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de Zoete RMJ, Nikles J, Coombes JS, Onghena P, Sterling M. The effectiveness of aerobic versus strengthening exercise therapy in individuals with chronic whiplash-associated disorder: a randomised single case experimental design study. Disabil Rehabil 2023; 45:3519-3528. [PMID: 36173391 DOI: 10.1080/09638288.2022.2127937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 09/18/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Recent RCTs and meta-analyses compare the effectiveness of different types of exercise for chronic whiplash associated disorder (WAD). This study aimed to verify whether the results of these studies translate to statistically significant and clinically meaningful effects in individual participants. MATERIALS AND METHODS A series of replicated randomised single case experimental design studies (SCEDs) with A-B design (A: baseline, B: intervention). Eight participants with chronic WAD (8 female, mean [SD] age 47 [10] years) were randomised into one of four baseline durations (5, 8, 11, and 14 days) and to one of two eight-week exercise interventions (aerobic or strengthening). Daily measures of pain intensity, bothersomeness, and interference were collected during the baseline phase and the intervention phase. RESULTS Visual analyses indicated that three participants in the aerobic exercise group meaningfully improved. No improvements were found in the strengthening group. Effect sizes favoured the aerobic exercise group, yet randomisation tests of pooled effects did not show a difference in between-intervention effectiveness. CONCLUSION Contrary to our expectations, three out of four participants were nearly pain-free at the end of the aerobic exercise intervention, whereas none of the participants in the strengthening group improved meaningfully. This suggests that aerobic exercise may be favourable for WAD.Implications for RehabilitationOur results suggest that aerobic exercises are favourable over strengthening exercises and may be the preferred option for patients with chronic WAD.We found substantial variability in self-reported outcomes within participants, clinicians should be aware of this in the judgement of treatment effectiveness.
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Affiliation(s)
- Rutger M J de Zoete
- Recover Injury Research Centre, NHMRC Centre of Research Excellence: Better Health Outcomes for Compensable Injury, The University of Queensland, Herston, Australia
- School of Allied Health Science and Practice, The University of Adelaide, Adelaide, Australia
| | - Jane Nikles
- Recover Injury Research Centre, NHMRC Centre of Research Excellence: Better Health Outcomes for Compensable Injury, The University of Queensland, Herston, Australia
| | - Jeff S Coombes
- School of Human Movement and Nutrition Sciences, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, Australia
| | - Patrick Onghena
- Research Unit on Methods, Individual and Cultural Differences, Affect and Social Behaviour, Faculty of Psychology and Educational Sciences, Leuven, Belgium
| | - Michele Sterling
- Recover Injury Research Centre, NHMRC Centre of Research Excellence: Better Health Outcomes for Compensable Injury, The University of Queensland, Herston, Australia
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de Zoete RMJ, McMahon KL, Coombes JS, Sterling M. The effects of physical exercise on structural, functional, and biochemical brain characteristics in individuals with chronic whiplash-associated disorder: A pilot randomized clinical trial. Pain Pract 2023; 23:759-775. [PMID: 37157897 DOI: 10.1111/papr.13240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 02/01/2023] [Accepted: 04/24/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Exercise for people with whiplash associated disorder (WAD) induces hypoalgesic effects in some, but hyperalgesic effects in others. We investigated the exercise-induced neurobiological effects of aerobic and strengthening exercise in individuals with chronic WAD. METHODS Sixteen participants (8 WAD, 8 pain-free [CON]) were randomised to either aerobic or strengthening exercise. MRI for brain morphometry, functional MRI for brain connectivity, and magnetic resonance spectroscopy for brain biochemistry, were used at baseline and after the 8-week intervention. RESULTS There were no differences in brain changes between exercise groups in either the WAD or CON group, therefore aerobic and strengthening data were combined to optimise sample size. After the exercise intervention, the CON group demonstrated increased cortical thickness (left parahippocampus: mean difference = 0.04, 95% CI = 0.07-0.00, p = 0.032; and left lateral orbital frontal cortex: mean difference = 0.03, 95% CI = 0.00-0.06, p = 0.048). The WAD group demonstrated an increase in prefrontal cortex (right medial orbital frontal) volume (mean difference = 95.57, 95% CI = 2.30-192.84, p = 0.046). Functional changes from baseline to follow-up between the default mode network and the insula, cingulate cortex, temporal lobe, and somatosensory and motor cortices, were found in the CON group, but not in the WAD group. There were no changes post-exercise in brain biochemistry. CONCLUSION Aerobic and strengthening exercises did not exert differential effects on brain characteristics, however differences in structural and functional changes were found between WAD and CON groups. This suggests that an altered central pain modulatory response may be responsible for differential effects of exercise in individuals with chronic WAD.
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Affiliation(s)
- Rutger M J de Zoete
- Recover Injury Research Centre, NHMRC Centre of Research Excellence in Recovery Following Road Traffic Injuries, The University of Queensland, Brisbane, Queensland, Australia
- School of Allied Health Science and Practice, The University of Adelaide, Adelaide, South Australia, Australia
| | - Katie L McMahon
- Herston Imaging Research Facility, Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
- School of Clinical Sciences, Faculty of Health, Centre for Biomedical Technologies, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Jeff S Coombes
- School of Human Movement and Nutrition Sciences, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Michele Sterling
- Recover Injury Research Centre, NHMRC Centre of Research Excellence in Recovery Following Road Traffic Injuries, The University of Queensland, Brisbane, Queensland, Australia
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Hwang BK, Park KS, Ku SH, Kim SH, Moon HW, Park MS, Baek HK, Namgoong J, Hwangbo SY, Seo JY, Lee YJ, Lee J, Ha IH. Efficacy and Safety of Korean Herbal Medicine for Patients with Post-Accident Syndrome, Persistent after Acute Phase: A Pragmatic Randomized Controlled Trial. Healthcare (Basel) 2023; 11:healthcare11040534. [PMID: 36833066 PMCID: PMC9957496 DOI: 10.3390/healthcare11040534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/15/2023] Open
Abstract
This is a pragmatic, two-armed, parallel, single-center, randomized controlled clinical trial for comparative evaluation between the effectiveness of integrated Korean medicine (IKM) and herbal medicine treatment with that of IKM monotherapy (control) for post-accident syndrome persistent after the acute phase. Participants were randomized into Herbal Medicine (HM, n = 20) and Control groups (n = 20) to receive the allocated treatment of 1-3 sessions/week for 4 weeks. Intention-to-treat analysis was conducted. The Difference of Numeric Rating Scale (NRS) change of overall post-accident syndromes from baseline to week 5 for the two groups was 1.78 (95% CI: 1.08-2.48; p < 0.001). Regarding secondary outcomes, a significant decrease compared to the baseline values was confirmed for NRS of musculoskeletal, neurological, psychiatric complaints and general symptoms of post-accident syndromes. In a survival analysis based on the recovery criteria of "patients with a reduction in the NRS of overall post-accident syndromes of ≥50%," the HM group showed a shorter time to recovery than the control group during the 17-week study period (p < 0.001 by the log-rank test). IKM combined with herbal medicine treatment significantly improved the quality of life by relieving somatic pain and alleviating the overall post-accident syndrome persistent after the acute phase; this effect was maintained for at least 17 weeks.
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Affiliation(s)
- Bo-Kyung Hwang
- Bucheon Jaseng Hospital of Korean Medicine, 17, Buil-ro, 191beon-gil, Bucheon-si 14598, Republic of Korea
| | - Kyoung Sun Park
- Jaseng Hospital of Korean Medicine, 536, Gangna-daero, Gangnam-gu, Seoul 06110, Republic of Korea
| | - Seung-Hyeok Ku
- Bucheon Jaseng Hospital of Korean Medicine, 17, Buil-ro, 191beon-gil, Bucheon-si 14598, Republic of Korea
| | - Sung-Hyun Kim
- Bucheon Jaseng Hospital of Korean Medicine, 17, Buil-ro, 191beon-gil, Bucheon-si 14598, Republic of Korea
| | - Hyun-Woo Moon
- Bucheon Jaseng Hospital of Korean Medicine, 17, Buil-ro, 191beon-gil, Bucheon-si 14598, Republic of Korea
| | - Mi-So Park
- Bucheon Jaseng Hospital of Korean Medicine, 17, Buil-ro, 191beon-gil, Bucheon-si 14598, Republic of Korea
| | - Hye-Kyung Baek
- Bucheon Jaseng Hospital of Korean Medicine, 17, Buil-ro, 191beon-gil, Bucheon-si 14598, Republic of Korea
| | - Jin Namgoong
- Bucheon Jaseng Hospital of Korean Medicine, 17, Buil-ro, 191beon-gil, Bucheon-si 14598, Republic of Korea
| | - Seung-Yoon Hwangbo
- Bucheon Jaseng Hospital of Korean Medicine, 17, Buil-ro, 191beon-gil, Bucheon-si 14598, Republic of Korea
| | - Ji-Yeon Seo
- Bucheon Jaseng Hospital of Korean Medicine, 17, Buil-ro, 191beon-gil, Bucheon-si 14598, Republic of Korea
| | - Yoon Jae Lee
- Bucheon Jaseng Hospital of Korean Medicine, 17, Buil-ro, 191beon-gil, Bucheon-si 14598, Republic of Korea
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, 2F 540 Gangnam-daero, Gangnam-gu, Seoul 06110, Republic of Korea
| | - Jinho Lee
- Jaseng Hospital of Korean Medicine, 536, Gangna-daero, Gangnam-gu, Seoul 06110, Republic of Korea
| | - In-Hyuk Ha
- Bucheon Jaseng Hospital of Korean Medicine, 17, Buil-ro, 191beon-gil, Bucheon-si 14598, Republic of Korea
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, 2F 540 Gangnam-daero, Gangnam-gu, Seoul 06110, Republic of Korea
- Correspondence: ; Tel.: +82-2-2222-2740
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Webb AL, Lynch JT, Pickering MR, Perriman DM. Shape modelling of the oropharynx distinguishes associations with body morphology but not whiplash-associated disorder. J Anat 2022; 242:535-543. [PMID: 36300770 PMCID: PMC9919469 DOI: 10.1111/joa.13783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/10/2022] [Accepted: 10/11/2022] [Indexed: 11/30/2022] Open
Abstract
Characterization of the oropharynx, a subdivision of the pharynx between the soft palate and the epiglottis, is limited to simple measurements. Structural changes in the oropharynx in whiplash-associated disorder (WAD) cohorts have been quantified using two-dimensional (2D) and three-dimensional (3D) measures but the results are inconsistent. Statistical shape modelling (SSM) may be a more useful tool for systematically comparing morphometric features between cohorts. This technique has been used to quantify the variability in boney and soft tissue structures, but has not been used to examine a hollow cavity such as the oropharynx. The primary aim of this project was to examine the utility of SSM for comparing the oropharynx between WAD cohorts and control; and WAD severity cohorts. The secondary aim was to determine whether shape is associated with sex, height, weight and neck length. Magnetic resonance (MR) T1-weighted images were obtained from healthy control (n = 20), acute WAD (n = 14) and chronic WAD (n = 14) participants aged 18-39 years. Demographic, WAD severity (neck disability index) and body morphometry data were collected from each participant. Manual segmentation of the oropharynx was undertaken by blinded researchers between the top of the soft palate and tip of the epiglottis. Digital 3D oropharynx models were constructed from the segmented images and principal component (PC) analysis was performed with the PC weights normalized to z-scores for consistency. Statistical analyses were undertaken using multivariate linear models. In the first statistical model the independent variable was group (acute WAD, chronic WAD, control); and in the second model the independent variable was WAD severity (recovered/mild, moderate/severe). The covariates for both models included height, weight, average neck length and sex. Shape models were constructed to visualize the effect of perturbing these covariates for each relevant mode. The shape model revealed five modes which explained 90% of the variance: mode 1 explained 59% of the variance and primarily described differences in isometric size of the oropharynx, including elongation; mode 2 (13%) primarily described lateral (width) and AP (depth) dimensions; mode 3 (8%) described retroglossal AP dimension; mode 4 (6%) described lateral dimensions at the retropalatal-retroglossal junction and mode 5 (4%) described the lateral dimension at the inferior retroglossal region. There was no difference in shape (mode 1 p = 0.52; mode 2 p = 0.96; mode 3 p = 0.07; mode 4 p = 0.54; mode 5 p = 0.74) between control, acute WAD and chronic WAD groups. There were no statistical differences for any mode (mode 1 p = 0.12; mode 2 p = 0.29; mode 3 p = 0.56; mode 4 p = 0.99; mode 5 p = 0.96) between recovered/mild and moderate/severe WAD. Sex was not significant in any of the models but for mode 1 there was a significant association with height (p = 0.007), mode 2 neck length (p = 0.044) and in mode 3 weight (p = 0.027). Although SSM did not detect differences between WAD cohorts, it did detect associations with body morphology indicating that it may be a useful tool for examining differences in the oropharynx.
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Affiliation(s)
- Alexandra L. Webb
- Medical School, College of Health and MedicineAustralian National UniversityCanberra, ACTAustralia
| | - Joseph T. Lynch
- Medical School, College of Health and MedicineAustralian National UniversityCanberra, ACTAustralia,Trauma and Orthopaedic Research Unit, Canberra Health ServicesCanberra, ACTAustralia
| | - Mark R. Pickering
- School of Engineering and Information TechnologyUniversity of New South WalesCanberra, ACTAustralia
| | - Diana M. Perriman
- Medical School, College of Health and MedicineAustralian National UniversityCanberra, ACTAustralia,Trauma and Orthopaedic Research Unit, Canberra Health ServicesCanberra, ACTAustralia
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Shergill Y, Côté P, Shearer H, Wong JJ, Stupar M, Tibbles A, Cassidy JD. Inter-rater reliability of the Quebec Task Force classification system for recent-onset Whiplash Associated Disorders. J Can Chiropr Assoc 2021; 65:186-192. [PMID: 34658390 PMCID: PMC8480375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
PURPOSE The inter-rater reliability of the Quebec Task Force (QTF) classification system for Whiplash-Associated Disorders (WAD) remains unknown. Our objective was to determine the inter-rater reliability of the WAD classification between an experienced chiropractic clinician and two chiropractic residents. METHODS We conducted an inter-rater reliability study using baseline clinical data from 80 participants assessed for inclusion in a randomized clinical trial of the conservative management of WAD grades I and II. We reported reliability using Cohen's kappa (k) and 95% confidence intervals (CI). RESULTS The mean duration of WAD symptoms was 7.6 days (s.d.=5.2). In our study, the interrater reliability of the WAD grade classification varied from k=0.04 (95% CI -0.04 to 0.12) to k=0.80 (95% CI 0.67 to 0.94). CONCLUSION Inter-rater reliability of the WAD classification varied greatly across raters and may be associated with the experience of the raters and with their understanding of the criteria. Our results suggest that clinicians may benefit from training to standardize how they classify WAD. Furthermore, our results need to be tested in a different sample of patients and with a range of clinicians from different clinical disciplines.
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Affiliation(s)
- Yaadwinder Shergill
- Department of Health Research Methods, Evidence, and Impact – McMaster University
- One Elephant Integrative Health Team, Oakville
| | - Pierre Côté
- Faculty of Health Sciences, Ontario Tech University and Institute for Disability and Rehabilitation Research
- Dalla Lana School of Public Health, University of Toronto
| | - Heather Shearer
- Faculty of Health Sciences, Ontario Tech University and Institute for Disability and Rehabilitation Research
- Dalla Lana School of Public Health, University of Toronto
| | - Jessica J. Wong
- Faculty of Health Sciences, Ontario Tech University and Institute for Disability and Rehabilitation Research
- Dalla Lana School of Public Health, University of Toronto
| | - Maja Stupar
- Department of Graduate Education and Research, Canadian Memorial Chiropractic College
| | | | - J. David Cassidy
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto
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Stogicza AR, Guo MYF, Rabago D. Whiplash injury successfully treated with prolotherapy: a case report with long-term follow up. Regen Med 2020; 15:2075-2084. [PMID: 33259262 DOI: 10.2217/rme-2020-0063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Chronic whiplash-associated disorder (WAD) can develop after flexion/extension injuries and may be refractory to standard-of-care therapies. Aim: To present successful treatment of severe, longstanding, treatment resistant WAD with prolotherapy. Materials & methods: Four, monthly sessions of fluoroscopically guided prolotherapy with phenol-glycerin-glucose. Electronic data on pain (visual analog score), disability (Oswestry Disability Index), pain interference, depression, anxiety, sleep and quality of life were collected with University of Washington's (WA, USA) online tool for a total of 21 months. This study conforms to the Case Report Guidelines (CARE). Results: Significant improvement was achieved and maintained through 18 months after treatment in all assessed pain and functional measures. Conclusion: Regenerative medicine, including prolotherapy may be an appropriate treatment option for carefully selected patients with WAD.
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Affiliation(s)
- Agnes R Stogicza
- Department of Anesthesia and Pain Medicine, MOM, Saint Magdolna Private Hospital, Budapest, Hungary
| | - Michael Yu Feng Guo
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - David Rabago
- Department of Family and Community Medicine, Pennsylvania State University College of Medicine, Hershey PA, 17033, USA
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Juuso P, Skär L, Söderberg S. Recovery despite everyday pain: Women's experiences of living with whiplash-associated disorder. Musculoskeletal Care 2020; 18:20-28. [PMID: 31917514 DOI: 10.1002/msc.1434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/18/2019] [Accepted: 09/19/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Living with whiplash-associated disorders (WAD) means living every day under the influence of pain and limitations. As the incidence of WAD and the related intensity of pain are somewhat higher among women than men, the aim of the present study was to describe women's experiences of living with WAD. METHODS A purposive sample of seven women participated in individual in-depth qualitative interviews, the transcripts of which were subjected to qualitative content analysis. RESULTS The results of the analysis suggested six themes of women's experiences with WAD: living with unpredictable pain; trying to manage the pain; living with limitations; being unable to work as before; needing support and understanding; and learning to live with limitations. The findings showed that unpredictable pain limited women's strength to engage in activities of daily life and be as active as before. Support and understanding were important for their ability to manage changes in their daily lives. CONCLUSIONS Pain considerably affects the daily lives of women with WAD, particularly by limiting their ability to perform activities and to enjoy their professional and social lives. As women with WAD need support with managing their daily lives, nurses and other healthcare personnel should adopt a person-centred approach, in order to support such women according to their individual needs and circumstances.
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Affiliation(s)
- Päivi Juuso
- Division of Nursing, Department of Health Science, Luleå University of Technology, Luleå, Sweden
| | - Lisa Skär
- Department of Health, Blekinge Institute of Technology, Karlskrona, Sweden
| | - Siv Söderberg
- Department of Nursing Sciences, Mid Sweden University, Östersund, Sweden
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De Pauw R, Coppieters I, Caeyenberghs K, Kregel J, Aerts H, Lenoir D, Cagnie B. Associations between brain morphology and motor performance in chronic neck pain: A whole-brain surface-based morphometry approach. Hum Brain Mapp 2019; 40:4266-4278. [PMID: 31222905 DOI: 10.1002/hbm.24700] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 02/27/2019] [Accepted: 05/29/2019] [Indexed: 12/15/2022] Open
Abstract
Changes in brain morphology are hypothesized to be an underlying process that drive the widespread pain and motor impairment in patients with chronic neck pain. However, no earlier research assessed whole-brain cortical morphology in these patients. This case-control study assesses group-differences in whole-brain morphology between female healthy controls (HC; n = 34), and female patients with chronic idiopathic neck pain (CINP; n = 37) and whiplash-associated disorders (CWAD; n = 39). Additionally, the associations between whole-brain morphology and motor performance including balance, strength, and neuromuscular control were assessed. Cortical volume, thickness, and surface area were derived from high resolution T1-weighted images. T2*-weighted images were obtained to exclude traumatic brain injury. Vertex-wise general-linear-model-analysis revealed cortical thickening in the left precuneus and increased volume in the left superior parietal gyrus of patients with CINP compared to HC, and cortical thickening of the left superior parietal gyrus compared to HC and CWAD. Patients with CWAD showed a smaller cortical volume in the right precentral and superior temporal gyrus compared to HC. ANCOVA-analysis revealed worse neuromuscular control in CWAD compared to HC and CINP, and in CINP compared to HC. Patients with CWAD showed decreased levels of strength and sway area compared to CINP and HC. Partial correlation analysis revealed significant associations between the volume of the precentral gyrus, and neuromuscular control and strength together with an association between the volume of the superior temporal gyrus and strength. Our results emphasize the role of altered gray matter alterations in women with chronic neck pain, and its association with pain and motor impairment.
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Affiliation(s)
- Robby De Pauw
- Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Iris Coppieters
- Physiotherapy- Human Physiology- and Anatomy KIMA, Vrije Universiteit Brussel, Brussels, Belgium.,Pain in Motion International Research Group
| | - Karen Caeyenberghs
- School of Psychology, Faculty of Health Sciences, Australian Catholic University, Brisbane, Queensland, Australia
| | - Jeroen Kregel
- Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.,Physiotherapy- Human Physiology- and Anatomy KIMA, Vrije Universiteit Brussel, Brussels, Belgium.,Pain in Motion International Research Group
| | - Hannelore Aerts
- Department of Data Analysis, Faculty of Psychology and Educational Sciences, Ghent University, Ghent, Belgium
| | - Dorine Lenoir
- Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.,Physiotherapy- Human Physiology- and Anatomy KIMA, Vrije Universiteit Brussel, Brussels, Belgium.,Pain in Motion International Research Group
| | - Barbara Cagnie
- Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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Nikles J, Khan S, Leou J, Keijzers G, Ng J, Bond C, Nakamura G, Le R, Sterling M. Retrospective descriptive observational study of patients who presented to an Australian hospital emergency department with neck soft tissue injury. Emerg Med Australas 2019; 31:805-812. [PMID: 30895739 DOI: 10.1111/1742-6723.13253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 01/26/2019] [Accepted: 01/29/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe clinical presentation and management of neck soft tissue injury in an Australian ED. METHODS This is a retrospective cohort study conducted in a tertiary hospital ED in Queensland, Australia. This study included all patients aged 18-65 years presenting with neck sprain/strain in 2016. Main outcome measures are patient demographics, comorbidities, presentation, acute management and follow up. RESULTS Of 339 patients, 176 (52%) had cervical computed tomography (CT) scans and 3% plain radiographs. Two had fractures (CT yield of 2/176; 1.1%) and three were admitted with neurological symptoms, leaving 334 patients. Of 264 patients receiving medications in the ED, simple analgesia + oral opioid (146, 55.3%) was most frequently used, followed by simple analgesia (89, 33.7%) and opioid + benzodiazepine +/- simple analgesia (16, 6%). Opioids were prescribed for 169 (64%) (including i.v. opioids for 34 [12.9%] and for 85/97 (88%) with pain scores ≤4), and benzodiazepines for 22 (8.3%). Ten (3%) were referred for physiotherapy management in ED and eight (2.4%) for outpatient physiotherapy follow up. Of 113/334 (33.8%) receiving discharge prescription, 60 (53.1%) were prescribed oral opioid + simple analgesia, 37 (32.7%) oral opioids and seven (6.2%) opioids + benzodiazepines; 205 (61%) were discharged without a recorded follow-up plan. CONCLUSIONS There is large practice variation in management of neck soft tissue injury in ED. Over half of the patients received CT scans with modest yield. Opioids were commonly used both in ED and on discharge. There is need for a standard management plan to be developed for patients presenting with acute neck soft tissue injury.
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Affiliation(s)
- Jane Nikles
- RECOVER Injury Research Centre, The University of Queensland, Brisbane, Queensland, Australia.,NHMRC Centre of Research Excellence in Recovery Following Road Traffic Injuries, The University of Queensland, Brisbane, Queensland, Australia
| | - Subaat Khan
- NHMRC Centre of Research Excellence in Recovery Following Road Traffic Injuries, The University of Queensland, Brisbane, Queensland, Australia
| | - John Leou
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,School of Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Joanna Ng
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Catherine Bond
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Gota Nakamura
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Rhonda Le
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Michele Sterling
- RECOVER Injury Research Centre, The University of Queensland, Brisbane, Queensland, Australia.,NHMRC Centre of Research Excellence in Recovery Following Road Traffic Injuries, The University of Queensland, Brisbane, Queensland, Australia
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10
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Nikles J, Keijzers G, De Silva MID, Khan S, Sterling M. Use of and attitudes to the role of medication for acute whiplash injury: A preliminary survey of emergency department doctors. Emerg Med Australas 2018; 31:471-474. [PMID: 30317691 DOI: 10.1111/1742-6723.13190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 08/20/2018] [Accepted: 09/19/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Describe current practice of medication prescribing for acute whiplash-associated disorders (WAD) in the ED and explore attitudes towards pregabalin prescription for WAD. METHODS Questionnaire-based survey in two EDs collected data on demographics and self-reported medication prescribing for WAD. Comfort in various scenarios for pregabalin prescribing was rated. RESULTS A total of 145/170 (85%) doctors responded; 42.8% were junior doctors. Self-reported medications prescribed were nonsteroidal anti-inflammatory drug (77.9% [95% confidence interval (CI) 70.1-84.2]), paracetamol (75.2% [95% CI 67.2-81.8]), opioids (43.5% [95% CI 35.3-51.9]) and benzodiazepines (11.0% [95% CI 6.6-17.6]). Most were comfortable to prescribe pregabalin in evidence-based or advised-by-specialists scenarios. CONCLUSIONS Opioids appear to be over-prescribed. Further research into pregabalin prescription in ED is warranted.
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Affiliation(s)
- Jane Nikles
- RECOVER Injury Research Centre, The University of Queensland, Brisbane, Queensland, Australia.,NHMRC Centre of Research Excellence in Road Traffic Injury Recovery, The University of Queensland, Brisbane, Queensland, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,School of Medicine, Bond University, Gold Coast, Queensland, Australia
| | | | - Subaat Khan
- Menzies Health Institute, Griffith University, Gold Coast, Queensland, Australia
| | - Michele Sterling
- RECOVER Injury Research Centre, The University of Queensland, Brisbane, Queensland, Australia.,NHMRC Centre of Research Excellence in Road Traffic Injury Recovery, The University of Queensland, Brisbane, Queensland, Australia
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Abstract
BACKGROUND This review aims to evaluate the effectiveness and safety of acupuncture treatment for patients with whiplash-associated disorder (WAD). METHODS We will search the following databases from their inception to October 2018: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health Literature, the Allied and Complementary Medicine Database, 1 Chinese database (China National Knowledge Infrastructure), 1 Japanese database (Japan Science and Technology Information Aggregator, Electronic), and 5 Korean databases (KoreaMed, Research Information Service System, Korean Studies Information Service System, Database Periodical Information Academic, and Oriental Medicine Advanced Searching Integrated System). All randomized controlled trials of acupuncture for WAD will be considered for inclusion without language restrictions. The risk of bias will be assessed using the Cochrane risk of bias tool. The mean difference or standard mean difference for continuous data and risk ratio for dichotomous data will be calculated with 95% confidence intervals. DISSEMINATION The results of this review will be disseminated through peer-reviewed journal articles or conference presentations, and may provide important guidance for clinicians and patients regarding the use of acupuncture treatment for treating WAD. TRIAL REGISTRATION NUMBER PROSPERO 2018: CRD42018106964.
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Affiliation(s)
| | - Dae-Hyun Jo
- Department of Acupuncture & Moxibustion Medicine, Graduate School, Kyung Hee University, Seoul
| | - Kun Hyung Kim
- Department of Acupuncture & Moxibustion, School of Korean Medicine, Pusan National University, Yangsan, South Korea
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Greening J, Anantharaman K, Young R, Dilley A. Evidence for Increased Magnetic Resonance Imaging Signal Intensity and Morphological Changes in the Brachial Plexus and Median Nerves of Patients With Chronic Arm and Neck Pain Following Whiplash Injury. J Orthop Sports Phys Ther 2018; 48:523-32. [PMID: 29690828 DOI: 10.2519/jospt.2018.7875] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background Whiplash following a motor vehicle accident can result in chronic neck and arm pain. Patients frequently present with cutaneous hypersensitivities and hypoesthesia, but without obvious clinical signs of nerve injury. T2-weighted magnetic resonance imaging (MRI) has previously been used to identify nerve pathology. Objectives To determine whether there are signs of peripheral nerve pathology on MRI in patients with chronic arm and neck pain following whiplash injury. Methods This cross-sectional study used T2-weighted MRI to examine the brachial plexus and median nerve in patients and age-matched, healthy control subjects. Clinical examination included tests of plexus and nerve trunk mechanical sensitivity. Results The T2 signal intensity was greater in the brachial plexus and median nerve at the wrist in the patient group (mean intensity ratio = 0.52 ± 0.13 and 2.09 ± 0.33, respectively) compared to the control group (mean intensity ratio = 0.45 ± 0.07 and 1.38 ± 0.31, respectively; P<.05). Changes in median nerve morphology were also observed, which included an enlargement (mean area: patient group, 8.05 ± 1.29 mm2; control group, 6.52 ± 1.08 mm2; P<.05) and flattening (mean aspect ratio: patient group, 2.46 ± 0.53; control group, 1.62 ± 0.30; P<.05) at the proximal carpal row. All patients demonstrated signs of nerve trunk mechanical sensitivity. Conclusion These findings suggest that patients with chronic whiplash may have inflammatory changes and/or mild neuropathy, which may contribute to symptoms. J Orthop Sports Phys Ther 2018;48(7):523-532. Epub 24 Apr 2018. doi:10.2519/jospt.2018.7875.
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Abstract
More than 30,000 people die in motor vehicle collisions each year in the United States. Distracted, drowsy, and drunk driving cause most motor vehicle collision injuries and deaths. An editorial published in the October 2016 issue of JOSPT identified the global need for effective strategies to reduce, if not eliminate, preventable injuries, including whiplash-associated disorders and deaths from distracted driving. This is a call to action for everyone who gets behind the wheel of a car. J Orthop Sports Phys Ther 2017;47(7):449. doi:10.2519/jospt.2017.0506.
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Abstract
A previous special issue of JOSPT (October 2016) discussed whiplash in terms of the clinical problems and current research surrounding prevention, biomechanics of injury, emergent care, imaging advancements, recovery pathways and prognosis, pathogenesis of posttrauma pain, acute and chronic management, and new predictive clinical tools. While great strides have been made in the field of whiplash and are continuing in earnest, a key group of clinicians and academics have recognized that inconsistent outcomes in published literature hamper our ability to meaningfully synthesize research findings, leading to results of systematic reviews that provide very few concrete clinical recommendations. We are optimistic that improved outcomes for people with whiplash-associated disorder (WAD) are attainable in the near future, as interdisciplinary research efforts continue to align internationally, new mechanisms are identified and explored, and advanced statistical techniques allow complex questions to be answered in clinically meaningful ways. J Orthop Sports Phys Ther 2017;47(7):444-446. doi:10.2519/jospt.2017.0106.
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Abstract
This special issue of JOSPT is the second of a 2-part series on whiplash-associated disorders (WADs). Part 1 was published in the October 2016 issue of the Journal. The articles in these 2 special issues highlight that, while we know a great deal about WAD, there are profound gaps in our understanding of how to more effectively work with patients to limit the consequences of this disorder. The information provided in the special-issue articles can help move physical therapy practice and research toward pragmatic and effective solutions for the perplexing condition of WAD. J Orthop Sports Phys Ther 2017;47(7):447-448. doi:10.2519/jospt.2017.0107.
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Courtney DM. Assessment and Management of Whiplash From the Emergency and Acute Care Setting: Care, Questions, and Future Global Research Needs. J Orthop Sports Phys Ther 2016; 46:822-5. [PMID: 27690841 DOI: 10.2519/jospt.2016.0114] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The primary goal of this editorial is to discuss the care patients typically receive in the immediate post-motor vehicle collision setting and the questions patients typically ask with respect to their symptoms and prognosis. Commentary and guidance are provided from the perspective of an acute care physician on what we should be able to tell patients and providers going forward. J Orthop Sports Phys Ther 2016;46(10):822-825. doi:10.2519/jospt.2016.0114.
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Abstract
In the past decade, distracted driving has emerged as one of the most prominent global road safety concerns. The singular and combined efforts of many organizations, such as Drop It And Drive (DIAD) and the Traffic Injury Research Foundation (TIRF), have identified the need for partnerships, shared information, and access to interpretable research findings to guide decision making and to identify effective strategies to reduce, if not eliminate, preventable injuries/fatalities from distracted driving, including whiplash-associated disorders. This editorial describes activities in 5 target areas identified in our environmental scan in Canada: (1) provincial/territorial government strategies, (2) enforcement, (3) data collection and measurement, (4) awareness campaigns, and (5) legislation. We will also reinforce the potential benefits of seeking and establishing meaningful interdisciplinary partnerships to reduce distracted driving across the globe. Finally, this editorial provides an example of how these interdisciplinary partnerships can help reduce preventable, life-altering injuries/deaths caused by distracted driving. J Orthop Sports Phys Ther 2016;46(10):818-821. doi:10.2519/jospt.2016.0113.
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Abstract
There have been many advances in the management of neck pain disorders, but a personal frustration as a clinician and researcher in the field is that the incidence of full recovery following a whiplash injury as a result of a motor vehicle crash has not increased and, subsequently, the rate of transition to chronic neck pain has not lessened. The commentaries in this special issue reflect the multifaceted nature of whiplash-associated disorders and the wide-ranging research in the field. While management of whiplash, especially the challenge of lessening the rate of transition to chronicity, has yet to be achieved, the picture is becoming clearer. This should give great confidence and some hope to individuals with whiplash-associated disorders who have long-term pain and functional disability that after the next decade of research and clinical development, the outcomes following whiplash are likely to be vastly improved. J Orthop Sports Phys Ther 2016;46(10):815-817. doi:10.2519/jospt.2016.0112.
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De Kooning M, Daenen L, Roussel N, Cras P, Buyl R, Ickmans K, Struyf F, Nijs J. Endogenous pain inhibition is unrelated to autonomic responses in acute whiplash-associated disorders. ACTA ACUST UNITED AC 2016; 52:431-40. [PMID: 26348457 DOI: 10.1682/jrrd.2014.06.0154] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 02/24/2014] [Indexed: 11/05/2022]
Abstract
Patients with acute whiplash-associated disorder (WAD) demonstrate an inefficient endogenous pain inhibition and may experience a dysfunction in autonomic nervous system reactivity to pain. This study compared the autonomic response to painful stimuli between patients with acute and chronic WAD and healthy controls. In addition, the role of the autonomic nervous system for explaining inefficient endogenous pain inhibition was examined in acute WAD. Seventeen patients with acute WAD, 30 patients with chronic WAD, and 31 healthy controls participated in an experiment evaluating the autonomic nervous system at rest and during painful stimuli. Skin conductance and heart rate variability (HRV) parameters were monitored continuously during conditioned pain modulation. A significant autonomic response to pain was present for skin conductance and two HRV parameters in all experimental groups. There was an interaction effect in the skin conductance response to pain but not in HRV responses in any of the groups. In patients with acute WAD, no significant correlations were present between pain, pressure pain thresholds, pain inhibition, and any of the autonomic parameters. This study refutes autonomic dysfunction at rest and in response to pain in acute WAD. The dysfunctional conditioned pain modulation appears unrelated to autonomic responses to pain.
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Affiliation(s)
- Margot De Kooning
- Pain in Motion Research Group, Departments of Human Physiology and Physiotherapy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
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Pettersson S, Bring A, Åsenlöf P. Stressful events and coping related to acute and sub-acute whiplash-associated disorders. Disabil Rehabil 2016; 39:578-585. [PMID: 26985631 DOI: 10.3109/09638288.2016.1152607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Purpose To describe daily stressors affecting and coping strategies employed by individuals with whiplash-associated disorders (WAD) immediately to one month (acute) and three to four months (sub-acute) after injury events using a daily coping assessment. Levels of pain, anxiety, depressed mood and activity are also compared between phases. Method A descriptive prospective design with a content analysis approach was used. Participants completed daily coping assessments for one week during both acute and sub-acute phases. Main measure was whiplash-associated disorders-daily coping assessment (WAD-DCA). Results Nine participants used words describing recovery in the sub-acute phase; 31 described stressful events during both phases. Most frequently reported stressors were related to "symptoms", "emotions" and "occupations/studies". These were equally reported during both phases. Cognitive coping strategies were employed more often during the sub-acute phase (p = 0.008). The only behavioral strategy that increased in prevalence over time was the "relaxed" strategy (p = 0.001). Anxiety levels declined over time (p = 0.022). Conclusion The reported stressors were largely uniform across both acute and sub-acute phases; however, the use of cognitive coping strategies increased over time. The WAD-DCA captures individual stressors and coping strategies employed during a vulnerable phase of rehabilitation and can thus provide information that is useful to clinical practice. Implications for rehabilitation The WAD-DCA provides valuable information for clinical practice when employed during early phases of whiplash-associated disorder development. Reported stressors during the acute and sub-acute phases are essentially the same, whereas cognitive coping strategies grow in prevalence over time. Tailored treatments in early phases of whip-lash associated disorders may benefit from strategies aimed at matching patient-specific stressors with contextually adapted coping strategies.
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Affiliation(s)
- Susanne Pettersson
- a Department of Neuroscience, Section of Physiotherapy , Uppsala University , Uppsala , Sweden
| | - Annika Bring
- a Department of Neuroscience, Section of Physiotherapy , Uppsala University , Uppsala , Sweden
| | - Pernilla Åsenlöf
- a Department of Neuroscience, Section of Physiotherapy , Uppsala University , Uppsala , Sweden
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Whiplash: are you at risk for ongoing pain or disability? J Orthop Sports Phys Ther 2015; 45:251. [PMID: 25827123 DOI: 10.2519/jospt.2015.0501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Have you recently sustained an injury and been diagnosed with whiplash or a whiplash-associated disorder? If so, you may be wondering what your recovery will be like. If health care providers could identify, soon after the initial injury, which patients would probably improve naturally over time and which ones would not, they could better manage the patient's treatment in the early stages of recovery. A study published in the April 2015 issue of JOSPT provides new insights into this challenge, which may help improve decision making for providers and outcomes for patients.
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Ritchie C, Hendrikz J, Jull G, Elliott J, Sterling M. External validation of a clinical prediction rule to predict full recovery and ongoing moderate/severe disability following acute whiplash injury. J Orthop Sports Phys Ther 2015; 45:242-50. [PMID: 25827122 DOI: 10.2519/jospt.2015.5642] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Retrospective secondary analysis of data. OBJECTIVES To investigate the external validity of the whiplash clinical prediction rule (CPR). BACKGROUND We recently derived a whiplash CPR to consolidate previously established prognostic factors for poor recovery from a whiplash injury and predicted 2 recovery pathways. Prognostic factors for full recovery were being less than 35 years of age and having an initial Neck Disability Index (NDI) score of 32% or less. Prognostic factors for ongoing moderate/severe pain and disability were being 35 years of age or older, having an initial NDI score of 40% or more, and the presence of hyperarousal symptoms. Validation is required to confirm the reproducibility and accuracy of this CPR. Clinician feedback on the usefulness of the CPR is also important to gauge acceptability. METHODS A secondary analysis of data from 101 individuals with acute whiplash-associated disorder who had previously participated in either a randomized controlled clinical trial or prospective cohort study was performed using accuracy statistics. Full recovery was defined as NDI score at 6 months of 10% or less, and ongoing moderate/severe pain and disability were defined as an NDI score at 6 months of 30% or greater. In addition, a small sample of physical therapists completed an anonymous survey on the clinical acceptability and usability of the tool. Results The positive predictive value of ongoing moderate/severe pain and disability was 90.9% in the validation cohort, and the positive predictive value of full recovery was 80.0%. Surveyed physical therapists reported that the whiplash CPR was simple, understandable, would be easy to use, and was an acceptable prognostic tool. CONCLUSION External validation of the whiplash CPR confirmed the reproducibility and accuracy of this dual-pathway tool for individuals with acute whiplash-associated disorder. Further research is needed to assess prospective validation, the impact of inclusion on practice, and to examine the efficacy of linking treatment strategies with predicted prognosis. LEVEL OF EVIDENCE Prognosis, level 1b.
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Takasaki H, Johnston V, Treleaven J, Jull G. Neck pain driving index: appropriateness of the rating scale and unidimensionality of the strategic, tactical, and operational levels. Arch Phys Med Rehabil 2013; 94:1842-6. [PMID: 23466291 DOI: 10.1016/j.apmr.2013.02.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 01/01/2013] [Accepted: 02/20/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To establish an appropriate scoring system using Rasch scores for the strategic, tactical, and operational levels of the Neck Pain Driving Index (NPDI) and to refine the NPDI by testing the unidimensionality of each driving performance level using Rasch analysis. DESIGN Cross-sectional. SETTING Tertiary institution. PARTICIPANTS Individuals with chronic whiplash-associated disorders (WAD) (N=123). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE The NPDI, which was developed to evaluate self-reported driving difficulty in people with chronic WAD. RESULTS On the basis of Rasch analyses, modifications were made to the response format, changing it from a 0 to 4 scale (0=no difficulty, 1=slight difficulty, 2=moderate difficulty, 3=great difficulty, 4=unable to drive because of the injury) to a 0 to 3 scale (0=no difficulty, 1=slight difficulty, 2=moderate difficulty, 3=great difficulty and unable to drive because of the injury). Unidimensionality of the strategic and operational levels was confirmed. Modification of the tactical level was necessary to ensure its unidimensionality. After removing the tasks "driving near (your) collision site," "driving in a bad weather condition," and "driving at night," unidimensionality of the 4-item tactical level was confirmed. A 9-item NPDI was established. A table converting raw total scores into Rasch scores was created for each level. CONCLUSIONS This study established the 9-item NPDI, and its 3 subsections (strategic, tactical, and operational levels) are unidimensional. The magnitude of self-reported driving difficulty at each of the 3 subsections can be assessed with the use of a 0 to 3 scale and Rasch scores.
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Affiliation(s)
- Hiroshi Takasaki
- NHMRC Centre of Clinical Research Excellence - Spinal Pain, Injury and Health, Division of Physiotherapy, School of Health and Rehabilitation Science, The University of Queensland, Brisbane, QLD, Australia.
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