent in the older population. Management of osteoarthritis-related pain includes conservative or surgical treatment. Although knee or hip joint replacement is associated with positive outcomes, up to 30% of patients report postoperative pain in the first two years. This study aimed to synthesize current evidence on prognostic factors for predicting postoperative pain after knee or hip replacement. An umbrella review of systematic reviews was conducted to summarize the magnitude and quality of the evidence for prognostic preoperative factors predictive of postoperative chronic pain (>6 months after surgery) in patients who had received knee or hip replacement. Searches were conducted in MEDLINE, CINAHL, PubMed, PEDro, SCOPUS, Cochrane Library, and Web of Science databases from inception up to 5 August 2022 for reviews published in the English language. A narrative synthesis, a risk of bias assessment, and an evaluation of the evidence confidence were performed. Eighteen reviews (nine on knee surgery, four on hip replacement, and seven on both hip/knee replacement) were included. From 44 potential preoperative prognostic factors, just 20 were judged as having high or moderate confidence for robust findings. Race, opioid use, preoperative function, neuropathic pain symptoms, pain catastrophizing, anxiety, other pain sites, fear of movement, social support, preoperative pain, mental health, coping strategies, central sensitization-associated symptoms, and depression had high/moderate confidence for an association with postoperative chronic pain. Some comorbidities such as heart disease, stroke, lung disease, nervous system disorders, and poor circulation had high/moderate confidence for no association with postoperative chronic pain. This review has identified multiple preoperative factors (i.e., sociodemographic, clinical, psychological, cognitive) associated with postoperative chronic pain after knee or hip replacement. These factors may be used for identifying individuals at a risk of developing postoperative chronic pain. Further research can investigate the impact of using such prognostic data on treatment decisions and patient outcomes.

Patient-reported outcome measures in physical therapy practice for neck pain: an overview of reviews

BACKGROUND

Understanding which patient-reported outcome measures are being collected and utilized in clinical practice and research for patients with neck pain will help to inform recommendations for a core set of measures that provide value to patients and clinicians during diagnosis, clinical decision-making, goal setting and evaluation of responsiveness to treatment. Therefore, the aim of this study was to conduct a review of systematic reviews using a qualitative synthesis on the use of patient-reported outcome measures (PROMs) for patients presenting with neck pain to physical therapy.

METHODS

An electronic search of systematic reviews and guideline publications was performed using MEDLINE (OVID), Embase (Elsevier), CINAHL Complete (EBSCOhost), and Web of Science (Clarivate) databases to identify reviews that evaluated physical therapy interventions or interventions commonly performed by a physical therapist for individuals with neck pain and included at least one patient-reported outcome measure. The frequency and variability in which the outcome measures were reported among the studies in the review and the constructs for which they measured were evaluated. The evaluation of a core set of outcome measures was assessed. Risk of bias and quality assessment was performed using A Measurement Tool to Assess systematic Reviews 2.

RESULTS

Of the initial 7,003 articles, a total of 37 studies were included in the final review. Thirty-one PROMs were represented within the 37 reviews with eleven patient-reported outcome measures in three or more reviews. The eleven PROMs assessed the constructs of disability, pain intensity, psychosocial factors and quality of life. The greatest variability was found amongst individual measures assessing psychosocial factors. Assessment of psychosocial factors was the least represented construct in the included studies. Overall, the most frequently utilized patient reported outcome measures were the Neck Disability Index, Visual Analog Scale, and Numeric Pain Rating Scale. The most frequently used measures evaluating the constructs of disability, pain intensity, quality of life and psychosocial functioning included the Neck Disability Index, Visual Analog Scale, Short-Form-36 health survey and Fear Avoidance Belief Questionnaire respectively. Overall risk of bias and quality assessment confidence levels ranged from critically low (2 studies), low (12 studies), moderate (8 studies), and high (15 studies).

CONCLUSION

This study identified a core set of patient-reported outcome measures that represented the constructs of disability, pain intensity and quality of life. This review recommends the collection and use of the Neck Disability Index and the Numeric Pain Rating Scale or Visual Analog Scale. Recommendation for a QoL measure needs to be considered in the context of available resources and administrative burden. Further research is needed to confidently recommend a QoL and psychosocial measure for patients presenting with neck pain. Other measures that were not included in this review but should be further evaluated for patients with neck pain are the Patient Reported Outcomes Measurement Information System (PROMIS) Physical function, PROMIS Pain Interference and the Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) tool.

Effects of a Novel Web-Based Sensorimotor Exercise Program for Patients With Subacute Whiplash-Associated Disorders: Protocol for a Randomized Clinical Trial

INTRODUCTION

Whiplash-associated disorder (WAD) often becomes a persistent problem and is one of the leading causes of disability in the world. It is a costly condition for individuals, for insurance companies, and for society. Guidelines for the management of WAD have not been updated since 2014, and the use of computer-based sensorimotor exercise programs in treatment for this patient group has not been well documented. The purpose of this randomized clinical trial is to explore the degree of association between self-reported and clinical outcome measures in WAD.

METHODS

Individuals (n = 180) with subacute WAD grades I and II will be randomized into 3 groups using block randomization. The 2 primary intervention groups (A and B) will receive physical therapy involving manual therapy and either a remote, novel, computer-based cervical kinesthetic exercise (CKE) program starting at visit 2 (Group A) or neck exercises provided by the corresponding physical therapist (Group B). These groups will be compared to a "treatment as usual" Group C. Movement control, proprioception, and cervical range of motion will be measured. Neck disability and pain intensity, general health, self-perceived handicap, and physical, emotional, and functional difficulties due to dizziness will be measured using questionnaires. The short-term effects will be measured 10 to 12 weeks after the baseline measurements, and the long-term effects will be measured 6 to 12 months after the baseline measurements.

IMPACT

The successful completion of this trial will help guide clinicians in the selection of outcome measures for patients with subacute WAD in the assessment of the short- and long-term effectiveness of treatment combining manual therapy with computer-based CKE compared with manual therapy and non-computer-based exercises. This trial will also demonstrate the potential of using a computer-based intervention to increase the exercise dose for this patient group and how this influences outcomes such as levels of pain and disability in the short and long term.

Prognostic factors for persistent symptoms in adults with mild traumatic brain injury: an overview of systematic reviews

BACKGROUND

Mild traumatic brain injury (mTBI) is an increasing public health problem, because of its persistent symptoms and several functional consequences. Understanding the prognosis of a condition is an important component of clinical decision-making and can help to guide the prevention of persistent symptoms following mTBI. The prognosis of mTBI has stimulated several empirical primary research papers and many systematic reviews leading to the identification of a wide range of factors. We aim to synthesize these factors to get a better understanding of their breadth and scope.

METHODS

We conducted an overview of systematic reviews. We searched in databases systematic reviews synthesizing evidence about the prognosis of persistent symptoms after mTBI in the adult population. Two reviewers independently screened all references and selected eligible reviews based on eligibility criteria. They extracted relevant information using an extraction grid. They also rated independently the risk of bias using the ROBIS tool. We synthesized evidence into a comprehensive conceptual map to facilitate the understanding of prognostic factors that have an impact on persistent post-concussion symptoms.

RESULTS

From the 3857 references retrieved in a database search, we included 25 systematic reviews integrating the results of 312 primary articles published between 1957 and 2019. We examined 35 prognostic factors from the systematics reviews. No single prognostic factor demonstrated convincing and conclusive results. However, age, sex, and multiple concussions showed an affirmatory association with persistent post-concussion outcomes in systematic reviews.

CONCLUSION

We highlighted the need for a comprehensive picture of prognostic factors related to persistent post-concussion symptoms. We believe that these prognostic factors would guide clinical decisions and research related to prevention and intervention regarding persistent post-concussion symptoms.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020176676.

Cervical and axioscapular muscle stiffness measured with shear wave elastography: A comparison between different levels of work-related neck disability

Assessing muscle mechanical properties in terms of stiffness may provide important insights into mechanisms underlying work-related neck pain. This study compared stiffness of cervical and axioscapular muscles between 92 participants (sonographers) with no (n = 31), mild (n = 43) or moderate/severe (n = 18) neck disability. It was hypothesized that participants with more severe neck pain and disability would present with altered distribution of stiffness in cervical and axioscapular muscles than those with no disability. Using shear wave elastography, the shear modulus (kPa) of five cervical and six axioscapular muscles or muscle segments were measured in a relaxed seated upright or side-lying position. Muscle activity was measured simultaneously using surface electromyography during the elastography measurements and scapular depression was measured using a measurement tape and inclinometer before the elastography measurements to evaluate their potential confounding influences on shear modulus. Increased shear modulus was found in deeper than superficial cervical muscles and more cranial than caudal axioscapular muscles. However, no differences in shear modulus of the cervical or axioscapular muscles were found between sonographers with varying levels of disability. This study suggests no alterations in stiffness of cervical and axioscapular muscles were associated with work-related neck pain and disability.

A study protocol for the validation of a prognostic model with an emphasis on modifiable factors to predict chronic pain after a new episode of acute- or subacute nonspecific idiopathic, non-traumatic neck pain presenting in primary care

BACKGROUND

The primary objective of this study is to identify which modifiable and non-modifiable factors are independent predictors of the development of chronic pain in patients with acute- or subacute nonspecific idiopathic, non-traumatic neck pain, and secondly, to combine these to develop and internally validate a prognostic prediction model.

METHODS

A prospective cohort study will be conducted by physiotherapists in 30 primary physiotherapy practices between January 26, 2020, and August 31, 2022, with a 6-month follow-up until March 17, 2023. Patients who consult a physiotherapist with a new episode of acute- (0 to 3 weeks) or subacute neck pain (4 to 12 weeks) will complete a baseline questionnaire. After their first appointment, candidate prognostic variables will be collected from participants regarding their neck pain symptoms, prior conditions, work-related factors, general factors, psychological and behavioral factors. Follow-up assessments will be conducted at six weeks, three months, and six months after the initial assessment. The primary outcome measure is the Numeric Pain Rating Scale (NPRS) to examine the presence of chronic pain. If the pain is present at six weeks, three months, and six months with a score of NPRS ≥3, it is classified as chronic pain. An initial exploratory analysis will use univariate logistic regression to assess the relationship between candidate prognostic factors at baseline and outcome. Multiple logistic regression analyses will be conducted. The discriminative ability of the prognostic model will be determined based on the Area Under the receiver operating characteristic Curve (AUC), calibration will be assessed using a calibration plot and formally tested using the Hosmer and Lemeshow goodness-of-fit test, and model fit will be quantified as Nagelkerke's R2. Internal validation will be performed using bootstrapping-resampling to yield a measure of overfitting and the optimism-corrected AUC.

DISCUSSION

The results of this study will improve the understanding of prognostic and potential protective factors, which will help clinicians guide their clinical decision making, develop an individualized treatment approach, and predict chronic neck pain more accurately.

"FastSchool": A single session of an interprofessional pain management program for chronic pain patients inspired by cognitive behavioral therapy

OBJECTIVES

Multidisciplinary approaches to treating chronic pain have been proven effective. Currently, chronic pain patients face lengthy waitlists in pain medicine departments. To overcome this problem, we developed the "FastSchool" program to educate patients about pain management and treatment. In this study, we evaluated the benefit of a "FastSchool" session on pain and catastrophizing in chronic pain patients.

METHODS

Included patients had chronic non-cancer pain, no more than 2 visits to a pain medicine department. Patients attended a single 3-hour session, conducted by an interprofessional team. Four topics were addressed: chronic pain mechanisms, pharmacological therapies, physical activity, and the management of analgesics. Patients completed questionnaires at baseline and at 3 months post-session to assess pain interference, pain intensity, and catastrophizing.

RESULTS

The study population included 88 patients; 71 completed the follow-up questionnaires. Pain interference (p = 0.002), average pain intensity (p = 0.013), and catastrophizing (p < 0.001) decreased 3 months after FastSchool. At M3, 35 % of patients felt their pain had improved based on the Patient Global Impression of Change.

CONCLUSION

FastSchool, an innovative short-term educational program inspired by cognitive behavioral therapy, showed positive results in reducing pain impact.

PRACTICE IMPLICATIONS

Implementation of FastSchool in pain medicine departments would reduce waitlist times for non-pharmacological treatment.

Perceived pain and disability but not fear of movement are associated with altered cervical kinematics in people with acute neck pain following a whiplash injury

OBJECTIVES

To determine if measures of cervical kinematics are altered in people with acute whiplash associated disorders (WAD) and secondarily, to examine whether kinematic variables are associated with self-reported outcomes.

METHODS

We recruited people with acute WAD within 15 days after a motor vehicle collision and asymptomatic control participants. All participants performed active neck movements at a self-determined velocity. Maximal range of motion (ROM), peak and mean velocity of movement, smoothness of movement, and cervical joint position error were assessed. Moreover, self-reported measures of perceived pain and disability, pain catastrophising, and fear of movement were obtained.

RESULTS

Sixty people participated: 18 with acute WAD (mean age [SD] 38.7 [12.0]) and 42 as asymptomatic controls (mean age [SD] 38.4 [10.2]). Participants with acute WAD showed significantly decreased ROM in all movement directions (p < 0.0001). All participants with acute WAD showed a reduction in the mean and peak velocity of movement in all directions (p < 0.0001) and the number of velocity peaks was significantly higher (i.e., reduced smoothness of movement) in those with acute WAD in all directions (p < 0.0001). Repositioning acuity following cervical rotation was not significantly different between groups. Neck pain-related disability showed the largest number of significant associations with kinematic features, while fear of movement was not associated with measures of cervical kinematics.

CONCLUSIONS

Participants with acute WAD presented with altered cervical kinematics compared to asymptomatic participants. Several measures of cervical kinematics were associated with the level of pain and disability in people with acute WAD but not their fear of movement.

Exploring visual pain trajectories in neck pain patients, using clinical course, SMS-based patterns, and patient characteristics: a cohort study

Background

The dynamic nature of neck pain has so far been identified through longitudinal studies with frequent measures, a method which is time-consuming and impractical. Pictures illustrating different courses of pain may be an alternative solution, usable in both clinical work and research, but it is unknown how well they capture the clinical course. The aim of this study was to explore and describe self-reported visual trajectories in terms of details of patients’ prospectively reported clinical course, their SMS-based pattern classification of neck pain, and patient’s characteristics.

Methods

Prospective cohort study including 888 neck pain patients from chiropractic practice, responding to weekly SMS-questions about pain intensity for 1 year from 2015 to 2017. Patients were classified into one of three clinical course patterns using definitions based on previously published descriptors. At 1-year follow-up, patients selected a visual trajectory that best represented their retrospective 1-year course of pain: single episode, episodic, mild ongoing, fluctuating and severe ongoing.

Results

The visual trajectories generally resembled the 1-year clinical course characteristics on group level, but there were large individual variations. Patients selecting Episodic and Mild ongoing visual trajectories were similar on most parameters. The visual trajectories generally resembled more the clinical course of the last quarter.

Discussion

The visual trajectories reflected the descriptors of the clinical course of pain captured by weekly SMS measures on a group level and formed groups of patients that differed on symptoms and characteristics. However, there were large variations in symptoms and characteristics within, as well as overlap between, each visual trajectory. In particular, patients with mild pain seemed predisposed to recall bias. Although the visual trajectories and SMS-based classifications appear related, visual trajectories likely capture more elements of the pain experience than just the course of pain. Therefore, they cannot be seen as a proxy for SMS-tracking of pain over 1 year.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-022-00443-3.

The association between different outcome measures and prognostic factors in patients with neck pain: a cohort study

Background

Health domains like pain, disability, and health-related quality of life are commonly used outcomes for musculoskeletal disorders. Most prognostic studies include only one outcome, and it is unknown if prognostic factors and models may be generic across different outcomes. The objectives of this study were to examine the correlation among commonly used outcomes for neck pain (pain intensity, disability, and health-related quality of life) and to explore how the predictive performance of a prognostic model differs across commonly used outcomes.

Methods

We conducted an observational prospective cohort study with data from patients with neck pain aged 18–84 years consulting Norwegian chiropractors. We used three different outcomes: pain intensity (Numeric Pain Rating Scale), the Neck Disability Index (NDI), and health-related quality of Life (EQ-5D). We assessed associations between change in outcome scores at 12-weeks follow-up with Pearson’s correlation coefficient. We used multivariable linear regression models to explore differences in explained variance and relationship between predictors and outcomes.

Results

The study sample included 1313 patients and 941 (72%) completed follow-up at 12 weeks. The strongest correlation was between NDI and EQ-5D (r = 0.57) while the weakest correlation was between EQ-5D and pain intensity (r = 0.39). The correlation between NDI and pain intensity was moderate (r = 0.53) In the final regression models, the explained variance ranged from adjusted R² of 0.26 to 0.60, highest with NDI and lowest with pain intensity as outcome. The predictive contributions of the included predictors were similar across outcomes. Among the investigated predictors, pain patterns and the baseline measure of the corresponding outcome measure contributed the most to explained variance across all outcomes.

Conclusions

The highest correlation was found between NDI and EQ-5D and the lowest with pain intensity. The same prognostic model showed highest predictive performance with NDI as outcome and poorest with pain intensity as outcome. These results suggest that we need more knowledge on the reasons for the differences in predictive performance variation across outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05558-5.

Cervical Motor and Nociceptive Dysfunction After an Acute Whiplash Injury and the Association With Long-Term Non-Recovery: Revisiting a One-Year Prospective Cohort With Ankle Injured Controls

Aims

To explore the development of cervical motor and nociceptive dysfunction in patients with whiplash (WPs) and non-recovery based on injury-related work disability 1-year after injury when compared with ankle-injured controls (ACs).

Methods

A 1-year observational prospective study examining consecutive WPs and age- and sex-matched ACs at 1 week,3 months, 6 months, and 1 year post-injury using semi-structured interviews; global pain rating (VAS0-10) and the pain rating index (PRI-T) and number-of-words-chosen (NWC) from the McGill Pain Questionnaire; examining nociceptive functioning using the cold pressor test (CPT), pressure algometry, and methodic palpation, and central pain processing using counter-stimulation; and examining motor functioning by active cervical range-of-motion (CROM), and neck strength [maximal voluntary contraction flexion/extension (MVC)]. One-year work disability/non-recovery was determined using a semi-structured interview.

Results

A total of 141 WPs and 40 ACs were included. Total pain rating index (PRI-T) NWC were higher in ACs after 1 week but higher in WPs after 3 months, 6 months, and 1 year. Ongoing global pain was higher in WPs after 1 week and after 3 and 6 months but not after 1 year. Pressure pain thresholds were reduced, and palpation was higher in the neck and jaw in WPs after 1 week but was not consistently different afterward from ACs. Cervical mobility was reduced in WPs after 1 week, 3 months, and 6 months but not after 1 year, and MVC was significantly reduced in WPs when compared with ACs after 1 week and 1 year but not after 3 and 6 months. One-year non-recovery was only encountered in 11 WPs and not in the AC group. Non-recovered WPs (N-WPs) had consistently significantly higher VAS₀₋₁₀, PRI-T, NWC, reduced pressure pain thresholds, raised muscle-tenderness, reduced active cervical range-of-motion, reduced active-neck-flexion/extension, and reported higher neck disability scores than recovered WPs. Of special interest, there was increasing tenderness in trigeminal-derived muscles based on palpation scores, and marked reduction of PPDT was most pronounced in N-WPs when compared with recovered WPs and ACs.

Conclusion

Cervical motor dysfunction and segmental nociceptive sensitization were present from early after injury in WPs and prolonged in N-WPs. Differences in trigeminal and cervical motor and sensory function in N-WPs could be of interest for future treatment studies.

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

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

Management of Chronic Musculoskeletal Pain Through a Biopsychosocial Lens

Chronic musculoskeletal pain continues to constitute a rising cost and burden on individuals and society on a global level, thus driving the demand for improved management strategies. The biopsychosocial model has long been a recommended approach to help manage chronic pain, with its consideration of the person and his or her experiences, psychosocial context, and societal considerations. However, the biomedical model continues to be the basis of athletic therapy and athletic training programs and therefore clinical practice. For more than 30 years, psychosocial factors have been identified in the literature as outcome predictors relating to chronic pain, including (but not limited to) catastrophizing, fear avoidance, and self-efficacy. Physical assessment strategies such as validated outcome measures can be used by the athletic therapist and athletic trainer to determine the presence or severity (or both) of nonbiogenic pain. Knowledge of these predictors and strategies allows the athletic therapist and athletic trainer to frame the use of exercise (eg, graded exposure), manual therapy, and therapeutic modalities in the appropriate way to improve clinical outcomes. Through changes in educational curricula content, such as those recommended by the International Association for the Study of Pain, athletic therapists and athletic trainers can develop profession-specific knowledge and skills that will enhance their clinical practice and enable them to better assist those living with chronic musculoskeletal pain conditions.

Psychometric validation of the Polish version of the Central Sensitization Inventory in subjects with chronic spinal pain

BACKGROUND

Central sensitization is an amplification of neuronal signaling within the central nervous system. The Central Sensitization Inventory was introduced in 2012. A Polish version of the CSI (CSI-Pol) was developed in 2019, but it was not psychometrically validated. The aim of this study was to validate the CSI-Pol in a sample of Polish-speaking patients with chronic spinal pain and compare them with a group of healthy control subjects.

METHODS

The CSI-Pol was administered to 151 patients with chronic spinal pain recruited from two centers. It was re-administered 7 days later. The psychometric properties were then evaluated, including test-retest reliability, construct validity, factor structure and internal consistency. We correlated the CSI-Pol with functional scales, depression and social support scales and compared CSI-Pol scores in the clinical subjects with 30 healthy control subjects recruited from medical staff and their families.

RESULTS

The CSI-Pol demonstrated excellent internal consistency (Cronbach's α =0,933) and test-retest reliability (Intraclass Correlation Coefficients - ICC =0.96), as well as significant positive associations with other patient-reported scales, including the Neck Disability Index (r = 0.593), Revised Oswestry Low Back Pain Disability Questionnaire (r = 0.422), and other measures of functional and depressive states. An exploratory factor analysis resulted in a 4-factor model. CSI-Pol scores in the clinical sample (35.27 ± 17.25) were significantly higher than the control sample (23.3 ± 8.9).

CONCLUSION

The results of this study suggest that the CSI-Pol may be a useful clinical tool for assessing central sensitization related symptoms and guiding appropriate treatment in Polish-speaking patients with spinal pain.

The effects of active break and postural shift interventions on recovery from and recurrence of neck and low back pain in office workers: A 3-arm cluster-randomized controlled trial

OBJECTIVES

To investigate the efficacy of active break and postural shift interventions aimed to reduce sitting discomfort on recovery duration and recurrence of neck and low back pain among high-risk office workers.

METHODS

A 3-arm cluster-randomized controlled trial with 12-month follow-up was conducted in 193 healthy but high-risk office workers. Participants in the intervention groups received custom-designed apparatus to facilitate either active breaks or postural shifts to reduce sitting discomfort at work. Participants in a control group received a placebo seat pad. Incidence of neck and low back pain with pain intensity and disability level was recorded monthly. Main outcome measures were recovery time and recurrent rate of neck and low back pain. Analyses were performed using log rank test and Cox proportional hazard models.

RESULTS

Median time to recovery in those receiving active break and postural shift interventions (1 month) was significantly shorter than those in the control group (2 months). Neck and low back pain recurrent rates for the active break, postural shift, and control groups were 21%, 18%, and 44%, respectively. Hazard rate (HR) ratios after adjusting for biopsychosocial factors indicated a protective effect of active break and postural shift interventions for neck and low back pain recurrence (HR_adj 0.22, 95% CI 0.06-0.83 for active breaks and HR_adj 0.35, 95% CI 0.16-0.77 for postural shift).

CONCLUSION

Active break and postural shift interventions shortened recovery time and reduced recurrence of neck and low back pain among high-risk office workers.

Use of Soft Cervical Collar among Whiplash Patients in Two Italian Emergency Departments Is Associated with Persistence of Symptoms: A Propensity Score Matching Analysis

Purpose: Although the use of soft cervical collars in the emergency department (ED), for whiplash-associated disorders (WAD), is controversial, it is still widely adopted. The purpose of our study was to investigate the impact of the early use of soft cervical collars on the return to the ED, within three months of a road traffic collision. Methods: We conducted a retrospective observational study on WAD patients from two EDs in Verona (Italy). Patients in the earlier acute phase of WAD (within 48 h from the trauma) were included; those with serious conditions (WAD IV) were excluded. As an end point, we considered patients who returned to the ED complaining of WAD symptoms within three months as positive outcome for WAD persistence. Results: 2162 patients were included; of those, 85.4% (n = 1847/2162) received a soft cervical collar prescription. Further, 8.4% (n = 156/1847) of those with a soft cervical collar prescription, and 2.5% (n = 8/315) of those without a soft cervical collar (p < 0.001) returned to the ED within three months. The use of the soft cervical collar was an independent risk factor for ED return within three months, with an OR, adjusted for possible clinical confounders, equal to 3.418 (95% CI 1.653–7.069; p < 0.001). After the propensity score matching, 25.5% of the patients (n = 25/98) using the soft cervical collar returned to the ED at three months, compared to the 6.1% (n = 6/98) that did not adopt the soft cervical collar. The use of a soft cervical collar was associated with ED return with an OR = 4.314 (95% CI 2.066–11.668; p = 0.001). Conclusions: Our study shows that the positioning of the soft collar in a cohort of patients with acute WAD, following a rear-end car collision, is an independent potential risk factor to the return to the ED. Clinically, the use of the collar is a non-recommended practice and seems to be related to an increased risk of delayed recovery. There is a need to inform healthcare providers involved in the ED of the aim to limit the use of the soft cervical collar. A closer collaboration between clinicians (e.g., physicians, physical therapists, nurses) is suggested in the ED. Future primary studies should determine differences between having used or not having used the collar, and compare early physical therapy in the ED compared with the utilization of the collar.

Vigorous regular leisure-time physical activity is associated with a clinically important improvement in back pain - a secondary analysis of randomized controlled trials

Background

Neck and back pain are musculoskeletal conditions with serious individual and societal consequences. Current evidence about the prognostic value for neck and back pain is limited and conflicting. This prospective cohort study aimed to assess the association between leisure-time physical activity (LPA) and improvement of neck and/or back pain in a working population receiving manual therapy or general care in one of two randomized controlled trials (RCTs).

Methods

Analyses of data from two RCTs evaluating the effect of manual therapies for neck and/or back pain was conducted. Participants (n = 1 464) answered questionnaires about frequency and effort level of LPA at baseline. LPA on moderate or vigorous levels was compared to no or low/irregular moderate and vigorous levels. Pain intensity was assessed with numerical scales at baseline and 3-, 6-, and 12-month follow-up. The outcome was minimal clinically important improvement in pain intensity, defined as ≥2 points improvement in mean pain intensity at follow-up. Crude- and adjusted risk ratios (RR) with 95% confidence intervals (CI) were calculated with Poisson regression analysis and stratified by pain location.

Results

Participants with neck and/or back pain performing vigorous LPA showed a minimal clinically important improvement after 12 months compared to the control group; RR 1.35 (95% CI; 1.06-1.73). No effect was observed at 3 or 6 months. Moderate LPA did not improve pain intensity in any follow-up. Stratified analyses revealed that the effect of vigorous LPA at 12 months in back pain was RR 1.83 (95% CI; 1.26-2.66) and neck pain RR 1.06 (95% CI; 0.75-1.49).

Conclusions

Persons with neck and/or back pain receiving manual therapy or general evidence-based care have greater chance of improvement after 12 months if they prior to treatment frequently practice vigorous LPA. When analyzed separately, the effect was only present for back pain.

Trial registration

Registration in Current Controlled Trials (ISRCTN), Stockholm Manual Intervention Trial (MINT), ISRCTN92249294 BJORN-trial, ISRCTN56954776

Development and internal validation of prognostic models for recovery in patients with non-specific neck pain presenting in primary care

OBJECTIVES

Development and internal validation of prognostic models for post-treatment and 1-year recovery in patients with neck pain in primary care.

DESIGN

Prospective cohort study.

SETTING

Primary care manual therapy practices.

PARTICIPANTS

Patients with non-specific neck pain of any duration (n=1193).

INTERVENTION

Usual care manual therapy.

OUTCOME MEASURES

Recovery defined in terms of pain intensity, disability, and global perceived improvement directly post-treatment and at 1-year follow-up.

RESULTS

All post-treatment models exhibited acceptable discriminative performance after derivation (AUC≥0.7). The developed post-treatment disability model exhibited the best overall performance (R²=0.24; IQR, 0.22-0.26), discrimination (AUC=0.75; 95% CI, 0.63-0.84), and calibration (slope 0.92; IQR, 0.91-0.93). After internal validation and penalization, this model retained acceptable discriminative performance (AUC=0.74). The five other models, including those predicting 1-year recovery, did not reach acceptable discriminative performance after internal validation. Baseline pain duration, disability, and pain intensity were consistent predictors across models.

CONCLUSION

A post-treatment prognostic model for disability was successfully developed and internally validated. This model has potential to inform primary care clinicians about a patient's individual prognosis after treatment, but external validation is required before clinical use can be recommended.

Heightened pain facilitation rather than impaired pain inhibition distinguishes those with moderate/severe disability in work-related neck pain

ABSTRACT

To better understand the mechanisms underpinning work-related neck pain, this cross-sectional and single-blinded study compared somatosensory profiles among sonographers with varied neck disability levels. Based on K-mean cluster analysis of scores on the neck disability index (NDI), participants were classified into no (NDI ≤ 8%, n = 31, reference group), mild (NDI = 10%-20%, n = 43), or moderate/severe (NDI ≥ 22%, n = 18) disability groups. Data were collected on bodily pain distribution and severity and psychological measures including depression, anxiety, pain-catastrophizing, and fear-avoidance beliefs using validated scales. Participants attended 1 session of quantitative sensory testing performed according to a standardized protocol, including local and remote thermal and mechanical pain thresholds, temporal summation of pain (TSP), conditioned pain modulation, and an exercise-induced analgesia paradigm. Compared with participants with no and mild disability, those with moderate/severe disability showed more widespread pain, cold and mechanical hyperalgesia at a remote nonpainful site, and significantly higher TSP. Participants with mild disability demonstrated significantly higher TSP than those with no disability. These group differences were attenuated after adjusting for depression or anxiety, indicating these psychological factors may mediate the somatosensory changes associated with neck disability. Group differences were not found for conditioned pain modulation or exercise-induced analgesia. These findings suggest that heightened pain facilitation, rather than impaired pain inhibition may underpin nociplastic pain in participants with moderate/severe disability, and it may be associated with depression and anxiety. Clinicians should be aware that individuals with work-related neck pain presenting with moderate/severe disability display distinct somatosensory features and tailor management strategies accordingly.

Is Preexisting Cervical Degeneration a Risk Factor for Poor Prognosis in Whiplash-Associated Disorder?

BACKGROUND

The term whiplash describes the acceleration-deceleration mechanism of injury to the cervical spine. Whiplash injuries present with a variety of clinical and psychological manifestations, collectively termed as whiplash-associated disorders (WADs). Although largely self-limiting, some patients may experience long-lasting symptoms. This review aimed to summarize the current literature regarding the predictive value of cervical degeneration in the prognosis of patients with WAD.

METHODS

A comprehensive search of the literature was performed. Nine studies were identified, including 894 patients, with an age range between 16 and 76 years.

RESULTS

A statistically significant association was found between moderate facet joint degeneration and nonrecovery. Although no association was established between isolated disc degeneration and nonrecovery, total cervical degeneration (facet joint + disc degeneration) was shown to correlate with nonrecovery.All included studies demonstrated the lack of correlation between preexisting disc degeneration and clinical outcomes. Four studies showed a significant correlation between cervical degeneration and poor prognosis following whiplash injury. A significantly higher proportion of patients who remained symptomatic at 2 years following a whiplash injury had preexisting degenerative changes.

CONCLUSIONS

This review highlights the presence of significant variability in the existing literature concerning WAD in terms of study methodology, definitions of cervical degeneration, and outcome measures. Degenerative changes of the facet joint lead to alterations in its biomechanics. Several cadaveric, biomechanical, and clinical studies have demonstrated facet joints as a source of pain in patients with chronic WAD. We present moderate evidence to suggest that preexisting facet joint degeneration is a negative prognostic indicator for long-lasting symptoms in WAD. Conversely, preexisting disc degeneration is not associated with chronicity of WAD symptoms. We propose facet joint instability due to facet joint capsule rupture as a potential mechanism for nonrecovery. Further studies are needed to inform our knowledge of the long-term sequelae of WAD among patients with preexisting cervicalspine degeneration.

External validation of prognostic models for recovery in patients with neck pain

Background

Neck pain is one of the leading causes of disability in most countries and it is likely to increase further. Numerous prognostic models for people with neck pain have been developed, few have been validated. In a recent systematic review, external validation of three promising models was advised before they can be used in clinical practice.

Objective

The purpose of this study was to externally validate three promising models that predict neck pain recovery in primary care.

Methods

This validation cohort consisted of 1311 patients with neck pain of any duration who were prospectively recruited and treated by 345 manual therapists in the Netherlands. Outcome measures were disability (Neck Disability Index) and recovery (Global Perceived Effect Scale) post-treatment and at 1-year follow-up. The assessed models were an Australian Whiplash-Associated Disorders (WAD) model (Amodel), a multicenter WAD model (Mmodel), and a Dutch non-specific neck pain model (Dmodel). Models’ discrimination and calibration were evaluated.

Results

The Dmodel and Amodel discriminative performance (AUC < 0.70) and calibration measures (slope largely different from 1) were poor. The Mmodel could not be evaluated since several variables nor their proxies were available.

Conclusions

External validation of promising prognostic models for neck pain recovery was not successful and their clinical use cannot be recommended. We advise clinicians to underpin their current clinical reasoning process with evidence-based individual prognostic factors for recovery. Further research on finding new prognostic factors and developing and validating models with up-to-date methodology is needed for recovery in patients with neck pain in primary care.

Self-reported prognostic factors in adults reporting neck or low back pain: An umbrella review

BACKGROUND

Numerous systematic reviews have attempted to synthesize evidence on prognostic factors for predicting future outcomes such as pain, disability and return-to-work/work absence in neck and low back pain populations.

DATABASES AND DATATREATMENT

An umbrella review of systematic reviews was conducted to summarize the magnitude and quality of the evidence for each prognostic factor investigated. Searches were limited to the last 10 years (2008-11th April 2018, updated 28th September 2020). A two-stage approach was undertaken: in stage one, data on prognostic factors was extracted from systematic reviews identified from the systematic search that met the inclusion criteria. Where a prognostic factor was investigated in ≥1 systematic review and where 50% or more of those reviews found an association between the prognostic factor and one of the outcomes of interest, it was taken forward to stage two. In stage two, additional information extracted included the strength of association found, consistency of effects and risk of bias. The GRADE approach was used to grade confidence in the evidence.

RESULTS

Stage one identified 41 reviews (90 prognostic factors), with 35 reviews (25 prognostic factors) taken forward to stage two. Seven prognostic factors (disability/activity limitation, mental health; pain intensity; pain severity; coping; expectation of outcome/recovery and fear-avoidance) were judged as having moderate confidence for robust findings.

CONCLUSIONS

Although there was conflicting evidence for the strength of association with outcome, these factors may be used for identifying vulnerable subgroups or people able to self-manage. Further research can investigate the impact of using such prognostic information on treatment/referral decisions and patient outcomes.

Application and utility of a clinical framework for spinally referred neck-arm pain: A cross-sectional and longitudinal study protocol

BACKGROUND

The clinical presentation of neck-arm pain is heterogeneous with varying underlying pain types (nociceptive/neuropathic/mixed) and pain mechanisms (peripheral/central sensitization). A mechanism-based clinical framework for spinally referred pain has been proposed, which classifies into (1) somatic pain, (2) neural mechanosensitivity, (3) radicular pain, (4) radiculopathy and mixed pain presentations. This study aims to (i) investigate the application of the clinical framework in patients with neck-arm pain, (ii) determine their somatosensory, clinical and psychosocial profile and (iii) observe their clinical course over time.

METHOD

We describe a study protocol. Patients with unilateral neck-arm pain (n = 180) will undergo a clinical examination, after which they will be classified into subgroups according to the proposed clinical framework. Standardized quantitative sensory testing (QST) measurements will be taken in their main pain area and contralateral side. Participants will have to complete questionnaires to assess function (Neck Disability Index), psychosocial factors (Tampa Scale of Kinesiophobia, Pain Catastrophizing Scale, Depression, anxiety and stress scale), neuropathic pain (Douleur Neuropathique 4 Questions, PainDETECT Questionnaire) and central sensitization features (Central Sensitization Inventory). Follow-ups at three, six and 12 months include the baseline questionnaires. The differences of QST data and questionnaire outcomes between and within groups will be analyzed using (M)AN(C)OVA and/or regression models. Repeated measurement analysis of variance or a linear mixed model will be used to calculate the differences between three, six, and 12 months outcomes. Multiple regression models will be used to analyze potential predictors for the clinical course.

CONCLUSION

The rationale for this study is to assess the usability and utility of the proposed clinical framework as well as to identify possible differing somatosensory and psychosocial phenotypes between the subgroups. This could increase our knowledge of the underlying pain mechanisms. The longitudinal analysis may help to assess possible predictors for pain persistency.

The contemporary management of neck pain in adults

Neck pain is a common condition with a high prevalence worldwide. Neck pain is associated with significant levels of disability and is widely considered an important public health problem. Neck pain is defined as pain perceived between the superior nuchal line and the spinous process of the first thoracic vertebra. In some types of neck conditions, the pain can be referred to the head, trunk and upper limbs. This article aims to provide an overview of the available evidence on prevalence, costs, diagnosis, prognosis, risk factors, prevention and management of patients with neck pain.

Recovery expectations of neck pain patients do not predict treatments outcome in manual therapy

Patient recovery expectations can predict treatment outcome. Little is known about the association of patient recovery expectations on treatment outcome in patients with neck pain consulting a manual therapist. This study evaluates the predictive value of recovery expectations in neck pain patients consulting manual therapists in the Netherlands. The primary outcome measure 'recovery' is defined as 'reduction in pain and perceived improvement'. A prospective cohort study a total of 1195 neck pain patients. Patients completed the Patient Expectancies List (PEL) at baseline (3 item questionnaire, score range from 3 to 12), functional status (NDI), the Global Perceived Effect (GPE) for recovery (7-points Likert scale) post treatment and pain scores (NRS) at baseline and post treatment. The relationship between recovery expectancy and recovery (dichotomized GPE scores) was assessed by logistic regression analysis. Patients generally reported high recovery expectations on all three questions of the PEL (mean sumscores ranging from 11.3 to 11.6). When adjusted for covariates the PEL sum-score did not predict recovery (explained variance was 0.10 for the total PEL). Separately, the first question of the PEL showed predictive potential (OR 3.7; 95%CI 0.19-73.74) for recovery, but failed to reach statistical significance. In this study patient recovery expectations did not predict treatment outcome. Variables predicting recovery were recurrence and duration of pain. The precise relationship between patient recovery expectations and outcome is complex and still inconclusive. Research on patient expectancy would benefit from more consistent use of theoretical expectancy and outcome models.

Cross-cultural adaptation and validation of the Dutch language version of the Pictorial Fear of Activity Scale - Cervical

Background

The Pictorial Fear of Activity Scale-Cervical (PFActS-C) is a reliable and valid instrument to assess fear of movement in people with whiplash associated disorders. It is not available in Dutch and has not been evaluated in other neck pain populations. This study aimed to systematically translate the PFActS-C into Dutch and evaluate the psychometric properties of this Dutch Language Version (DLV) in people with non-specific neck pain.

Methods

The PFActS-C was translated according to international guidelines. Internal consistency, test-retest reliability, floor and ceiling effects, face validity and construct validity (convergent and discriminant validity by hypotheses testing and structural validity by confirmatory and exploratory factor-analyses) of the PFActS-C-DLV were tested in 125 people with non-specific neck pain.

Results

The PFActS-C-DLV showed good to excellent internal consistency (Cronbach’s alpha: 0.98) and stability over time (ICC: 0.90 [95%CI: 0.82–0.93). Four out of five a priori formulated hypotheses regarding related (convergent validity) and unrelated (discriminant validity) constructs were confirmed. However, the confirmatory factor analysis could not confirm the expected 1-factor solution. Furthermore, the exploratory factor analyses revealed that also a higher factor solution would not lead to a good fit of the model.

Conclusions

The PFActS-C-DLV is a reliable region-specific instrument for people with non-specific neck pain. The construct validity was supported, based on hypotheses testing. However, factor analyses could not confirm a 1-factor solution, so the underlying construct of the PFActS-C-DLV remains unclear. Given the PFActS-C’s photographic format, we believe these findings also have relevance for the original English version.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12891-020-03724-1.

Do measures of physical function enhance the prediction of persistent pain and disability following a whiplash injury? Protocol for a prospective observational study in Spain

INTRODUCTION

Not all factors that predict persistent pain and disability following whiplash injury are known. In particular, few physical factors, such as changes in movement and muscle behaviour, have been investigated. The aim of this study is to identify predictive factors that are associated with the development of persistent pain and disability following a whiplash injury by combining contemporary measures of physical function together with established psychological and pain-related predictive factors.

METHODS AND ANALYSIS

A prospective observational study will recruit 150 consecutive eligible patients experiencing whiplash-related symptoms, admitted to a private physiotherapy clinic in Spain within 15 days of their whiplash injury. Poor outcome will be measured using the Neck Disability Index (NDI), defined as an NDI score of 30% or greater at 6 months post injury. Candidate predictors, including demographic characteristics, injury characteristics, pain characteristics, self-reported psychosocial factors and physical factors, will be collected at baseline (within 15 days of inception). Regression analyses will be performed to identify factors that are associated with persistent neck pain and disability over the study period.

ETHICS AND DISSEMINATION

The project has been approved by the Ethics Committee of the province of Malaga, Spain (#30052019). The results of this study will be published in peer-reviewed journals.

Consensus of potential modifiable prognostic factors for persistent pain after a first episode of nonspecific idiopathic, non-traumatic neck pain: results of nominal group and Delphi technique approach

BACKGROUND

Identify and establish consensus regarding potential prognostic factors for the development of chronic pain after a first episode of idiopathic, non-traumatic neck pain.

DESIGN

This study used two consensus group methods: a modified Nominal Group (m-NGT) and a Delphi Technique.

METHODS

The goal of the m-NGT was to obtain and categorize a list of potential modifiable prognostic factors. These factors were presented to a multidisciplinary panel in a two-round Delphi survey, which was conducted between November 2018 and January 2020. The participants were asked whether factors identified are of prognostic value, whether these factors are modifiable, and how to measure these factors in clinical practice. Consensus was a priori defined as 70% agreement among participants.

RESULTS

Eighty-four factors were identified and grouped into seven categories during the expert meeting using the modified NGT. A workgroup reduced the list to 47 factors and grouped them into 12 categories. Of these factors, 26 were found to be potentially prognostic for chronification of neck pain (> 70% agreement). Twenty-one out of these 26 factors were found to be potentially modifiable by physiotherapists based on a two-round Delphi survey.

CONCLUSION

Based on an expert meeting (m-NGT) and a two-round Delphi survey, our study documents consensus (> 70%) on 26 prognostic factors. Twenty-one out of these 26 factors were found to be modifiable, and most factors were psychological in nature.

Defining pain and interference recovery trajectories after acute non-catastrophic musculoskeletal trauma through growth mixture modeling

BACKGROUND

Recovery trajectories support early identification of delayed recovery and can inform personalized management or phenotyping of risk profiles in patients. The objective of this study was to investigate the trajectories in pain severity and functional interference following non-catastrophic musculoskeletal (MSK) trauma in an international, mixed injury sample.

METHODS

A prospective longitudinal cohort (n = 241) was formed from patients identified within four weeks of trauma, from attendance at emergency or urgent care centres located in London, ON, Canada, or Chicago, IL, USA. Pain interference was measured via the Brief Pain Inventory (London cohort) or the Neck Disability Index (Chicago cohort). Pain severity was captured in both cohorts using the numeric pain rating scale. Growth mixture modeling and RM repeated measures ANOVA approaches identified distinct trajectories of recovery within pain interference and pain severity data.

RESULTS

For pain interference, the three trajectories were labeled accordingly: Class 1 = Rapid recovery (lowest intercept, full or near full recovery by 3 months, 32.0% of the sample); Class 2 = Delayed recovery (higher intercept, recovery by 12 months, 26.7% of the sample); Class 3 = Minimal or no recovery (higher intercept, persistently high interference scores at 12 months, 41.3% of the sample). For pain severity, the two trajectories were labeled: Class 1 = Rapid recovery (lower intercept, recovery by 3 months, 81.3% of the sample); and Class 2 = Minimal or no recovery (higher intercept, flat curve, 18.7% of the sample). The "Minimal or No Recovery" trajectory could be predicted by female sex and axial (vs. peripheral) region of trauma with 74.3% accuracy across the 3 classes for the % Interference outcome. For the Pain Severity outcome, only region (axial trauma, 81.3% accuracy) predicted the "Minimal or No Recovery" trajectory.

CONCLUSIONS

These results suggest that three meaningful recovery trajectories can be identified in an international, mixed-injury sample when pain interference is the outcome, and two recovery trajectories emerge when pain severity is the outcome. Females in the sample or people who suffered axial injuries (head, neck, or low back) were more likely to be classed in poor outcome trajectories.

TRIAL REGISTRATION

National Institutes of Health - clinicaltrials.gov ( NCT02711085 ; Retrospectively registered Mar 17, 2016).

The significance of cervical sagittal alignment for nonrecovery after whiplash injury

BACKGROUND CONTEXT

Whiplash-associated disorder is a common cause of chronic neck pain. Several radiological cervical angular variables are suggested to have constitutional characteristics, that is, them being minimally influenced by body positioning. However, the association between these variables and pain conditions remains poorly understood. To our knowledge, no previous studies have investigated the association between constitutional angular variables and the outcome after whiplash trauma.

PURPOSE

Our objectives were (1) to study the inter-rater agreement of sagittal radiologic variables between 2 raters and (2) to investigate any association between these variables and self-perceived nonrecovery after whiplash injury.

STUDY DESIGN

Prospective cohort study.

PATIENT SAMPLE

Forty-six patients aged 16 to 70 years, attending an emergency department after a motor vehicle accident resulting in neck pain were recruited.

OUTCOME MEASURES

Self-perceived nonrecovery (yes/no) was the primary outcome measure. The secondary outcome measure was pain level on a numeric rating scale.

METHODS

The participants underwent computed tomography scans in a supine position. Sagittal alignment variables (T1 slope, neck tilt, thoracic inlet angle [TIA], and C2-C7 angle) on the computed tomography scans were measured by 2 independent raters. Inter-rater agreement was tested with a paired sample t test and Bland-Altman plots for each variable. The patients were followed up after 6 months.

RESULTS

No systematic differences for the assessed variables were found between the 2 raters. The overall nonrecovery rate was 28%. For the group with low neck tilt, the nonrecovery rate was 50% (95% CI: 36%-78%) and for the group with high neck tilt, 8% (95% CI: 3%-25%). The nonrecovery rate for the group low TIA was 50% (95% CI 29%-72%) and for those with high TIA 14% (95% CI 4%-26%). The associations remained significant after adjustments for possible confounders. The inter-rater analysis shows satisfactory agreement without proportional bias.

CONCLUSIONS

This study indicates the existence of an association between the constitutional sagittal alignment of the cervical spine and the outcome after whiplash injuries.

Creation and validation of the 4-item BriefPCS-chronic through methodological triangulation

Background

The Pain Catastrophizing Scale (PCS) is a widely used self-report tool to evaluate pain related catastrophizing. The PCS was developed using classical test theory and has been shown to be psychometrically sound among various populations. However, it’s current three subscales are rarely used in clinical practice, offering potential for an abbreviated version that reduces administrative burden and can be used to estimate full scale scores, yet is not bound by the inclusion of items from each subscale. Hence, the aim of the current study was to develop a unidimensional abbreviated version of the PCS through findings from qualitative, classical test theory, and newer Rasch analysis.

Methods

The current cross-sectional study used data from the Quebec Pain Registry (n = 5646) to obtain PCS scores of people seeking care at tertiary chronic pain centres. To develop an abbreviated unidimensional tool, items were removed based on triangulation of qualitative review of each item and response, corrected item-total correlations, and Rasch analysis. Confirmatory factor analysis was conducted on the final remaining items to confirm the tool was assessing a single latent construct (catastrophizing). Fit was assessed using the cumulative fit index (CFI), Tucker Lewis Index (TLI), and root-mean-squared error of approximation (RMSEA).

Results

After triangulation, a final abbreviated 4-item scale showed adequate model fit with a strong correlation (r > 0.95) with the original scale and properties that were stable across age, sex, cause, and medicolegal status. Additionally, the brief version addressed some problematic wording on some items on the original scale. Both the original and new abbreviated tool were associated with the Beck Depression Inventory and the Brief Pain Inventory at the same magnitude.

Conclusion

The abbreviated scale may allow for a decrease in administrator burden and greater clinical uptake when a quick screen for exaggerated negative orientation towards pain is needed.

Intervention with an educational video after a whiplash trauma - a randomised controlled clinical trial

Background and aims Previous systematic reviews have considered that providing patient information is ineffective for patients with whiplash-associated disorders (WAD), with the exception of interventional educational videos. The aim of this randomised controlled clinical trial was to determine if use of an educational video as an intervention in the acute stage after a whiplash injury might improve self-reported recovery at 6 months after the injury. Methods In total, 289 consecutive patients with a whiplash injury following a motor vehicle collision were randomised to an intervention group (educational video) or to a control group (written information sheet). The video focused on information about pain mechanisms, deep flexor physiotherapy and reassurance. Emailed questionnaires were used to collect baseline data within 2 weeks after the accident and then to collect outcome data at 6 months post-injury. Non-responders were followed up with a brief telephone interview regarding the outcome. The primary outcome measure was self-reported recovery (yes/no) at 6 months post-injury. The secondary outcomes measures were pain level according to a numeric rating scale (NRS) and the whiplash disability questionnaire (WDQ) score at the same time point. Results The response rate for the baseline questionnaire was 70% (203/289). The follow-up rate was 97% (196/203). The non-recovery rates were similar between the intervention group, at 37.9% (39/103), and the control group, at 33.3% (31/93) (p = 0.55). No differences between the groups were noted in pain levels, NRS scores (1.9 vs. 2.2, p = 0.35) or the mean WDQ scores (17.5 vs. 21.2, p = 0.42). Conclusions The intervention with the educational video used in this study had no effect on the non-recovery rate when compared to a basic written information sheet. Implications The results of this trial add knowledge to the area of patient education for patients with acute WAD. Further studies are needed before the current recommendations for patient information are modified.

Measuring the impact of the French version of The Whiplash Book on both treatment approach and fear-avoidance beliefs among emergency physicians. A cluster randomized controlled trial

Background

Whiplash-associated disorders have been the subject of much attention in the scientific literature and remain a major public health problem.

Objective

Measure the impact of a validated information booklet on the fear-avoidance beliefs of emergency physicians and their approach to management regarding the treatment of whiplash-associated disorders.

Methods

A prospective cluster randomized controlled study conducted with a sample of emergency medicine physicians. Fear-avoidance beliefs were measured using The Whiplash Belief Questionnaire (WBQ) and Fear-Avoidance Beliefs Questionnaire (FABQ). We assessed the approach to management based on the prescription of pharmacological and non-pharmacological treatments based on the advice given to patients. The validated information booklet was the French version of The Whiplash Book. A set of questionnaires was sent to participants pre- and post-intervention. The experimental intervention was the provision of The Whiplash Book. The control arm did not receive any training or information.

Results

Mean fears and beliefs scores on inclusion were high: WBQ = 19.09 (± 4.06); physical activity FABQ = 11.45 (± 4.73); work FABQ = 13.85 (± 6.70). Improvement in fear-avoidance beliefs scores being greater in the intervention group was further confirmed by the variation in WBQ (-20 [-32; -6] vs. -6 [-16; 9]; p = 0.06), physical activity FABQ (-70 [-86; -50] vs. -15 [-40; 11]; p < 0.001), and work FABQ (-40 [-71; 0] vs. 0 [-31; 50]; p = 0.02). The emergency physicians' initial approach to management was not consistent with current guidelines. Reading the French version of The Whiplash Book could contribute to changing their approach to management in several areas on intra-group analysis.

Conclusion

The French version of The Whiplash Book positively influenced fear-avoidance beliefs among emergency physicians.

Small fibre pathology in chronic whiplash-associated disorder: A cross-sectional study

BACKGROUND

Mechanisms underpinning ongoing symptoms in chronic whiplash associated-disorder (WAD) are not well understood. People with chronic WAD can exhibit sensory dysfunction consistent with small nerve fibre pathology, including thermal hypoaesthesia and hyperalgesia. This study investigated small fibre structure and function in chronic WAD.

METHODS

Twenty-four people with chronic WAD (median [IQR] age 49 [15] years, 16 females) and 24 pain-free controls (50 [17] years, 16 females) were recruited. Intraepidermal nerve fibre density (IENFD) and dermal innervation were assessed by skin biopsy. This was performed at (a) the lateral index finger on the primary side of pain and (b) superior to the lateral malleolus on the contralateral side. Quantitative sensory testing was performed over the hand.

RESULTS

The WAD group exhibited lower IENFD at the finger (WAD: median [IQR] 4.5 [4.9] fibres/mm; control 7.3 [3.9]; p = .010), but not the ankle (WAD: mean [SD] 7.3 [3.7] fibres/mm; control 9.3 [3.8]; p = .09). Dermal innervation was lower in the WAD group at the finger (WAD: median [IQR] 3.7 [2.8] nerve bundles/mm² ; controls: 4.9 [2.1]; p = .017) but not the ankle (WAD: median [IQR] 2.1 [1.9] nerve bundles/mm² ; controls: 1.8 [1.8]; p = .70). In the WAD group, hand thermal and light touch detection were impaired, and heat pain thresholds were lowered (p ≤ .037).

CONCLUSIONS

Findings suggest small fibre structural and functional deficits in chronic WAD, implicating potential involvement of small fibre pathology.

SIGNIFICANCE

Our study found decreased intraepidermal nerve fibre density, reduced dermal innervation, thermal hypoaesthesia and hypersensitivity in people with chronic WAD, suggestive of small fibre pathology. This observation of peripheral nervous system pathology in chronic whiplash provides novel insights on mechanisms underpinning symptoms and challenges commonly held beliefs regarding this condition.

Association between cervical degeneration and self-perceived nonrecovery after whiplash injury

BACKGROUND CONTEXT

Pre-existing radiological degenerative changes have not previously been considered a risk factor for nonrecovery from neck pain due to motor vehicle accidents (MVA). Results from previous studies are however often based on assessment of plain radiography or MRI and little consideration has been given to facet joints. Furthermore, previous studies have often lacked a validated scoring system for degenerative changes.

PURPOSE

To investigate the association between cervical degeneration on computed tomography (CT) and nonrecovery after whiplash trauma.

STUDY DESIGN

Longitudinal cohort study.

PATIENT SAMPLE

One hundred twenty-one patients attending the Emergency Department because of neck pain after MVA, 2015-2017, with a valid CT-scan of the cervical spine and completion of follow up after 6 months.

OUTCOME MEASURES

The primary outcome measure was self-perceived nonrecovery (yes/no) after 6 months. A secondary outcome measure was self-reported pain level (Numeric Rating Scale).

METHODS

Baseline data regarding demographics and health factors were gathered through a web-based questionnaire. Degeneration of facet joints and intervertebral discs was assessed on CT-scans according to a validated scoring system. Binary logistic regression was used to study the association between cervical degeneration and nonrecovery.

RESULTS

Moderate facet joint degeneration was associated with nonrecovery. In the group with moderate degree of facet joint degeneration, 69.6% reported nonrecovery compared with 23.6% among patients without any signs of degeneration (adjusted odds ratio 6.7 [95% confidence interval: 1.9-24.3]). There was no association between disc degeneration and nonrecovery. Combined facet joint degeneration and disc degeneration were associated with nonrecovery (adjusted odds ratio 6.2 [2.0-19.0]).

CONCLUSIONS

These results suggest that cervical degeneration, especially facet joint degeneration, is a risk factor for nonrecovery after whiplash trauma. We hypothesize that whiplash trauma can be a trigger for painful manifestation of previously asymptomatic facet joint degeneration.

Are physical factors associated with poor prognosis following a whiplash trauma?: a protocol for a systematic review and data synthesis

INTRODUCTION

Mitigating the transition from acute to chronic whiplash-associated disorders (WAD) is fundamental, and this could be achieved through early identification of individuals at risk. Several physical factors such as angular velocity, smoothness of neck movement and coactivation of neck flexors and extensors, have been observed in patients with WAD, but their predictive ability after a whiplash injury have not been considered in previous reviews. Therefore, the aim of the current protocol is to outline the protocol for a systematic review that synthesises the current evidence of which physical factors can predict ongoing pain and disability following a whiplash trauma.

METHODS AND ANALYSIS

Two independent reviewers will search for studies in several electronic databases including MEDLINE, Embase, CINAHL, PsycINFO, Scopus and Web of Science as well as grey literature. Observational cohort studies will be considered if they involve participants with acute WAD followed for at least 3 months post-injury. Studies will be required to assess the prognostic ability of one or more physical factors that directly involve a body function and/or structure and can be measured objectively. Further, patient-reported outcomes of physical function will be considered. The primary outcome for this review is Neck Disability Index, while all other validated measures will be considered as secondary outcomes. Risk of bias across individual studies will be assessed using the Quality In Prognostic Studies tool along with the Grades of Recommendation, Assessment, Development and Evaluation method to assess the quality of evidence. A meta-analysis will be conducted depending on homogeneity and the number of available studies. If appropriate, data will be pooled and presented as odds ratios, otherwise, a qualitative synthesis will be conducted.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review. The result from this review will be published in peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42019122559.

Healthy lifestyle behaviour and risk of long-duration troublesome neck pain among men and women with occasional neck pain: results from the Stockholm public health cohort

OBJECTIVES

The effect of a healthy lifestyle on the prognosis of neck pain is unknown. This study aimed to investigate if a healthy lifestyle behaviour influences the risk of long-duration troublesome neck pain among men and women with occasional neck pain.

DESIGN

Longitudinal cohort study.

SETTINGS

General population, and a subsample of the working population, in Stockholm County, Sweden.

PARTICIPANTS

This study involved 5342 men and 7298 women, age 18 to 84, from the Stockholm Public Health Cohort, reporting occasional neck pain at baseline in 2006.

MEASURES

Baseline information about leisure physical activity, smoking, alcohol consumption and consumption of fruits and vegetables were dichotomised into recommendations for healthy/not healthy behaviour. The exposure, a healthy lifestyle behaviour, was categorised into four levels according to the number of healthy behaviours (HB) met. Generalised linear models were applied to assess the exposure on the outcome long-duration troublesome neck pain (activity-limiting neck pain ≥2 days/week during the past 6 months), at follow-up in 2010.

RESULTS

The adjusted risk of long-duration troublesome neck pain decreased with increasing adherence to a healthy lifestyle behaviour among both men and women (trend test: p<0.05). Compared with the reference category, none or one HB, the risk decreased by 24% (risk ratio 0.76, 95% CI 0.58 to 0.98) among men and by 34% (0.66, 0.54 to 0.81) among women, with three or four HBs. The same comparison showed an absolute reduction of the outcome by 3% in men (risk difference -0.03, 95% CI -0.05 to -0.01) and 5% in women (-0.05,-0.08 to -0.03). Similar results were found in the working population subsample.

CONCLUSION

Adhering to a healthy lifestyle behaviour decreased the risk of long-duration troublesome neck pain among men and women with occasional neck pain. The results add to previous research and supports the importance of promoting a healthy lifestyle behaviour.

Neck pain in South Africa: An overview of the prevalence, assessment and management for the contemporary clinician

BACKGROUND

Neck pain is a prevalent condition and is associated with high levels of disability and pain. The long-term prognosis can be poor, and therefore effective management in the acute stage is important.

OBJECTIVES

To provide an overview of the prevalence of neck pain and physiotherapy management and to provide evidence-informed recommendations for clinical practice within a South African context.

METHOD

The literature was reviewed considering prevalence, risk factors and examination. Management recommendations were derived from the highest levels of evidence of clinical practice guidelines, systematic reviews and randomised clinical trials.

RESULTS

Neck pain is classified into four grades, and three trajectories of recovery have been identified. Although the incidence of neck pain globally is high, in the South African context the majority of the population have limited access to physiotherapy management. Sound clinical reasoning is important in the assessment and decision-making process for management. Exercise, and mobilisation or manipulation are effective treatment options in the management of most types of neck pain. Other physical modalities such as needling, transcutaneous electrical nerve stimulation, laser and intermittent traction may be used as an adjunct to management.

CONCLUSION

The burden of neck pain globally is high; however, there is a lack of information on current practice, prevalence and burden of neck pain in the South African context. Sound evidence-informed clinical reasoning to inform a working diagnosis and to enable patient-centred management is important.

CLINICAL IMPLICATIONS

A thorough assessment is essential to gather information to formulate hypotheses regarding diagnosis and prognosis for neck pain. Exercise, and mobilisation or manipulation are effective management options.

Beyond symptom resolution: insurance case manager's perspective on predicting recovery after motor vehicle crash

PURPOSE

Insurance company case managers can play a critical role in the rehabilitation process of people with musculoskeletal disorders sustained following minor motor vehicle crash injury due to their interaction with multiple stakeholders and their role in approving various services. This study aimed to identify factors that case managers perceive as predictive of recovery in people with musculoskeletal disorders after minor motor vehicle crash injury.

MATERIALS AND METHODS

To explore the perspectives of cases managers in Australia and the United States, semi-structured interviews explored factors that case managers thought provided an early indication of likely recovery outcomes in people with musculoskeletal disorders after minor motor vehicle crash injury. A framework analysis was applied and factors were displayed within the ICF-framework.

RESULTS

Case managers (n = 40) demonstrated a broad, detailed understanding of biopsychosocial and contextual issues influencing recovery. They emphasized the importance of the injured worker's expressed affect and motivation, style of communication, the role of lawyers, the worker's family and friends, as well as cultural and geographic influences. The overarching themes perceived as having a major influence on recovery outcomes were general health, pain processing and response, work situation, and compensation entitlement.

CONCLUSIONS

Case managers' broad and detailed perceptions about recovery may provide additional, valuable perspectives for professionals involved in the rehabilitation process of people with musculoskeletal disorders after minor motor vehicle crash injury. Further research needs to be conducted to explore the effects of case manager involvement in the process of recovery.Implications for rehabilitationInsurance Case Managers identified multiple factors including affect and motivation, style of communication, the role of lawyers, family and friends, cultural and geographic variation provide opportunities for more effective treatment of people with musculoskeletal disorders related to minor motor vehicle collisions. These managers' perceptions about recovery may be informative to and provide opportunities for health professionals involved in the rehabilitation of people with musculoskeletal disorders related to minor motor vehicle collisions.While the Insurance Case Managers involved in this research did not use formalized assessment techniques, tools and assessment protocols could be developed jointly between for the needs of Insurance Case Managers and other stakeholders to tackle recovery of people with musculoskeletal disorders related to minor motor vehicle collision.

Prognostic factors for persistent pain after a first episode of nonspecific idiopathic, non-traumatic neck pain: A systematic review

BACKGROUND

Prognosis of acute idiopathic neck pain is poor. An overview of modifiable and non-modifiable prognostic factors for the development of chronic musculoskeletal neck pain after an episode of idiopathic, non-traumatic neck pain is needed.

OBJECTIVE

Identify prognostic factors for pain intensity and perceived non-recovery at three, six and 12 months after a first episode of idiopathic, non-traumatic neck pain.

STUDY DESIGN

Systematic review METHODS: Systematic literature search up to October 21, 2017 for prospective prognostic studies with main outcomes perceived non-recovery and pain intensity. The QUIPS was used for quality assessment.

RESULTS

Out of 2737 screened articles six prospective studies with high-risk-of-bias were identified, analyzing 47 and 43 factors for the outcome variables 'pain intensity' and 'perceived non-recovery', respectively. Based on univariate- and multivariate analyses we found moderate evidence for 'age> 40 years' and 'concomitant back pain' to be prognostic for 'pain intensity'. For the outcome 'perceived non-recovery' at 12 months, we found moderate evidence for both 'a previous period of neck pain' and 'accompanying headache' as prognostic variables for persistent pain, based on univariate analysis. No prognostic factor was found which was retained in more than one multivariate analysis for the outcome variable 'perceived non-recovery'. However, the quality of the evidence for these prognostic factors was low to very low.

CONCLUSION

This review identifies prognostic factors for neck pain, of which only a few are modifiable. Further research is needed before drawing definite conclusions about the prognostic value of these factors.

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

Background and aims

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

Methods

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

Results

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

Conclusions

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

Implications

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

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.

Predictive models for short-term and long-term improvement in women under physiotherapy for chronic disabling neck pain: a longitudinal cohort study

OBJECTIVES

To develop predictive models for short-term and long-term clinically important improvement in women with non-specific chronic disabling neck pain during the clinical course of physiotherapy.

DESIGN

Longitudinal cohort study based on data from a randomised controlled trial evaluating short-term and long-term effects on sensorimotor function over 11 weeks of physiotherapy.

PARTICIPANTS AND SETTINGS

Eighty-nine women aged 31-65 years with non-specific chronic disabling neck pain from Gävle, Sweden.

MEASURES

The outcome, clinically important improvement, was measured with the Patient Global Impression of Change Scale (PGICS) and the Neck Disability Index (NDI), assessed by self-administered questionnaires at 3, 9 and 15 months from the start of the interventions (baseline). Twelve baseline prognostic factors were considered in the analyses. The predictive models were built using random-effects logistic regression. The predictive ability of the models was measured by the area under the receiver operating characteristic curve (AUC). Internal validity was assessed with cross-validation using the bootstrap resampling technique.

RESULTS

Factors included in the final PGICS model were neck disability and age, and in the NDI model, neck disability, depression and catastrophising. In both models, the odds for short-term and long-term improvement increased with higher baseline neck disability, while the odds decreased with increasing age (PGICS model), and with increasing level of depression (NDI model). In the NDI model, higher baseline levels of catastrophising indicated increased odds for short-term improvement and decreased odds for long-term improvement. Both models showed acceptable predictive validity with an AUC of 0.64 (95% CI 0.55 to 0.73) and 0.67 (95% CI 0.59 to 0.75), respectively.

CONCLUSION

Age, neck disability and psychological factors seem to be important predictors of improvement, and may inform clinical decisions about physiotherapy in women with chronic neck pain. Before using the developed predictive models in clinical practice, however, they should be validated in other populations and tested in clinical settings.

Are trajectories of neck-shoulder pain associated with sick leave and work ability in workers? A 1-year prospective study

OBJECTIVES

The study aimed to determine the extent to which latent trajectories of neck-shoulder pain (NSP) are associated with self-reported sick leave and work ability based on frequent repeated measures over 1 year in an occupational population.

METHODS

This longitudinal study included 748 Danish workers (blue-collar, n=620; white collar, n=128). A questionnaire was administered to collect data on personal and occupational factors at baseline. Text messages were used for repeated measurements of NSP intensity (scale 0-10) over 1 year (14 waves in total). Simultaneously, self-reported sick leave (days/month) due to pain was assessed at 4-week intervals, while work ability (scale 0-10) was assessed using a single item (work ability index) at 12-week intervals over the year. Trajectories of NSP, distinguished by latent class growth analysis, were used as predictors of sick leave and work ability in generalised estimation equations with multiple adjustments.

RESULTS

Sick leave increased and work ability decreased across all NSP trajectory classes (low, moderate, strong fluctuating and severe persistent pain intensity). In the adjusted model, the estimated number of days on sick leave was 1.5 days/month for severe persistent NSP compared with 0.1 days/month for low NSP (relative risk=13.8, 95% CI 6.7 to 28.5). Similarly, work ability decreased markedly for severe persistent NSP (OR=12.9, 95% CI 8.5 to 19.7; median 7.1) compared with low NSP (median 9.5).

CONCLUSION

Severe persistent NSP was associated with sick leave and poor work ability over 1 year among workers. Preventive strategies aiming at reducing severe persistent NSP among working populations are needed.