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The Risk Assessment Score in Acute Whiplash Injury Predicts Outcome and Reflects Biopsychosocial Factors
Abstract
One-year prospective study of 141 acute whiplash patients (WLP) and 40 acute ankle-injured controls.
This study investigates a priori determined potential risk factors to develop a risk assessment tool, for which the expediency was examined.
The whiplash-associated disorders (WAD) grading system that emerged from The Quebec Task-Force-on-Whiplash has been of limited value for predicting work-related recovery and for explaining biopsychosocial disability after whiplash and new predictive factors, for example, risk criteria that comprehensively differentiate acute WLP in a biopsychosocial manner are needed.
Consecutively, 141 acute WLP and 40 ankle-injured recruited from emergency units were examined after 1 week, 1, 3, 6, and 12 months obtaining neck/head visual analog scale score, number of nonpainful complaints, epidemiological, social, psychological data and neurological examination, active neck mobility, and furthermore muscle tenderness and pain response, and strength and duration of neck muscles. Risk factors derived (reduced cervical range of motion, intense neck pain/headache, multiple nonpain complaints) were applied in a risk assessment score and divided into seven risk strata.
A receiver operating characteristics curve for the Risk Assessment Score and 1-year work disability showed an area of 0.90. Risk strata and number of sick days showed a log-linear relationship. In stratum 1 full recovery was encountered, but for high-risk patients in stratum 6 only 50% and 7 only 20% had returned to work after 1 year (P < 5.4 × 10). Strength measures, psychophysical pain measurements, and psychological and social data (reported elsewhere) showed significant relation to risk strata.
The Risk Assessment score is suggested as a valuable tool for grading WLP early after injury. It has reasonable screening power for encountering work disability and reflects the biopsychosocial nature of whiplash injuries.
... We have previously developed and validated 8,9 a risk assessment score: The Danish Whiplash Group Risk Assessment Score (DWGRAS) and the 7 derived Risk Strata have shown a capability of predicting a 1-year pain disability and work disability. DWGRAS was reported to reflect biological factors, including a 1-year development in neck strength and endurance 10 using a control group sustaining an acute ankle injury, and to reflect changes in pain response. ...
... [19][20][21][22][23] The DWGRAS classification was derived from these 2 studies. 8,9 Study 1 was an observational prospective study of consecutively included (n = 187) acute whiplash patients during 1997-1999 with an age-matched and sex-matched control group of 40 patients exposed to an ankle sprain. The patients were all recruited from the hospital units in Aarhus County covering a population of ∼400,000 inhabitants. ...
... [19][20][21]24 The obtained 11-point numeric rating scale (NRS) pain scores, the number-ofnonpainful symptoms, and the total cervical range of motion 25,26 were merged into an algorithm, which was used to calculate the individual risk scores. From an early point after injury all whiplash-exposed patients were divided into 7 risk strata 8,9 ( Table 1). ...
Objective:
To evaluate the long-term predictive value of The Danish Whiplash Group Risk Assessment Score (DWGRAS) with 7 risk-strata.
Design:
E-questionnaire based follow-up study (n=927) combining two cohorts of whiplash injured subjects, one observational (n=187) one interventional RCT (n=740).
Methods:
927 previously healthy persons exposed to acute whiplash injury during motor vehicle collision were sent letter by postal service asking the addressee if they would respond to an e-questionnaire. Outcome measures were: whiplash-related disability, pain, use of medication/non-medical treatment, work-capacity.
Results:
The response rate was 37%. Fifty-five percent reported whiplash-related disability. Fourteen percent reported daily complaints. A strong relationship was found between risk-strata and Impact of Event and between risk strata and disabling symptoms.
Conclusion:
Internal and long-term validation of DWGRAS has now been performed, but a low response rate of 37% indicates that results should be interpreted with caution. Furthermore, external validation needs to be done in long-term studies. A ROC curve of 0.73 (CI95 0.67; 0.79) predicting daily or weekly whiplash related disability after 12-14 years was found using the DWGRAS Risk Score.
... Several studies have found an association between early pessimistic illness beliefs and expectations and poor recovery rates [28][29][30][31][32][33][34]. These findings indicate that targeting beliefs concerning the nature and course of the injury might be important. ...
... Further complicating the matter, studies suggest that patients affected by whiplash trauma are a heterogeneous group involving subgroups with significant differences in clinical outcome [5,33]. Creating an intervention that is helpful for the entire range of patients while adequately targeting risk factors that may only be relevant for subgroups is challenging. ...
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.
... Other authors describe that psychosocial stress is one of the best documented risk factors for adverse events in low back pain with or without sciatic disorders [28][29][30]. Screening tools for identifying patients at risk of long-term sickleave have, e.g., been used in Denmark for both neck distortion [31] and lumbar spine pain [32]. This type of instrument enables identification of subgroups with different predictions, which can facilitate differentiated and individualized care. ...
... Using valid clinical prediction models improves prognosis prediction compared to clinical judgement alone [3]. Several models aimed at predicting recovery from NAD secondary to traffic collisions have been developed [4][5][6][7][8][9][10][11][12][13][14][15]. However, few of these models have been internally [8] or externally validated [5-7, 15, 16] and only one study developed a clinical prediction rule [14]. ...
Objective
Few clinical prediction models are available to clinicians to predict the recovery of patients with post-collision neck pain and associated disorders. We aimed to develop evidence-based clinical prediction models to predict (1) self-reported recovery and (2) insurance claim closure from neck pain and associated disorders (NAD) caused or aggravated by a traffic collision.
Methods
The selection of potential predictors was informed by a systematic review of the literature. We used Cox regression to build models in an incident cohort of Saskatchewan adults (n = 4923). The models were internally validated using bootstrapping and replicated in participants from a randomized controlled trial conducted in Ontario (n = 340). We used C-statistics to describe predictive ability.
Results
Participants from both cohorts (Saskatchewan and Ontario) were similar at baseline. Our prediction model for self-reported recovery included prior traffic-related neck injury claim, expectation of recovery, age, percentage of body in pain, disability, neck pain intensity and headache intensity (C = 0.643; 95% CI 0.634–0.653). The prediction model for claim closure included prior traffic-related neck injury claim, expectation of recovery, age, percentage of body in pain, disability, neck pain intensity, headache intensity and depressive symptoms (C = 0.637; 95% CI 0.629–0.648).
Conclusions
We developed prediction models for the recovery and claim closure of NAD caused or aggravated by a traffic collision. Future research needs to focus on improving the predictive ability of the models.
... Only one study [32] contributed data to meta-analyses (see Figures 2 and 3). Results from this study by Nguyen and colleagues [32] for the rate of RTW at 12 months was consistent with several other studies in the meta-analysis [59,65,66]. The use of sick leave at 12 months was highest in this study across the five studies in this meta-analysis, however likely balanced out in the meta-analysis by a corresponding low usage rate from another study [52]. ...
Musculoskeletal injuries occur frequently after road traffic crashes (RTCs), and the effect on work participation is not fully understood. The primary aim of this review was to determine the impact of sustaining a musculoskeletal injury during an RTC on the rate of return to work (RTW), sick leave, and other work outcomes. The secondary aim was to determine factors associated with these work-related outcomes. An electronic search of relevant databases to identify observational studies related to work and employment, RTC, and musculoskeletal injuries was conducted. Where possible, outcome data were pooled by follow-up period to answer the primary aim. Fifty-three studies were included in this review, of which 28 were included in meta-analyses. The pooled rate of RTW was 70% at 1 month, 67% at 3 months, 76% at 6 months, 83% at 12 months, and 70% at 24 months. Twenty-seven percent of participants took some sick leave by one month follow-up, 13% by 3 months, 23% by 6 months, 36% by 12 months, and 22% by 24 months. Most of the factors identified as associated with work outcomes were health-related, with some evidence also for sociodemographic factors. While 70% of people with RTC-related musculoskeletal injury RTW shortly after accident, many still have not RTW two years later.
... Goals (5,(40)(41)(42) To be met in 4 weeks: ...
La radiculopatía cervical es una disfunción de una raíz nerviosa de la columna cervical. La séptima raíz (C7) se compromete en un 60% de los casos y la sexta (C6) en un 25%. A menudo, las raíces nerviosas cervicales son las más afectadas en nuestro medio. Aproximadamente el 10% de la población adulta ha tenido dolor en el cuello en algún momento de su vida. Esta prevalencia es similar al dolor lumbar, pero muy pocos pacientes con dolor cervical se incapacitan y menos del 1% desarrolla déficit neurológico. Los trastornos clínicos que afectan la columna cervical pueden ser categorizados como la causa principal del dolor en el cuello. Estos trastornos son los que con mayor frecuencia causan dolor en las extremidades o disfunción neurológica. Las patologías que involucran dolor en el cuello son: esguince cervical, síndrome de compresión interna de disco o dolor discogénico, dolor cervical de tipo latigazo de origen neuropático y dolor miofascial. Los trastornos que de manera predominante causan síntomas en las extremidades o con disfunción neurológica incluyen la radiculopatía cervical y mielopatía cervical espondilótica. Los factores asociados con mayor riesgo son el trabajo manual pesado que requiere el levantamiento de más de 25 libras, el tabaquismo y conducir o utilizar equipo vibratorio. Otras causas menos frecuentes son los tumores de la columna vertebral, una ampliación de quiste sinovial, condromatosis sinovial, arteritis y las infecciones de la columna vertebral.En este artículo se estudian los conceptos contemporáneos del tratamiento de la radiculopatía cervical mediante la evaluación
... Goals (5,(40)(41)(42) To be met in 4 weeks: ...
... There are few examples of evidence-guided phenotyping using PPDT as the predictor variable. 12 If PPDT is to enter routine clinical use for prognostic, treatment, or outcomes decisions in neck pain then clinicians need a better understanding of how it can be used to classify patients and the clusters that exist in this population. The purpose of this study was to conduct a pooled secondary analysis of large international databases of people with mechanical neck pain (MNP) using latent class (cluster) analysis to identify clinically meaningful subgroups within the sample as a first step towards translating existing PPDT knowledge into more accessible clinical practice. ...
To determine Pressure Pain Detection Threshold (PPDT) related phenotypes of individuals with musculoskeletal neck pain (MNP) that may be identifiable in clinical practice.
This report describes a secondary analysis of 5 independent, international MNP databases of PPDT values taken at both a local and distal region (total N=1176). Minor systematic differences in mean PPDT values across cohorts necessitated z-transformation prior to analysis, and each cohort was split into male and female genders. Latent Profile Analysis (LPA) using the k-means approach was undertaken to identify the most parsimonious set of PPDT-based phenotypes that were both statistically and clinically meaningful.
LPA revealed 4 distinct clusters named according to PPDT levels at the local and distal zones: Low-Low PPDT (67%), Mod-Mod (25%), Mod-High (4%) and High-High (4%). Secondary predictor variables were evaluated for intra- and cross-cluster significance. Low-Low cluster was most affected, as indicated by pain intensity, disability, and catastrophization scores all significantly above the cohort- and gender-specific mean, and active range of motion scores significantly below the mean.
The results suggest that there is a large proportion of people with neck pain that present with signs indicating dysfunction beyond the local tissues. Ongoing exploration of these presentations may lead to more informed management and improved outcomes.
... Headaches are generally reported with high frequency and risk relevance among whiplash subjects, [43][44][45][46] as is lower back pain, [47][48][49] which would likely correlate with the Lifting subscale. Among a more general population of persons with mechanical neck pain, lower back pain is not expected to be as common. ...
Objective:
Because of previously published recommendations to modify the Neck Disability Index (NDI), we evaluated the responsiveness and dimensionality of the NDI within a population of adult whiplash-injured subjects. The purpose of the present study was to evaluate the responsiveness and dimensionality of the NDI within a population of adult whiplash-injured subjects.
Methods:
Subjects who had sustained whiplash injuries of grade 2 or higher completed an NDI questionnaire. There were 123 subjects (55% female, of which 36% had recovered and 64% had chronic symptoms. NDI subscales were analyzed using confirmatory factor analysis, considering only the subscales and, secondly, using sex as an 11th variable. The subscales were also tested with multiple linear regression modeling using the total score as a target variable.
Results:
When considering only the 10 NDI subscales, only a single factor emerged, with an eigenvalue of 5.4, explaining 53.7% of the total variance. Strong correlation (> .55) (P < .0001) between all variables was found. Multiple linear regression modeling revealed high internal consistency with all coefficients reaching significance (P < .0001). The 4 NDI subscales exerting the greatest effect were, in decreasing order, Sleeping, Lifting, Headaches, and Pain Intensity.
Conclusion:
A 2-factor model of the NDI is not justified based on our results, and in this population of whiplash subjects, the NDI was unidimensional, demonstrating high internal consistency and supporting the original validation study of Vernon and Mior.
... In line with findings in back pain research (Hill et al., 2008(Hill et al., , 2011, and WAD (Kasch et al., 2011;Ritchie et al., 2013), the present study emphasizes the importance of stratified care, targeting high-risk groups with specifically tailored interventions. Whether early targeting of PTSS, pain-catastrophizing and fear-avoidance beliefs will be able to prevent the development of chronic WAD still needs to be tested in a randomized controlled trial. ...
Background:
Knowledge about the course of recovery after whiplash injury is important. Most valuable is identification of prognostic factors that may be reversed by intervention. The mutual maintenance model outlines how post-traumatic stress symptoms (PTSS) and pain may be mutually maintained by attention bias, fear, negative affect and avoidance behaviours. In a similar vein, the fear-avoidance model describes how pain-catastrophizing (PCS), fear-avoidance beliefs (FA) and depression may result in persistent pain. These mechanisms still need to be investigated longitudinally in a whiplash cohort.
Methods:
A longitudinal cohort design was used to assess patients for pain intensity and psychological distress after whiplash injury. Consecutive patients were all contacted within 3 weeks after their whiplash injury (n = 198). Follow-up questionnaires were sent 3 and 6 months post-injury. Latent Growth Mixture Modelling was used to identify distinct trajectories of recovery from pain.
Results:
Five distinct trajectories were identified. Six months post-injury, 64.6% could be classified as recovered and 35.4% as non-recovered. The non-recovered (the medium stable, high stable and very high stable trajectories) displayed significantly higher levels of PTSS, PCS, FA and depression at all time points compared to the recovered trajectories. Importantly, PCS and FA mediated the effect of PTSS on pain intensity.
Conclusions:
The present study adds important knowledge about the development of psychological distress and pain after whiplash injury. The finding, that PCS and FA mediated the effect of PTSS on pain intensity is a novel finding with important implications for prevention and management of whiplash-associated disorders. WHAT DOES THIS STUDY ADD?: The study confirms the mechanisms as outlined in the fear-avoidance model and the mutual maintenance model. The study adds important knowledge of pain-catastrophizing and fear-avoidance beliefs as mediating mechanisms in the effect of post-traumatic stress on pain intensity. Hence, cognitive behavioural techniques targeting avoidance behaviour and catastrophizing may be beneficial preventing the development of chronic pain.
... The exploration and development of clinical tools and prediction rules have provided an opportunity for clinicians to confidently stratify acutely injured patients by level of risk (low, moderate, and high) [15][16][17]. While useful in some contexts, many such tools include nonmodifiable factors (e.g., age and gender) that have value for stratification but less obvious value for treatment planning. ...
. Chronic or persistent pain and disability following noncatastrophic “musculoskeletal” (MSK) trauma is a pervasive public health problem. Recent intervention trials have provided little evidence of benefit from several specific treatments for preventing chronic problems. Such findings may appear to argue against formal targeted intervention for MSK traumas. However, these negative findings may reflect a lack of understanding of the causal mechanisms underlying the transition from acute to chronic pain, rendering informed and objective treatment decisions difficult. The Canadian Institutes of Health Research (CIHR) Institute of Musculoskeletal Health and Arthritis (IMHA) has recently identified better understanding of causal mechanisms as one of three priority foci of their most recent strategic plan.
Objectives
. A 2-day invitation-only active participation workshop was held in March 2015 that included 30 academics, clinicians, and consumers with the purpose of identifying consensus research priorities in the field of trauma-related MSK pain and disability, prediction, and prevention.
Methods
. Conversations were recorded, explored thematically, and member-checked for accuracy.
Results
. From the discussions, 13 themes were generated that ranged from a focus on identifying causal mechanisms and models to challenges with funding and patient engagement.
Discussion
. Novel priorities included the inclusion of consumer groups in research from the early conceptualization and design stages and interdisciplinary longitudinal studies that include evaluation of integrated phenotypes and mechanisms.
... El médico forense ve al paciente entre 6-12 meses después de ocurrir el accidente, cuando ya han desaparecido todo tipo de signos y síntomas agudos que podrían explicar la realización generalizada de dichos exámenes complementarios, comprobando que la mayoría de las veces su realización no está justificada si no hay una sintomatología neurológica 4 Trauma Fund MAPFRE (2012) Vol 23 nº 2: 00-00 acompañante [7][8][9][10]. Esto se debe a factores no sanitarios, como son los educacionales y de aprendizaje, psicosociales, compensaciones económicas, etc., pudiendo favorecer así la cronicidad de la sintomatología dolorosa, no evidenciando, en la mayoría de ellas, cambios que indiquen lesión a nivel de las estructuras cervicales que puedan justificar dicha sintomatología [11][12][13][14]. ...
... El médico forense ve al paciente entre 6-12 meses después de ocurrir el accidente, cuando ya han desaparecido todo tipo de signos y síntomas agudos que podrían explicar la realización generalizada de dichos exámenes complementarios, comprobando que la mayoría de las veces su realización no está justificada si no hay una sintomatología neurológica 4 Trauma Fund MAPFRE (2012) Vol 23 nº 2: 00-00 acompañante [7][8][9][10]. Esto se debe a factores no sanitarios, como son los educacionales y de aprendizaje, psicosociales, compensaciones económicas, etc., pudiendo favorecer así la cronicidad de la sintomatología dolorosa, no evidenciando, en la mayoría de ellas, cambios que indiquen lesión a nivel de las estructuras cervicales que puedan justificar dicha sintomatología [11][12][13][14]. ...
Objectives: To determine whether it is possible to carry out a more efficient management in whiplash injuries. Materials and methods: We have analyzed 1.905 injured -1,085 were men (57%) with an average age of 31 and 820 were women (43%) with an average age of 33- with cervical pain, etiology (car occupants and aggression), without prior pathology or sequels, also analyzing non sanitary variables and ancillary proofs performed. Results: There is an observable difference in the assessment that is carried out concerning those who were injured in car accidents and those who were assaulted, regarding media diagnosis, as well as in complementary examinations. Conclusions: It is compulsory to train assistant doctors and make them aware of the consequences of an incorrect assessment (evaluation); and to develop their skills for an adequate performance.
... Neck pain at baseline has indeed been shown to predict outcome after whiplash, 11 32 and head/neck pain is part of a risk assessment score for non-recovery in whiplash. 33 To account for this, we adjusted our analyses for neck pain at baseline as well as collision severity. The preferences for taking medications, sickness absence and being referred to a physiotherapist/chiropractor remained significant risk factors after adjustment, indicating that coping not only reflects a more severe injury. ...
Objective Individuals exposed to whiplash collisions have to cope with the stressful event as well as early physical symptoms. As in other chronic pain conditions, coping has been associated with outcome after whiplash. In this study, our aim was to examine whether initial coping preferences were associated with the development of chronic whiplash.
Design Prospective study.
Setting Primary care.
Methods 740 acute whiplash patients were recruited from emergency units and general practitioners after car collisions in Denmark. Within 10 days postinjury, participants were asked what they believed could help them get better. At 12-month follow-up, the level of neck pain and capability to work was obtained. Whether coping preferences (baseline) were associated with outcome was investigated using multiple regression analyses.
Results Persistent neck pain was most strongly associated with preferring medications (mean difference=1.24 (95% CI 0.67 to 1.82)) and sickness absence (mean difference=1.18 (95% CI 0.53 to 1.82)). Reduced work capability was most strongly associated with preferring medications (OR=3.53 (95% CI 2.13 to 5.86)), sickness absence (OR=3.05 (95% CI 1.80 to 5.17)) and being referred to a physiotherapist/chiropractor (OR=3.03 (95% CI 1.33 to 6.91)). Active coping was associated with better outcomes: Participants preferring to change their lifestyle were protected against reduced work capability (OR=0.11 (95% CI 0.01 to 0.78)). Individuals who wanted to keep living as usual only (no other preference reported) were protected against neck pain (mean difference −1.62 (95% CI −2.39 to −0.84)) and reduced work capability (OR=0.09 (95% CI 0.01 to 0.64)).
Conclusions A simple nine-item measure of coping preferences is associated with the development of chronic neck pain and reduced capability to work following whiplash trauma and may be used to identify individuals at risk of poor recovery.
... In the acute phase, different factors regarding the trauma itself and thus which structures may be involved, have been studied both in experimental [3] and clinical settings [6]. There have also been attempts to identify patients at risk for persisting problems [7,8]. The WAD classification is today refuted by many, but there is still a lack of clinically suitable alternatives [9]. ...
... Since initial pain intensity has been found to be one important predictor of poor recovery in patients with whiplash injury 34 it is conspicuous that neck pain intensity at baseline was not associated with working ability 12 months later in the present study. This could be due to the way this variable was dichotomized in the present study (see 35 for a different approach to dichotomizing this variable), or alternatively it could be argued, that working ability is not a direct measure of recovery 36 because pain intensity might not be the only factor involved in patients ability to return to work or number of days off work. ...
Objectives:
To examine (1) whether the patients' perceptions of their symptoms immediately after the accident and at 3-month follow-up predict working ability and neck pain at 12-month follow-up and (2) the possible changes in patients' illness perceptions during the follow-up period.
Materials and methods:
A total of 740 consecutive patients exposed to acute whiplash trauma consulting emergency units and general practitioners in 4 Danish counties from 2001 to 2003. The patients completed questionnaires at baseline, 3-, and 12-month follow-up. Illness perceptions were measured using a condensed version of the Illness Perception Questionnaire and a 1-item question concerning return to work expectation. Neck pain was measured using an 11-point box scale, and working ability was measured by self-report at 12-month follow-up. Multiple logistic regression analyses were applied controlling for possible confounders.
Results:
Patients with pessimistic illness perceptions at baseline and 3-month follow-up were more likely to experience neck pain and affected working ability at 12 months compared with patients with optimistic illness perceptions. Negative return-to-work expectation predicted affected working ability at 12 months. Furthermore, patients with high neck pain intensity or affected working ability report more changes in their illness perceptions during follow-up than patients with low neck pain intensity or unaffected working ability.
Discussion:
The findings are in line with the common-sense model of illness and previous research demonstrating that patient's expectations for recovery and illness perceptions might influence the course after whiplash injury. Illness perceptions and expectations may provide a useful starting point for future interventions and be targeted in the prevention of chronicity.
... Previous research has stressed the heterogeneous nature of WAD. [65][66][67] There is evidence that generalized hypersensitivity occurs in a subgroup of patients with WAD. The presence of these sensory disturbances, indicative of altered central pain processing, was associated with higher levels of pain and disability and poor long-term recovery. ...
Widespread sensory hypersensitivity has been observed in acute whiplash associated disorders (WAD). Changes in descending pain modulation take part in central sensitization. However, endogenous pain modulation has never been investigated in acute WAD. Altered perception of distorted visual feedback has been observed in WAD. Both mechanisms (ie, pain modulation and perception of distorted visual feedback) may be different components of one integrated system orchestrated by the brain. This study evaluated conditioned pain modulation (CPM) in acute WAD. Secondly, we investigated whether changes in CPM are associated with altered perception of distorted visual feedback.
Thirty patients with acute WAD, 35 patients with chronic WAD and 31 controls were subjected to an experiment evaluating CPM and a coordination task inducing visual mediated changes between sensory feedback and motor output.
A significant CPM effect was observed in acute WAD (P = 0.012 and P = 0.006), which was significantly lower compared to controls (P = 0.004 and P = 0.020). No obvious differences in CPM were found between acute and chronic WAD (P = 0.098 and P = 0.041). Changes in CPM were unrelated to altered perception of distorted visual feedback (P > 0.01).
Changes in CPM were observed in acute WAD, suggesting less efficient pain modulation. The results suggest that central pain and sensorimotor processing underlie distinctive mechanisms.
... While some evidence exists to suggest that higher grades are associated with a worse prognosis [10,17], other systematic reviews have been inconclusive [11][12][13]. More recently, primary evidence from Kasch and colleagues [19,20] has provided greater support for the prognostic value of cervical range of motion, and may also be stimulating this practice. ...
Results of an international survey of health care providers for neck pain are reported. The survey specifically collected self-reported practice patterns for establishing a prognosis in neck pain. Over 440 responses from 27 countries were collected. Descriptive results indicate that respondents assigned large prognostic impact to factors including mechanism of injury and psychological or behavioral constructs. Range of motion, age and sex were routinely collected despite relatively moderate impact on prognosis. A comparison between chiropractic and manual/physical therapy groups showed differences in practice patterns that were unlikely to affect prognostic accuracy. The results suggest a gap exists between current best-evidence and actual practice when the goal is to establish a prognosis in neck pain.
... However, in a subgroup of patients, high levels of healthcare consultations were noted already long before the diagnosis of neck injury Given the expected heterogeneity of the patient category, our aim was to study health care consultation patterns before and after neck injury with the patients' preinjury consultation frequency in mind. In a recent study, Kasch et al 33 have presented a way of early stratification of patients with acute neck injury based on a risk score in relation to chronicity and work disability. Prior consultation frequency may serve as an additional variable for risk assessment of patients diagnosed with neck injury. ...
Recent studies based on self-assessed data on exposure and outcome suggest a negative association between poor health before neck injury and recovery. Our aim was to study actual healthcare consultation and work disability before and after neck injury (whiplash).
Cohort study with matched references studied prospectively and retrospectively via regional and national held registers.
Population-based study in Region Skåne, Sweden (population=1.21 million) including all levels of healthcare.
1443 participants aged ≥18 (54% women) with acute neck injury, Whiplash, (International Classification of Diseases-10-SE code S13.4*) in 2007 or 2008 and no such diagnosis since 1998. Each patient with a neck injury was assigned four randomly selected population references matched for age, sex and area of residence (97% of the patients and 94% of the references were followed during the whole study period).
We studied changes in healthcare consultations 3 years before to 3 years after diagnosis as well as sick leave episodes. Analyses were also stratified by preinjury frequency of consultation.
Before the injury, the mean number of total consultations over 36 months among the neck injured (n=1443) and references (n=5772) was 9.3 vs 7.2 (p<0.0001) and postneck injury 12.7 vs 7.8 (p<0.0001). In the group of high-frequent consulters, there were more women compared with frequent and low-frequent consulters (70.6% vs 32.8%; p<0.0001). Among low-frequent and frequent consulters preinjury (n=967, 67% of the cohort), 16% became high-frequent consulters attributable to the injury. The number of days of sick leave preinjury was correlated with the number of preinjury and postinjury consultations (r=0.47 (99% CI 0.38 to 0.49), r=0.32 (99% CI 0.25 to 0.37)).
People with a neck injury constitute a heterogeneous group. The preinjury level of healthcare consultation is associated with the postinjury level of consultation.
... Psychological distress is one of the best documented risk factors for adverse outcome in LBP patients [13,14,18]. The questionnaire used in the present study has been well validated [29] and has proven its value in a Danish context [40]. Many of the questions resemble questions of the General Health Questionnaire used in other LBP populations [17]. ...
Background
Many studies on low back pain (LBP) have identified prognostic factors, but prediction models for use in secondary health care are not available. The purpose of this cohort study, based on a randomised clinical study, was to identify risk factors for unsuccessful return to work (U-RTW) in sick-listed LBP patients with or without radiculopathy and to validate a prediction model for U-RTW.
Methods
325 sick-listed LBP patients with or without radiculopathy were included in an intervention study and followed for one year. Afterwards, 117 other LBP patients were recruited similarly, included in a validation study and also followed for one year. All patients were subjected to identical procedures and interventions and received a brief intervention by the same rehabilitation doctor and physiotherapist. Half of them received case manager guidance within a multidisciplinary setting. At baseline, they completed a questionnaire and went through a clinical low-back examination. Sciatica was investigated by magnetic resonance imaging (MRI). U-RTW was registered in a national database both initially and at 1-year.
Results
Neither initial U-RTW (24.0%) nor one-year U-RTW (38.2%) were statistically significantly different in the two intervention groups nor in patients with and without radiculopathy. Multivariate logistic regression analysis identified two clinical and five psychosocial baseline predictors for one-year U-RTW (primary outcome). The clinical predictors included pain score (back+leg pain) and side-flexion. The five psychosocial predictors included ‘bodily distress’ ‘low expectations of RTW’, ‘blaming the work for pain’, ‘no home ownership’ and ‘drinking alcohol less than once/month’. These predictors were not statistically significantly different in patients with and without radiculopathy, and they also predicted initial U-RTW (secondary outcome). Obesity and older age were only supplementary predictors in patients with radiculopathy. A prediction model was established and tested in the validation study group. The model predicted one-year U-RWT in patients with intermediate and high risk, but only partially in patients with low risk. The model predicted all three risk categories in initial U-RTW.
Conclusions
A prediction model combining baseline clinical and psychosocial risk factors predicted patients with low, intermediate and high risk for unsuccessful return to work, both initially and at 1-year.
... For these reasons, some researchers recommend categorising patients using biopsychosocial factors. 42 Furthermore new evidence on poorly recognised trauma induced structural changes will continue to help refine our understanding of WAD outcomes. [43][44][45] The intention of the treatment programme was not to control the injured person's care, but rather to guide a predominantly selfmanaged recovery. ...
Whiplash-Associated Disorders (WAD) represent a multifactorial condition often accompanied by altered nociceptive processing and psychological factors. This systematic review on acute and chronic WAD aimed to investigate the relationship between Quantitative Sensory Testing (QST) and psychological factors and quantify whether their trajectories over time follows a similar pattern to disability levels. Eight databases were searched until October 2022. When two prospective studies examined the same QST or psychological variable, data synthesis was performed with random-effects meta-analysis by pooling within-group standardized mean differences from baseline to 3-, 6-, and 12-month follow-ups. From 5,754 studies, 49 comprising 3,825 WAD participants were eligible for the review and 14 for the data synthesis. Altered nociceptive processing in acute and chronic WAD, alongside worse scores on psychological factors, were identified. However, correlations between QST and psychological factors were heterogeneous and inconsistent. Furthermore, disability levels, some QST measures, and psychological factors followed general positive improvement over time, although there were differences in magnitude and temporal changes. These results may indicate that altered psychological factors and increased local pain sensitivity could play an important role in both acute and chronic WAD, although this does not exclude the potential influence of factors not explored in this review. PERSPECTIVE: Acute WAD show improvements in levels of disability and psychological factors before significant improvements in nociceptive processing are evident. Facilitated nociceptive processing might not be as important as psychological factors in chronic WAD-related disability, which indicates that chronic and acute WAD should not be considered the same entity although there are similarities. Nonetheless, pressure pain thresholds in the neck might be the most appropriate measure to monitor WAD progression.
Cervical facet disease (aka cervical facet syndrome) is often one of exclusion. This disease implies axial pain from involvement of the posterior spinal column elements. Degenerative changes have been well documented in the literature. The facet joint is a structure which resists compression at higher loads, anterior shear, extension, lateral bending, and torsion (Sial et al., Waldman pain management, 2011). The structure and function of the spine give the trunk of the body stability and mobility, both of which are mediated largely by the zygapophysial joints (facets). The cervical spine is the most mobile of the spinal regions because of its articular shapes and orientations, and laxity of its joint capsules. Active movements of the cervical spine have been measured as up to 70 degrees each of extension and flexion with radiographic study, about 45 degrees of side bending and up to 40 degrees of rotation in either direction (Johnson et al., J Bone Joint Surg Am 59A:332–339, 1977; Alund and Larsson, Spine 15:87–91, 1990). Stability is provided in the cervical spine by the shape of the vertebral processes: the uncinate processes prevent lateral translation and limit side bending; spinous processes limit extension. Further stability is provided by spinal ligaments, the anterior longitudinal ligament, and the posterior longitudinal ligament, ligament flavum, and ligament nuchae (King and Borowczyk, Pain procedures in clinical practice, 2011). Facet joint pain results in referral patterns to the head, shoulders, and upper extremities. Both the synovium and capsule of each facet are richly supplied with nociceptor terminals. Medial branches innervate these facet joints sending afferent pain signals by way of A, D, and C fibers to higher cortical regions.
Clinical prediction rules (CPRs) developed to identify sub-groups of people with neck pain for different prognoses (i.e. prognostic) or response to treatments (i.e. prescriptive) have been recommended as a research priority to improve health outcomes for these conditions. A systematic review was undertaken to identify prognostic and prescriptive CPRs relevant to the conservative management of adults with neck pain and to appraise stage of development, quality and readiness for clinical application. Six databases were systematically searched from inception until 4th July 2016. Two independent reviewers assessed eligibility, risk of bias (PEDro and QUIPS), methodological quality and stage of development. 9840 records were retrieved and screened for eligibility. Thirty-two studies reporting on 26 CPRs were included in this review. Methodological quality of included studies varied considerably. Most prognostic CPR development studies employed appropriate designs. However, many prescriptive CPR studies (n = 12/13) used single group designs and/or analysed controlled trials using methods that were inadequate for identifying treatment effect moderators. Most prognostic (n = 11/15) and all prescriptive (n = 11) CPRs have not progressed beyond the derivation stage of development. Four prognostic CPRs relating to acute whiplash (n = 3) or non-traumatic neck pain (n = 1) have undergone preliminary validation. No CPRs have undergone impact analysis. Most prognostic and prescriptive CPRs for neck pain are at the initial stage of development and therefore routine clinical use is not yet supported. Further validation and impact analyses of all CPRs are required before confident conclusions can be made regarding clinical utility.
Study Design Observational cohort. Background Outcomes for acute musculoskeletal (MSK) injuries are currently suboptimal with an estimated 10 to 50% of injured individuals reporting persistent problems. Early risk-targeted intervention may hold value for improving outcomes. Objectives To describe the development and preliminary concurrent and longitudinal validation of the Traumatic Injuries Distress Scale (TIDS), a new tool intended to provide the magnitude and nature of risk for persistent problems following acute MSK injuries. Methods Two hundred participants recruited from emergency medicine departments or rehabilitation clinics completed the TIDS and a battery of other self-reported questionnaires. A sub-cohort (n = 76) was followed at 1 week and again 12 weeks after the inciting event. Exploratory factor analysis (EFA) and concurrent and longitudinal correlations were used to evaluate the ability of the TIDS to predict acute presentation and 3-month outcomes. Results EFA revealed 3 factors explaining 62.8% of total scale variance. Concurrent and longitudinal associations with established clinical measures supported the nature of each subscale. TIDS scores at baseline were significantly associated with variability in disability, pain intensity, satisfaction, anxiety, and depression at 12 weeks post-injury with adequate accuracy to endorse its use as part of a broader screening protocol. Limitations to interpretation are discussed. Conclusions We present the initial psychometric properties of a new measure of acute post-traumatic distress following MSK injury. The subscales may be useful as stratification variables in subsequent investigations of clinical interventions. J Orthop Sports Phys Ther, Epub 3 Sep 2016. doi:10.2519/jospt.2016.6594.
Wearable technology is an important development in the field of rehabilitation as it has the potential to progress understanding of activity and function in various patient groups. For lower limb amputees, falls occur frequently, and are likely to affect function in the community. Therefore, the purpose of this study was to use wearable technology to assess activity and participation characteristics in the home and various community settings for transtibial amputee fallers and non-fallers. Participants were provided with an accelerometer-based activity monitor and global positioning system (GPS) device to record activity and participation data over a period of seven consecutive days. Data from the accelerometer and GPS were linked to assess community activity and participation. Forty-six transtibial amputees completed the study (79% male, 35% identified as fallers). Participants with a history of falls demonstrated significantly lower levels of community activity (p=0.01) and participation (p=0.02). Specifically, activity levels were reduced for recreational (p=0.01) and commercial roles (p=0.02), while participation was lower for recreational roles (p=0.04). These findings highlight the potential of wearable technology to assist in the understanding of activity and function in rehabilitation and to further emphasise the importance of clinical falls assessments to improve the overall quality of life in this population.
Whiplash injury is surrounded by controversy in both the medical and legal world. The debate on whether it is either a potentially serious medical condition or a social problem is ongoing. This paper briefly examines a selection of studies on low velocity whiplash injury (LVWI) and whiplash associated disorder (WAD) and touches upon the pathophysiological and epidemiological considerations, cultural and geographical differences and the effect of litigation on chronicity. The study concludes that the evidence for significant physical injury after LVWI is poor, and if significant disability is present after such injury, it will have to be explained in terms of psychosocial factors.
Illness representations pertain to the ways in which an individual constructs and understands the experience of a health condition. The Brief Illness Perceptions Questionnaire (BIPQ) comprises 9 items intended to capture the key components of the Illness Representations Model. The purpose of this paper was to explore the utility of the BIPQ for evaluating and classifying uncomplicated mechanical neck pain in the rehabilitation setting. A convenience sample of 198 subjects presenting to physiotherapy for neck pain problems were used in this study. In the first step, 183 subjects completed the BIPQ and a series of related cognitive measures. Latent class analysis (LCA) was used to explore the number of identifiable classes amongst the sample based on BIPQ response patterns. A regression equation was created to facilitate classification. In the second step, an independent sample of 15 subjects were classified using the equation established in step 1, and they were followed over a 3 month period. The LCA revealed 3 classes of subjects with optimal fit statistics: mildly affected, moderately affected, and severely affected. Inter-group comparisons of the secondary cognitive measures supported these labels. Classification accuracy of a regression equation was high (94.5%). Applying the equation to the independent longitudinal sample revealed that it functioned equally well and that the classes may have prognostic value. The BIPQ may be a useful clinical tool for classification of neck pain.
Whiplash associated Disorders (WAD) are a very significant public health problem, particularly in relationship to chronic disability that occurs in 20 % of cases. WAD are heterogeneous entities with multiple clinical and psychological features. The Quebec Task Force classification of 1995 has been improved in 2008 with the integration of the concept of disability and social interference related to or associated to a post-traumatic neck pain. A central sensitization is probably the key of the different dysfunctions observed in WAD. Central sensitization to pain is related to a complex network of interactions between personal genetic, physical, affective, emotional, cognitive and behavioural factors but also with environmental factors. This new classification of WAD may allow, in the future, more precise studies of prognostic factors and therefore, a better approach of each patient. Today, if exercises and early mobilisation are the best therapeutic choices for acute and sub acute stages, there are many unresolved questions about the best effectiveness treatment in the chronic stage.
Given the challenges of chronic musculoskeletal pain and disability, establishing a clear prognosis in the acute stage has become increasingly recognized as a valuable approach to mitigate chronic problems. Neck pain represents a condition that is common, potentially disabling, and has a high rate of transition to chronic or persistent problems. As a field of research, prognosis in neck pain has stimulated several empirical primary research papers, and a number of systematic reviews. As part of the International Consensus on Neck (ICON) project, we sought to establish the general state of knowledge in the area through a structured, systematic review of systematic reviews (overview).
An exhaustive search strategy was created and employed to identify the 13 systematic reviews (SRs) that served as the primary data sources for this overview. A decision algorithm for data synthesis, which incorporated currency of the SR, risk of bias assessment of the SRs using AMSTAR scoring and consistency of findings across SRs, determined the level of confidence in the risk profile of 133 different variables. The results provide high confidence that baseline neck pain intensity and baseline disability have a strong association with outcome, while angular deformities of the neck and parameters of the initiating trauma have no effect on outcome. A vast number of predictors provide low or very low confidence or inconclusive results, suggesting there is still much work to be done in this field. Despite the presence of multiple SR and this overview, there is insufficient evidence to make firm conclusions on many potential prognostic variables. This study demonstrates the challenges in conducting overviews on prognosis where clear synthesis critieria and a lack of specifics of primary data in SR are barriers.
The lack of efficacy of rehabilitative approaches to the management of chronic whiplash associated disorders (WAD) may be in part due to heterogeneity of the clinical presentation of this patient population. The aim of this study was to identify homogeneous subgroups of patients with chronic WAD based on symptoms of PTSD and sensory hypersensitivity and to compare the clinical presentation of these sub-groups. Successive k-means cluster analyses using 2, 3 and 4 cluster solutions were performed using data for 331 (221 female) patients with chronic (> 3 months) WAD. The 4 cluster solution was identified as the most clinically relevant yielding 4 distinct clusters: no to mild post-traumatic stress symptoms and no sensory hypersensitivity (nPnH), no to mild post-traumatic stress symptoms and sensory hypersensitivity (nPH), moderate to severe post-traumatic stress and no sensory hypersensitivity (PnH) and moderate to severe post-traumatic stress and sensory hypersensitivity (PH). The nPnH cluster was the largest cluster comprising 43.5% of the sample. The PH cluster had significantly worse disability, pain intensity, self report mental health status and cervical ROM in comparison to the nPnH and nPH clusters. These data provide further evidence of the heterogeneity of the chronic WAD population and the association of a more complex clinical presentation with higher disability and pain in this patient group.
STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: To update a previous review and meta-analysis on risk factors for persistent problems following whiplash secondary to motor vehicle accident (MVA). BACKGROUND: Prognosis in whiplash-associated disorder (WAD) has become an active area of research, perhaps owing to the difficulty in treating chronic problems. The previously published review and meta-analysis of prognostic factors included primary sources up to May 2007. Since that time more research has become available, and an update to that original review is warranted. METHODS: A systematic search of international databases was conducted with rigorous inclusion criteria focusing on studies published between May 2007 and May 2012. Articles were scored and data were extracted and pooled to estimate the odds ratio for any factor that had at least 3 independent data points in the literature. RESULTS: Four new cohorts (n=1121) were identified. In combination with findings of a previous review, 12 variables were found to be significant predictors of poor outcome following whiplash, 9 of which were new (n = 2) or revised (n = 7) as a result of additional data. The significant variables included: high (>5.5 out of 10) baseline pain intensity, report of headache at inception, less than post-secondary education, no seat belt in use during the accident, report of low back pain at inception, high (>14.5 out of 50) Neck Disability Index (NDI) score, pre-injury neck pain, report of neck pain at inception (regardless of intensity), high catastrophizing, female sex, WAD grade 2 or 3, and WAD grade 3 alone. Those robust to publication bias included: High pain intensity, female sex, report of headache at inception, less than post-secondary education, high NDI score, and WAD grade 2 or 3. Three existing variables (pre-accident history of headache, rear-end collision, older age) and one additional novel variable (collision severity) were refined or added in this updated review but showed no significant predictive value. CONCLUSIONS: This review identified 2 additional prognostic factors and refined the estimates of 7 previously identified factors, bringing the total number of significant predictors across the two reviews to 12. These factors can be easily identified in a clinical setting to provide estimates of prognosis following whiplash. LEVEL OF EVIDENCE: Prognosis, level 1a.J Orthop Sports Phys Ther. Epub 14 January 2013. doi:10.2519/jospt.2013.4507.
Objectives An initial stratification of acute whiplash patients into seven risk-strata in relation to 1-year work disability as primary outcome is presented.
Design The design was an observational prospective study of risk factors embedded in a randomised controlled study.
Setting Acute whiplash patients from units, general practitioners in four Danish counties were referred to two research centres.
Participants During a 2-year inclusion period, acute consecutive whiplash-injured (age 18–70 years, rear-end or frontal-end car accident and WAD (whiplash-associated disorders) grades I–III, symptoms within 72 h, examination prior to 10 days postinjury, capable of written/spoken Danish, without other injuries/fractures, pre-existing significant somatic/psychiatric disorder, drug/alcohol abuse and previous significant pain/headache). 688 (438 women and 250 men) participants were interviewed and examined by a study nurse after 5 days; 605 were completed after 1 year. A risk score which included items of initial neck pain/headache intensity, a number of non-painful complaints and active neck mobility was applied. The primary outcome parameter was 1-year work disability.
Results The risk score and number of sick-listing days were related (Kruskal-Wallis, p<0.0001). In stratum 1, less than 4%, but in stratum 7, 68% were work-disabled after 1 year. Early work assessment (p<0.0001), impact of the event questionnaire (p<0.0006), psychophysical pain measures being McGill pain questionnaire parameters (p<0.0001), pressure pain algometry (p<0.0001) and palpation (p<0.0001) showed a significant relationship with risk stratification.
Analysis Findings confirm previous studies reporting intense neck pain/headache and distress as predictors for work disability after whiplash. Neck-mobility was a strong predictor in this study; however, it was a more inconsistent predictor in other studies.
Conclusions Application of the risk assessment score and use of the risk strata system may be beneficial in future studies and may be considered as a valuable tool to assess return-to-work following injuries; however, further studies are needed.
Objective:
To study the presence of cervical motor dysfunctions in acute whiplash-associated disorders, evaluate their course and assess their predictive value for long-term recovery.
Design:
Systematic literature review.
Methods:
PubMed and Web of Science databases were used to select studies of the presence of cervical motor dysfunctions within the acute stage (< 6 weeks) after whiplash trauma and/or their predictive value for the development of chronic whiplash-associated disorders.
Results:
The presence of cervical motor dysfunctions in the acute stage after whiplash trauma was investigated in 4 cohorts. The course of cervical motor dysfunctions in whiplash-associated disorders was examined in 4 cohorts, and the predictive value on outcome 1 year post-whiplash trauma was assessed in 3 cohorts. Reduced cervical mobility, disturbed kinaesthesia, and altered muscle activity were found in the acute stage, and these persisted over time in the moderate/severe group. The predictive value of examining the presence of cervical motor dysfunctions was doubtful. The course and predictive value of initial reduced cervical mobility was inconsistent.
Conclusion:
Cervical motor dysfunctions are present soon after whiplash trauma persisting in those with moderate/severe symptoms. However, these dysfunctions have limited predictive value, and hence may not explain the complex clinical picture of whiplash-associated disorders. This systematic review highlights the need for differentiating between patients with acute whiplash-associated disorders taking into account the biopsychological framework.
Objectives:
To estimate the direct and indirect factual costs of polyneuropathy in a national sample of patients and their spouses based on a national register-based cohort study with matched controls.
Methods:
Using records from the Danish National Patient Registry (1997-2009) all patients with a diagnosis of polyneuropathy and their partners were identified and compared with randomly chosen controls matched for age, gender, geographic area and civil status. Direct costs included frequencies of primary and secondary sector contacts and procedures, and medication. Indirect costs included the effect on labor supply. Social-transfer payments were included to illustrate the effect on national accounts. All cost data were extracted from national databases.
Results:
13,758 unspecified polyneuropathy patients were registered. They were compared with 54,900 matched controls identified from the National Danish Patient Registry. In addition, partners of patients in the case group were matched with partners in the corresponding control group. Almost half of the patients in the patient group had a partner. Patients had significantly higher rates of health-related contacts, medication use and greater socioeconomic costs than controls. They had very marginally lower employment rates, and those who were employed generally had lower incomes. The sum of direct net healthcare costs after the injury (general practitioner services, hospital services and medication) and indirect costs (loss of labor market income) was €12,647 for patients and €2,984 for their partners over and above that of controls. Social-transfer payments were all significantly larger in patients than in control subjects. Furthermore, the patients already exhibited a negative social- and health-related status up to eleven years before the first diagnosis, particularly for those with the highest costs. The health effects were present in all age groups and in both genders.
Conclusions:
Patients with a diagnosis of polyneuropathy experience increased mortality, morbidity and socioeconomic consequences.
A cohort study analyzing the cervical range of motion (ROM) of subjects with 4- or 5-level posterior laminectomy and fusion or anterior and posterior decompression and fusion operation.
The purpose of this study was to evaluate the effect of extending a C3-C7 fusion to C3-T1 on subject's ROM and level of disability.
Cadaveric studies show a reduction in the ROM of C3-C7 cervical fusion spines. In vivo, surgeons treat symptomatic cervical subaxial spine with either a C3-C7 fusion or C3-T1 fusion. While in some cases extending the fusion level to T1 is merited due to pathology, most cases are due to surgeon's preference to avoid future degeneration and reoperation of the C7-T1 junction.
This study involved 44 4-level fusion and 20 5-level fusion subjects along with 18 nonoperative controls. Operative subjects were divided according to early or late postoperative clinical visit. Subjects were asked to complete the neck disability index survey and their maximum ROM during flexion/extension, axial rotation, and lateral bending was measured using a virtual reality assisted electromagnetic tracking system. In addition, the helical axis of motion was calculated for flexion and extension motions. An analysis of variance statistical test was used to determine significant differences between study groups.
Five- level subjects had significantly less ROM than 4-level subjects and both groups were significantly less than control group during all motions. There was no effect of postoperative time on subject's ROM. In addition, there was no difference in the center of helical axis of rotation across the 3 groups. Finally, both operative groups exhibited similar levels of mild disability as measured by the neck disability index.
Extending the subaxial fusion from C3-C7 to include C7-T1 resulted in a significant loss of ROM, while postoperative time healing, center of rotation, and level of disability were similar across groups. This finding merits further investigation of the intersegmental motions of the cervical spine.
There are few diagnostic tools for chronic musculoskeletal pain as structural imaging methods seldom reveal pathological alterations. This is especially true for Whiplash Associated Disorder, for which physical signs of persistent injuries to the neck have yet to be established. Here, we sought to visualize inflammatory processes in the neck region by means Positron Emission Tomography using the tracer (11)C-D-deprenyl, a potential marker for inflammation. Twenty-two patients with enduring pain after a rear impact car accident (Whiplash Associated Disorder grade II) and 14 healthy controls were investigated. Patients displayed significantly elevated tracer uptake in the neck, particularly in regions around the spineous process of the second cervical vertebra. This suggests that whiplash patients have signs of local persistent peripheral tissue inflammation, which may potentially serve as a diagnostic biomarker. The present investigation demonstrates that painful processes in the periphery can be objectively visualized and quantified with PET and that (11)C-D-deprenyl is a promising tracer for these purposes.
To develop a methodology for translating the McGill Pain Questionnaire (MPQ) into a Danish version, and to make comparisons to studies of patients speaking other languages.
Finding suitable Danish adjectives using the same methodology as that in the original MPQ. Comparison of Danish descriptors to the words in the English version of MPQ. Survey in healthy subjects and patients with rheumatoid arthritis (RA) and fibromyalgia (F).
The general public and hospital outpatients.
A random sample of 186 healthy volunteers, 20 patients with rheumatoid arthritis and 41 patients with fibromyalgia.
Danish words translated as closely as possible to the descriptors in the original McGill Pain Questionnaire. A pain-assessment instrument making international pain description possible.
A Danish version of the McGill Pain Questionnaire was developed with scale values of Danish descriptors not differing more than 5 x SEM from the 'patient' words in the English version. The subdivision into classes and subclasses was respected. In the reliability experiment, the same rank values were found in 85% of subclasses. In a study using two experimental pain stimulus intensities, seven of 10 subjects obtained higher MPQ scores following the high-intensity stimulus. In the clinical study, the pain profiles of patients with RA and F in English, Italian, and Danish patients were almost the same.
The present methodology of translating the McGill Pain Questionnaire permits comparison of studies from English-speaking and non-English-speaking populations, thus facilitating international research exchange.
To determine whether a newly developed disability scale for patients with neck pain demonstrated acceptable reliability and validity.
Testing was conducted using three different samples of patients with neck pain (n = 162). Test-retest reliability of the scale was carried out on the same day with one sample (n = 39), and between-day reliability was carried out with another (n = 21). Differential item functioning with regard to the influence of gender and age was carried out with these two patient groups, as was construct validity. Responsiveness was measured using patients participating in a clinical trial involving patients with chronic neck pain (n = 102). Additionally, scale scores were compared with a wide range of physical measurements using the patients in the clinical trial.
Short-term, between-day and postal questionnaire reliability coefficients were all extremely high. The Cronbach's alpha coefficient for internal consistency was 0.9 for the entire scale, and the coefficients for individual items were all greater than 0.88. Disability scale scores correlated strongly to pain scores as well as to doctor and patient global assessments, indicating good construct validity. Relative changes in disability scores demonstrated a moderately strong correlation to changes in pain scores after treatment. Scale scores correlated weakly to all physical measurements.
The disability scale demonstrated excellent practicality and reliability. The scale accurately reflects patient perceptions regarding functional status and pain as well as doctor's global assessment and is responsive to change over long periods of time. We feel that this scale can be a valuable tool for the assessment of patients in future clinical trials and quality of care studies.
Whiplash injury to the neck is often considered a significant risk factor for development of temporomandibular disorders (TMD), and has been proposed to produce internal derangements of the temporomandibular joint (TMJ). Few studies, however, have examined TMD-related pain in acute whiplash patients compared with a matched control group. The aim of the present study was to assess pain and sensorimotor function in the craniofacial region in an unselected group of patients sustaining a motor vehicle accident involving a rear collision.
Prospectively, 19 acute whiplash patients exposed to a motor vehicle accident involving a rear collision participated in a study of TMD. The control group consisted of 20 age- and gender-matched ankle-injury patients. Participants were seen within 4 weeks and again at 6 months post-injury. The masticatory system was examined in accordance with the research diagnostic criteria. Participants underwent structured interviews, filled out the McGill Pain Questionnaire (MPQ), and had their masticatory system examined by a trained dentist, blinded to their diagnosis. Pain detection threshold (PDT) to pressure stimuli, and maximal voluntary occlusal force (MVOF) were obtained at each visit.
One whiplash patient and 1 ankle-injury patient had jaw pain at the first visit. Palpation scores of the TMJ and the summated palpation scores only tended to be higher in patients sustaining a whiplash injury than in ankle-injury controls at the first visit. However, MPQ, TMD symptoms and signs, MVOF and PDT were not significantly different in whiplash-injury and ankle-injury patients after 4 weeks and 6 months.
TMD pain after whiplash injury and ankle injury is rare, suggesting that whiplash injury is not a major risk factor for the development of TMD problems. Further studies are needed to identify which other factors may contribute to TMD pain.
We present a systematic review of prospective cohort studies. Our aim was to assess prognostic factors associated with functional recovery of patients with whiplash injuries. The failure of some patients to recover following whiplash injury has been linked to a number of prognostic factors. However, there is some inconsistency in the literature and there have been no systematic attempts to analyze the level of evidence for prognostic factors in whiplash recovery. Studies were selected for inclusion following a comprehensive search of MEDLINE, EMBASE, CINAHL, the database of the Dutch Institute of Allied Health Professions up until April 2002 and hand searches of the reference lists of retrieved articles. Studies were selected if the objective was to assess prognostic factors associated with recovery; the design was a prospective cohort study; the study population included at least an identifiable subgroup of patients suffering from a whiplash injury; and the paper was a full report published in English, German, French or Dutch. The methodological quality was independently assessed by two reviewers. A study was considered to be of 'high quality' if it satisfied at least 50% of the maximum available quality score. Two independent reviewers extracted data and the association between prognostic factors and functional recovery was calculated in terms of risk estimates. Fifty papers reporting on twenty-nine cohorts were included in the review. Twelve cohorts were considered to be of 'high quality'. Because of the heterogeneity of patient selection, type of prognostic factors and outcome measures, no statistical pooling was able to be performed. Strong evidence was found for high initial pain intensity being an adverse prognostic factor. There was strong evidence that for older age, female gender, high acute psychological response, angular deformity of the neck, rear-end collision, and compensation not being associated with an adverse prognosis. Several physical (e.g. restricted range of motion, high number of complaints), psychosocial (previous psychological problems), neuropsychosocial factors (nervousness), crash related (e.g. accident on highway) and treatment related factors (need to resume physiotherapy) showed limited prognostic value for functional recovery. High initial pain intensity is an important predictor for delayed functional recovery for patients with whiplash injury. Often mentioned factors like age, gender and compensation do not seem to be of prognostic value. Scientific information about prognostic factors can guide physicians or other care providers to direct treatment and to probably prevent chronicity.
In low back pain, clinical studies suggest that kinesiophobia (fear of movement/(re)injury) is important in the etiology of chronic symptoms. In this prospective cohort study, the predictive role of kinesiophobia in the development of late whiplash syndrome was examined.
Victims of car collisions with neck symptoms who initiated compensation claim procedures with a Dutch insurance company were sent a questionnaire containing symptom-related questions and the Tampa Scale of Kinesiophobia (TSK-DV). Follow-up questionnaires were administered 6 and 12 months after the collision. Survival analysis was used to study the relationship between the duration of neck symptoms and explanatory variables.
Of the 889 questionnaires sent, 590 (66%) were returned and 367 used for analysis. The estimated percentage of subjects with neck symptoms persisting 1 year after the collision was 47% (SE 2.7%). In a regression model without symptom-related variables, kinesiophobia was found to be related to a longer duration of neck symptoms (P=0.001). However, when symptom-related information was entered into the model, the effect of kinesiophobia did not reach statistical significance (P=0.089).
Although a higher score on the TSK-DV was found to be associated with a longer duration of neck symptoms, information on early kinesiophobia was not found to improve the ability to predict the duration of neck symptoms after motor vehicle collisions.
Individuals' expectations on returning to work after an injury have been shown to predict the duration of time that a person with work-related low back pain will remain on benefits; individuals with lower recovery expectations received benefits for a longer time than those with higher expectations. The role of expectations in recovery from traumatic neck pain, in particular whiplash-associated disorders (WAD), has not been assessed to date to our knowledge. The aim of this study was to investigate if expectations for recovery are a prognostic factor after experiencing a WAD.
We used a prospective cohort study composed of insurance claimants in Sweden. The participants were car occupants who filed a neck injury claim (i.e., for WAD) to one of two insurance companies between 15 January 2004 and 12 January 2005 (n = 1,032). Postal questionnaires were completed shortly (average 23 d) after the collision and then again 6 mo later. Expectations for recovery were measured with a numerical rating scale (NRS) at baseline, where 0 corresponds to "unlikely to make a full recovery" and 10 to "very likely to make a full recovery." The scale was reverse coded and trichotomised into NRS 0, 1-4, and 5-10. The main outcome measure was self-perceived disability at 6 mo postinjury, measured with the Pain Disability Index, and categorised into no/low, moderate, and high disability. Multivariable polytomous logistic regression was used for the analysis. There was a dose response relationship between recovery expectations and disability. After controlling for severity of physical and mental symptoms, individuals who stated that they were less likely to make a full recovery (NRS 5-10), were more likely to have a high disability compared to individuals who stated that they were very likely to make a full recovery (odds ratio [OR] 4.2 [95% confidence interval (CI) 2.1 to 8.5]. For the intermediate category (NRS 1-4), the OR was 2.1 (95% CI 1.2 to 3.2). Associations between expectations and disability were also found among individuals with moderate disability.
Individuals' expectations for recovery are important in prognosis, even after controlling for symptom severity. Interventions designed to increase patients' expectations may be beneficial and should be examined further in controlled studies.
Study Design. Best evidence synthesis. Objective. To undertake a best evidence synthesis on course and prognosis of neck pain and its associated disorders in the general population. Summary of Background Data. Knowing the course of neck pain guides expectations for recovery. Identifying prognostic factors assists in planning public policies, formulating interventions, and promoting lifestyle changes to decrease the burden of neck pain. to assemble the best evidence on neck pain. Findings from studies meeting criteria for scientific validity were abstracted into evidence tables and included in a best evidence synthesis. Results. We found 226 articles on the course and prog-nostic factors in neck pain and its associated disorders. After critical review, 70 (31%) of these were accepted on scientific merit. Six studies related to course and 7 to prognostic factors in the general population. Between half and three quarters of persons in these populations with current neck pain will report neck pain again 1 to 5 years later. Younger age predicted better outcome. General exercise was unassociated with outcome, although regular bicycling predicted poor outcome in 1 study. Psy-chosocial factors, including psychologic health, coping patterns, and need to socialize, were the strongest prog-nostic factors. Several potential prognostic factors have not been well studied, including degenerative changes, genetic factors, and compensation policies. Conclusion. The Neck Pain Task Force undertook a best evidence synthesis to establish a baseline of the current best evidence on the course and prognosis for this symptom. General exercise was not prognostic of better outcome; however, several psychosocial factors were prognostic of outcome.
Study Design. Physicians were surveyed regarding their beliefs about treatment efficacy for patients with low back pain. Objective. To document physician beliefs about the efficacy of specific treatmets and the extent to which these beliefs correspond to current knowledge. Summary of Background Data. Little is known about physician beliefs regarding the efficacy of specific back pain treatments. Methods. A national random sample of 2897 physicians were mailed questionnaires that asked about 1) the treatments they would order for hypothetical patients with low back pain and 2) the treatments they believed were effective for back pain. Responses were compared with guidelines suggested by the Quebec Task Force on Spinal Disorders. Results. Almost 1200 physicians responded. More than 80% of these physicians believed physical therapy is effective, but this consensus was lacking for other treatments. Fewer than half of the physicians believed that spinal manipulation is effective for acture or chronic back pain or that epidural steroid injections, traction, and corsets are effective for acute or chronic back painor that epidural steroid injections, traction, and corsets are effective for acute back pain. Bed rest and narcotic analgesics were recommended by substantial minorties of physicians for patients with chronic pain. The Quebec Task Force found little scientific support for the effectiveness of most of the treatments found to be in common use. Conclusions. The lack of consensus among physicians could be attributable to the absence of clear evidencebsed clinical guidelines, ignorance or rejection of existing scientific evidence, excessive commitment to a particular mode of therapy, or a tendency to discount the efficacy of competing treatments.
Objective: To develop a methodology for translating the McGill Pain Questionaire (MPQ) into a Danish version, and to make comparisons to studies of patients speaking other languages. Design: Finding suitable Danish adjectives using the same methodology as that in the original MPQ. Comparison of Danish descriptors to the words in the English version of MPQ. Survey in healthy subjects and patients with rheumatoid arthritis (RA) and fibromyalgia (F). Setting: The general public and hospital outpatients. Patients: A random sample of 186 healthy volunteers, 20 patients with rheumatoid arthritis and 41 patients with fibromyalgia. Main Outcome Measures: Danish words translated as closely as possible to the descriptors in the original McGill Pain Questionnarire. A pain-assessment instrument making international pain description possible. Results: A Danish version of the McGill Pain Questionnaire was developed with scale values of Danish descriptors not differing more than 5xSEM from the 'patient' words in the English version.The subdivision into classes and subclasses was respected. In the reliability experiment, the same rank values were found in 85% of subclasses. In a study using two experimental pain stimulus intensities, seven of 10 subjects obtained higher MPQ scores following the high-intensity stimulus. In the clinical study, the pain profiles of patients with RA and F in English, Italian, and Danish patients were almost the same. Conclusion: The present methodology of translating the McGill Pain Questionnaire permits comparison of studies from English-speaking and non-English-speaking populations, thus facilitating international research exchange.
Distinct developmental trajectories for neck disability and posttraumatic stress disorder (PTSD) symptoms after whiplash injury have recently been identified. This study aimed to identify baseline predictors of membership to these trajectories and to explore their dual development. In a prospective study, 155 individuals with whiplash were assessed at <1 month, 3, 6, and 12 months postinjury. Outcomes at each time point were assessed according to the Neck Disability Index and the Posttraumatic Stress Diagnostic Scale. Baseline predictor variables were age, gender, initial pain (based on a visual analogue scale [VAS]), pressure pain thresholds (PPT), cold pain thresholds (CPT), and sympathetic vasoconstrictor responses. Group-based trajectory analytical techniques were used to parameterise the optimal trajectories and to identify baseline predictors. A dual trajectory analysis was used to explore probabilities of conditional and joint trajectory group membership. CPT > or = 13° C (OR = 26.320, 95% CI = 4.981-139.09), initial pain level (VAS) (OR = 4.3, 95% CI = 4.98-139.1), and age (OR = 1.109, 95% CI = 1.043-1.180) predicted a chronic/severe disability trajectory. The same baseline factors also predicted chronic moderate/severe PTSD (CPT > or = 13° C, OR = 9.7, 95% CI = 2.22-42.44; initial pain level [VAS]: OR = 2.13, 95% CI = 1.43-3.17; age: OR = 1.07, 95% CI = 1.01-1.14). There was good correspondence of trajectory group for both disability and PTSD. These findings support the proposal of links between the development of chronic neck related disability and PTSD after whiplash injury. Developmental trajectories of disability and posttraumatic stress disorder (PTSD) after whiplash injury are mostly in synchrony, and similar factors predict their membership. This suggests links between the development of chronic neck pain-related disability and PTSD.
The mechanisms for developing long-lasting neck pain after whiplash injuries are still largely unrevealed. In the present study it was investigated whether a kyphotic deformity of the cervical spine, as opposed to a straight or a lordotic spine, was associated with the symptoms at baseline, and with the prognosis one year following a whiplash injury. MRI was performed in 171 subjects about 10 d after the accident, and 104 participated in the pain recording at 1-year follow-up. It was demonstrated that postures as seen on MRI can be reliably categorized and that a straight spine is the most frequent appearance of the cervical spine in supine MRI. In relation to symptoms it was seen that a kyphotic deformity was associated with reporting the highest intensities of headache at baseline, but not with an increased risk of long-lasting neck pain or headache. In conclusion, a kyphotic deformity is not significantly associated with chronic whiplash associated pain. Moreover, it is a clear clinical implication that pain should not be ascribed to a straight spine on MRI. We suggest that future trials on cervical posture focus upon the presence of kyphotic deformity rather than just on the absence of lordosis.
Chronic pain after hysterectomy is reported by 5% to 32% of women, but it is unknown whether the pain is a result of surgery or can be attributable to other factors such as preoperative and postoperative pain, physical, and psychosocial status. The aim of this prospective study was therefore to study the role of surgery and other possible predictors for pain 4 months after hysterectomy.
Ninety women referred for hysterectomy for benign conditions completed the study. The women were interviewed and completed pain questionnaires before surgery and after 3 weeks and 4 months. Questions were about pain location, intensity, and frequency, as well as medical treatment and impact on daily living. In addition, the Short Form-36 General Health Status Questionnaire and Coping Strategies Questionnaire were completed before surgery.
Fifteen women (16.7%) had persistent pain 4 months after hysterectomy. In 11 women, the pain resembled their preoperative pain, whereas 4 women had pain likely to be related to surgery. Preoperative "pain problems elsewhere" and a high "acute postoperative pain intensity" were associated with having pain 4 months after hysterectomy (P = 0.004 and P = 0.034). A similar tendency was seen for preoperative "pelvic pain" (P = 0.059). Women with pain at 4 months reported lower quality of life in 4 Short Form-36 subscales and less control of pain preoperatively (P < 0.05 and P = 0.023).
Pain persisting 4 months after hysterectomy is most often related to preoperative factors and acute postoperative pain. The relative contribution of surgery itself is small.
Physical mechanisms are the possible factors involved in the development and maintenance of long-term handicaps after acute whiplash injury. This study prospectively examined the role of active neck mobility, cervical and extra-cervical pains, as well as non-painful complaints after a whiplash injury as predictors for subsequent handicap.
Consecutive acute whiplash patients (n = 688) were interviewed and examined by a study nurse after the median of 5 days after injury, and divided into a high- or a low-risk group by an algorithm based on pain intensity, number of non-painful complaints and active neck mobility [active cervical range of motion (CROM)]. All 458 high-risk patients and 230 low-risk patients received mailed questionnaires after 3, 6 and 12 months. Two examiners examined all high-risk patients (n = 458) and 41 consecutive low-risk patients at median 11, 109, 380 days after injury. The main outcome measures were: handicaps, severe headaches, neck pain and neck disability.
The relative risk for a 1-year disability increased by 3.5 with initial intense neck pain and headaches, by 4.6 times with reduced CROM and by four times with multiple non-painful complaints.
Reduced active neck mobility, immediate intense neck pain and headaches and the presence of multiple non-painful complaints are the important prognostic factors for a 1-year handicap after acute whiplash.
Local sensitization to noxious stimuli has been previously described in acute whiplash injury and has been suggested to be a risk factor for chronic sequelae following acute whiplash injury. In this study, we prospectively examined the development of tender points and mechano-sensitivity in 157 acute whiplash injured patients, who fulfilled criteria for WAD grade 2 (n=153) or grade 3 (n=4) seen about 5 days after injury (4.8+/-2.3) and who subsequently had or had not recovered 1 year after a cervical sprain. Tender point scores and stimulus-response function for mechanical pressure were determined in injured and non-injured body regions at specific time-points after injury. Thirty-six of 157 WAD grade 2 patients (22.9%) had not recovered, defined as reduced work capacity after 1 year. Non-recovered patients had higher total tender point scores after 12 (p<0.05), 107 (p<0.05) and 384 days (p<0.05) relative to those who recovered. Tenderness was found in the neck region and in remote areas in non-recovered patients. The stimulus-response curves for recovered and non-recovered patients were similar after 12 days and 107 days after the injury, but non-recovered patients had steeper stimulus-response curves for the masseter (p<0.02) and trapezius muscles (p<0.04) after 384 days. This study shows early mechano-sensitization after an acute whiplash injury and the development of further sensitization in patients with long-term disability.
Pain threshold, nociceptive flexion reflex (NFR) threshold and responses to suprathreshold stimulation were investigated in
15 female patients (mean age 32 yr (range 22–48 yr)) before and 68 (range 48–96) h after gynaecological laparotomy. Control
measurements were performed in 17 healthy human volunteers (five males, age 30 yr (range 24–41 yr)). In the surgical patients,
pain threshold decreased and pain to suprathreshold stimulation increased significantly (?= 0.006and P =0.04, respectively)
from before to after surgery. A corresponding trend was demonstrated in neurophysiological measurements, although the decrease
in NFR threshold and increase in NFR amplitude to suprathreshold stzimulation were not significant (P =0.08 and P =0.24, respectively).
The correlations between the relative change in pain and reflex thresholds, and time from surgery, were statistically significant
(pain threshold: rs =0.53, P =0.04; NFR thresholds: rs= 0.54, P=0.04). In the healthy volunteers, no significant differences in thresholds and responses to suprathreshold stimulation
were observed between two recordings with an interval of at least 48 h. The allodynia and hyperalgesia observed in postsurgical
patients may be related to postoperative sensitization of central neurones.
The present study evaluated the use of psychologic measures, in particular, the relatively new Million Behavioral Health Inventory (MBHI), in predicting change in physical function of chronic low back pain patients undergoing a functional restoration program. The first 134 consecutive patients completing this program were assessed. Results demonstrated that various clinical scales of the MBHI were predictive of improvement in physical function. In addition, various scales enabled discrimination between patients who completed the program and those who prematurely dropped out. Although this inventory shows promise in helping to predict response to treatment, no single psychologic test can reliably be used as the sole predictor in clinical cases.
Forty patients with tension headache and 40 healthy comparable control persons were palpated by the same "blinded" observer. Tenderness in 10 pericranial muscles on each side was rated on a four-point scale. A Total Tenderness Score was calculated for each individual by adding the scores from all palpated areas. Headache patients had significantly higher scores than controls and also significantly higher tenderness in each point separately. Median normal values and confidence limits for tenderness are given. Among 23 patients with daily headache a correlation was found between headache intensity and Total Tenderness Score. It is likely that the pathologic tenderness in patients with tension headache is the source of nociception, but pain mechanisms are more complex, as evidenced by discrepancy between tenderness and pain in some patients. Pathologic tenderness should be a contributing criterion to the diagnosis of tension headache (muscle contraction headache).
SYNOPSIS
The present study evaluated the use of the Millon Behavioral Health Inventory (MBHI) in predicting response to a behavioral treatment program for headache reduction. A secondary goal was to also assess whether the MBHI could significantly differentiate among headache patients, patients with other types of chronic pain, and normal subjects. Twenty-three chronic headache sufferers were administered a behavioral treatment program which consisted of 16, one-hour weekly sessions. During the course of the treatment program, subjects were requested to keep daily records of four measures which later served as the treatment-outcome indices: (1) daily number of headaches, (2) duration of headaches, (3) intensity of headaches, (4) medications taken. Results demonstrated that a number of MBHI scales significantly predicted response to treatment. Also, it was found that the MBHI significantly differentiated the chronic headache patients from the normal controls and patients with other forms of chronic pain.
To study nociceptive processing in chronic tension-type headache.
Survey of the threshold for the nociceptive flexion reflex obtained by sural nerve stimulation in a convenience sample of 40 patients with chronic tension-type headache and in 29 sex- and age-matched healthy subjects. Muscular response was recorded from the biceps femoris muscle. For each stimulation, subjects recorded pain on a visual analogue scale.
In seven subjects (four headache sufferers and three healthy subjects), no nociceptive flexion reflex response could be elicited. The median nociceptive flexion reflex threshold in the headache group was significantly lower (median, 10 mA) than in the control group (median, 20 mA). Pain tolerance thresholds were significantly lower in the headache group than in the control group. A high degree of correlation was found between nociceptive flexion reflex threshold and tolerated stimulus strength. The slopes of the stimulus intensity/visual analogue scale pain rating response curves were steeper in patients with headache than in control subjects.
Chronic tension-type headache may represent a disorder of an endogenous antinociceptive system with a lowering of tone and recruitment of descending inhibitory systems.
The aim of the present study was to investigate the stimulus-response function for pressure versus pain in patients with myofascial pain. Forty patients with chronic tension-type headache and 40 healthy controls were examined. Tenderness in 8 pericranial muscles and tendon insertions was evaluated by manual palpation with a standardized evaluated methodology. Thereafter, a highly tender muscle and a largely normal muscle were palpated with 7 different pressure intensities using a palpometer, and the induced pain was recorded by the subjects on a visual analogue scale blinded for the observer. Pericranial myofascial tenderness was considerably higher in patients than in controls (P < 0.00001). The stimulus-response function recorded from normal muscle was well described by a power function. From highly tender muscle, the stimulus-response function was displaced towards lower pressures and, more importantly, it was linear, i.e., qualitatively different from normal muscle. Our results demonstrate for the first time that nociceptive processes are qualitatively altered in patients with chronic myofascial pain and suggest that myofascial pain may be mediated by low-threshold mechanosensitive afferents projecting to sensitized dorsal horn neurons. Further investigations of these mechanisms may lead to an increased understanding and better treatment of these common and often incapacitation pain disorders.
To investigate the perception of pain in tender muscles of patients with fibromyalgia.
Twenty-five women with fibromyalgia and 25 healthy women were examined. Seven different pressure intensities were used to palpate a highly tender muscle and a largely normal muscle. Subjects then recorded their response to induced pain on a visual analog scale. The examiner was blinded to each subject's response.
The stimulus-response function for pressure versus pain recorded for normal muscle was well described by a power function. For highly tender muscle, the stimulus-response function was displaced toward lower pressures and, more importantly, it was linear, i.e., qualitatively different from that of normal muscle.
This study demonstrates that nociception is qualitatively altered in patients with fibromyalgia, which is consistent with recent findings in other patients with tender muscles. The data strongly indicate that fibromyalgic pain, at least in part, is due to aberrant central pain mechanisms.
In a prospective study 29 patients fulfilled the criteria of Whiplash-Associated Disorders grade III in the Quebec classification.
One month postinjury, computerized neuropsychological tests, a clinical interview and the symptom checklist SCL-90-R were administered. Three whiplash scales were extrapolated from SCL-90-R: pain, subjective cognitive difficulties and sleep disorders. SCL-90-R was repeated 6 months later.
One month after the accident, 85% of the patients had resumed work. Subjective cognitive disturbances, however, were frequent but unrelated to test performances, which were within the normal range. Patients reporting stressful life events unrelated to the injury had more symptoms and elevated levels of distress on all SCL-90-R syndrome scales. At follow-up their distress was unchanged, and subjective cognitive function had deteriorated.
Stressful life events unrelated to the accident and a high level of distress 1 month postinjury may augment the risk of "late whiplash syndrome". Reassessment 3-6 weeks postinjury as recommended by the Quebec Task Force should include assessment of complicating social factors and a psychological symptom checklist.
The whiplash syndrome has immense socio-economic impact. Despite extensive studies over the past years, the mechanisms involved in maintaining the pain in chronic whiplash patients are poorly understood. The aim of the present experimental study was to examine the muscular sensibility in areas within and outside the region involved in the whiplash trauma. Eleven chronic whiplash patients and 11 sex and age matched control subjects were included in the study. Before the experiment, the whiplash patients had pain in the neck and shoulder region with radiating pain to the arm. Five patients reported pain that was more widespread. The somatosensory sensibility in the areas over the infraspinatus, brachioradial, and anterior tibial muscles was assessed by pressure stimulation, pin-prick stimulation, and cotton swap stimulation. Infusion of hypertonic saline (5.85%, 0.5 ml) into the infraspinatus and anterior tibial muscles was performed to assess the muscular sensibility and referred pain pattern. The saline-induced muscle pain intensity was assessed on a continuous visual analogue scale (VAS). The distribution of pain was drawn on an anatomical map. The pressure pain thresholds were significantly lower in patients (P<0. 01) compared with controls: infraspinatus (mean 152.2 vs. 172.7 kPa), brachioradial (mean 70.0 vs. 363.8 kPa), and anterior tibial muscle (mean 172.7 vs. 497.8 kPa). The skin sensibility to pin-prick stimulation and cotton swap stimulation was not different between patients and controls. Infusion of hypertonic saline caused significantly higher VAS scores with longer duration in patients compared to control subjects (P<0.01). The area under the VAS-time curve was significantly (P<0.01) increased in patients compared to control subjects after injection into the infraspinatus muscle (mean 4138.1 vs. 780.0 cm s) and anterior tibial muscle (mean 4370.8 vs. 978.7 cm s). The saline infusion caused local pain defined as pain located around the injection site and referred pain areas not included in the local pain area. The area of local and referred pain were significantly larger in patients compared to control subjects (P<0.01). In the control group, the referred pain areas to infusion of hypertonic saline into the anterior tibial muscle were found at the dorsal aspect of the ankle. In contrast, the areas of referred pain were quite widespread in the patient group with both distal and proximal referred pain areas. In the present study, muscular hyperalgesia and large referred pain areas were found in patients with chronic whiplash syndrome compared to control subjects both within and outside the traumatised area. The findings suggest a generalised central hyperexcitability in patients suffering from chronic whiplash syndrome. This indicates that the pain might be considered as a neurogenic type of pain, and new pharmacological treatments should be investigated accordingly.
A 6-month prospective study of neck mobility in patients with acute whiplash injury and a control group with acute ankle distortion was conducted.
To assess active neck mobility after acute whiplash and ankle distortion injuries, and to relate neck mobility to headache, neck pain, and speed of car at the time of collision.
A major problem after whiplash injury is restriction of neck mobility immediately subsequent to trauma. It is, however, unclear whether neck mobility changes after the acute injury are related to the associated headache and neck pain.
Cervical range of neck motion, neck pain, and headache were assessed after 1 week, then 1, 3, and 6 months after injury in 141 patients with acute whiplash injury, and in 40 patients with acute nonsport ankle distortion.
Patients with whiplash injury had significantly reduced flexion, extension, lateral flexion, and rotation of the neck immediately after injury, as compared with patients with ankle distortion injury. Neck mobility, however, was similar in the two groups after 3 months. In patients with whiplash injury, neck pain and neck mobility were found to be related inversely to reported headache and neck mobility. Neck mobility was not significantly related to a difference in car speed at the time of collision.
Neck mobility is reduced immediately after, but not 3 months after, a whiplash trauma. Headache and neck mobility are related inversely and neck pain and neck mobility are related inversely during the first 6 months after acute whiplash injury.
Exposure to a whiplash injury implies a risk for development of chronic disability and handicap, with reported frequencies ranging from 0% to 50% in follow-up studies. The exact risk for development of chronic whiplash syndrome is not known.
To prospectively determine the sensitivity and specificity of five possible predictors for handicap following a whiplash injury.
In a 1-year prospective study of persons with acute whiplash injury (n = 141) and control subjects who had acute ankle distortion (n = 40), pain intensity, number of nonpainful neurologic complaints, cervical mobility, workload during extension and flexion of the neck, and results of psychometric assessment were recorded. The consecutively sampled injured persons were assessed with structured and semistructured questionnaires, and underwent neurologic examination after 1 week and 1, 3, 6, and 12 months. After 3 to 4 years, participants with whiplash injury were questioned about legal issues.
After 1 year, 11 (7.8%) persons with whiplash injury had not returned to usual level of activity or work. The best single estimator of handicap was the cervical range-of-motion test, which had a sensitivity of 73% and a specificity of 91% (p < 0.01, Cox regression analysis). Accuracy and specificity increased to 94% and 99% when combined with pain intensity and other complaints. This increase was gained at the expense of a reduced sensitivity. Initiation of lawsuit within first month after injury did not influence recovery.
The cervical range-of-motion test has a high sensitivity in prediction of handicap after acute whiplash injury. The value of cervical range-of-motion test is further improved by additional recording of symptoms and pain intensity.
OBJECTIVE OF THE INVESTIGATION: In a 6-month prospective study of 141 consecutive acute whiplash-injured participants, and 40 acute, ankle-injured controls, pain and tenderness in the neck/head, and at a distant control site, were measured.
Muscle palpation and pressure algometry in five head/neck muscle-pairs were performed after 1 week and 1, 3 and 6 months after injury. Algometry was performed at a distant control site.
Whiplash-injured patients had lowered pressure-pain-detection thresholds and higher palpation-score initially in the neck/head, but the groups were similar after 6 months, and the control site was not sensitized.
Focal, but not generalized, sensitization to musculoskeletal structure is present until 3 months, but not 6 months, after whiplash injury, and probably does not play a major role in the development of late whiplash syndrome. Pressure algometry and palpation are useful clinical tools in the evaluation of neck and jaw pain in acute whiplash injury.
The mechanisms underlying chronic pain after whiplash injury are usually unclear. Injuries may cause sensitization of spinal cord neurons in animals (central hypersensitivity), which results in increased responsiveness to peripheral stimuli. In humans, the responsiveness of the central nervous system to peripheral stimulation may be explored by applying sensory tests to healthy tissues. The hypotheses of this study were: (1) chronic whiplash pain is associated with central hypersensitivity; (2) central hypersensitivity is maintained by nociception arising from the painful or tender muscles in the neck.
Comparison of patients with healthy controls.
Pain clinic and laboratory for pain research, university hospital.
Fourteen patients with chronic neck pain after whiplash injury (car accident) and 14 healthy volunteers.
Pain thresholds to: single electrical stimulus (intramuscular), repeated electrical stimulation (intramuscular and transcutaneous), and heat (transcutaneous). Each threshold was measured at neck and lower limb, before and after local anesthesia of the painful and tender muscles of the neck.
The whiplash group had significantly lower pain thresholds for all tests. except heat, at both neck and lower limb. Local anesthesia of the painful and tender points affected neither intensity of neck pain nor pain thresholds.
The authors found a hypersensitivity to peripheral stimulation in whiplash patients. Hypersensitivity was observed after cutaneous and muscular stimulation, at both neck and lower limb. Because hypersensitivity was observed in healthy tissues, it resulted from alterations in the central processing of sensory stimuli (central hypersensitivity). Central hypersensitivity was not dependent on a nociceptive input arising from the painful and tender muscles.
To prospectively examine the course of pain and other neurologic complaints in patients with acute whiplash injury and in controls with acute ankle injury.
Patients with acute whiplash (n = 141) and ankle-injured controls (n = 40) were consecutively sampled, and underwent interview and examination after 1 week and 1, 3, 6, and 12 months. Outcome measures were pain intensity, pain frequency, and associated symptoms.
Initial overall pain intensity above lower extremities (pain in neck, head, shoulder-arm, and low back) was similar in patients with whiplash (median Visual Analogue Scale [VAS](0-100) of 20 [25th and 75th percentile, 4, 39]) and ankle-injured controls (median VAS(0-100) of 15 [5, 34]). Whiplash-injured patients reported median overall VAS(0-100) pain intensity above lower extremities of 23 (12, 40) after 11 days and 14 (12, 40) after 1 year. Controls reported pain intensity of 0 (0, 4) after 12 days and 0 (0, 9) after 1 year. Reported overall pain frequency above lower extremities was 96% after 11 days and 74% after 1 year in whiplash-injured patients and 33% after 12 days and 47% after 1 year in controls. Associated neurologic symptoms were two to three times more common after whiplash injury. Correlation was found between pain intensity and associated symptoms in whiplash-injured patients but not controls.
Pain occurs with high frequency but low intensity after whiplash and ankle injury. Associated neurologic symptoms were not correlated to pain in ankle-injured controls, but were correlated to pain in patients with whiplash injury. Persistent symptoms in whiplash-injured patients may be caused by both specific neck injury-related factors and nonspecific post-traumatic reactions. Disability was only encountered in the whiplash group.
Predictors of outcome following whiplash injury are limited to socio-demographic and symptomatic factors, which are not readily amenable to secondary and tertiary intervention. This prospective study investigated the predictive capacity of early measures of physical and psychological impairment on pain and disability 6 months following whiplash injury. Motor function (ROM; kinaesthetic sense; activity of the superficial neck flexors (EMG) during cranio-cervical flexion), quantitative sensory testing (pressure, thermal pain thresholds, brachial plexus provocation test), sympathetic vasoconstrictor responses and psychological distress (GHQ-28, TSK, IES) were measured in 76 acute whiplash participants. The outcome measure was Neck Disability Index scores at 6 months. Stepwise regression analysis was used to predict the final NDI score. Logistic regression analyses predicted membership to one of the three groups based on final NDI scores (<8 recovered, 10-28 mild pain and disability, >30 moderate/severe pain and disability). Higher initial NDI score (1.007-1.12), older age (1.03-1.23), cold hyperalgesia (1.05-1.58), and acute post-traumatic stress (1.03-1.2) predicted membership to the moderate/severe group. Additional variables associated with higher NDI scores at 6 months on stepwise regression analysis were: ROM loss and diminished sympathetic reactivity. Higher initial NDI score (1.03-1.28), greater psychological distress (GHQ-28) (1.04-1.28) and decreased ROM (1.03-1.25) predicted subjects with persistent milder symptoms from those who fully recovered. These results demonstrate that both physical and psychological factors play a role in recovery or non-recovery from whiplash injury. This may assist in the development of more relevant treatment methods for acute whiplash.
Unlabelled:
Whiplash injury and chronic whiplash syndrome represent major health problems in certain western communities, pain being the main symptom. Sensitization of the nociceptive system may play a role for non-recovery after whiplash injury.
Aims:
This study examined if tolerance to endure pain stimuli may predict outcome in whiplash injury. In a prospective fashion, 141 acute whiplash patients exposed to rear-end car collision (WAD grade 1-3) and 40 ankle-injured controls were followed and exposed to a cold pressor test, respectively, 1 week, 1, 3, 6 and 12 months after the injury. VAS score of pain and discomfort was obtained before, during and after immersion of the dominant hand into cold water for 2 min. The McGill Pain Questionnaire showed that ankle-injured controls had higher initial pain scores than the corresponding whiplash group, while whiplash-injured subjects had higher scores at 6 months; pain scores being similar at other time points. No difference was found in cold pressor pain between recovered whiplash patients and ankle-injured subjects. Non-recovery was only encountered in whiplash injury. Eleven non-recovered whiplash patients (defined as: handicap after 1 year) showed reduced time to peak pain from 1 week to 3 months (P<0.001), 6 months (P<0.01), but not 12 months after the injury. A larger pain area was seen in non-recovered vs. recovered whiplash-injured subjects during the entire observation period (P<0.001). Non-recovery after whiplash was associated with initially reduced cold pressor pain endurance and increased peak pain, suggesting that dysfunction of central pain modulating control systems plays a role in chronic pain after acute whiplash injury.
Chronic post-operative pain is a well-recognized problem after various types of surgery, but little is known about chronic pain after orthopedic surgery. Severe pre-operative pain is the primary indication for total hip arthroplasty (THA). Therefore, we examined the prevalence of chronic pain after THA in relation to pre-operative pain and early post-operative pain.
A questionnaire was sent to 1231 consecutive patients who had undergone THA 12-18 months previously, and whose operations had been reported to the Danish Hip Arthroplasty Registry.
The response rate was 93.6%. Two hundred and ninety-four patients (28.1%) had chronic ipsilateral hip pain at the time of completion of the questionnaire, and pain limited daily activities to a moderate, severe or very severe degree in 12.1%. The chronic pain state was related to the recalled intensity of early post-operative pain [95% confidence interval (CI), 20.4-33.4%] and pain complaints from other sites of the body (95% CI, 20.7-32.1%), but not to the pre-operative intensity of pain.
Chronic pain after THA seems to be a significant problem in at least 12.1% of patients. Our results suggest that genetic and psychosocial factors are important for the development of chronic post-THA pain.
Population-based incidence cohort.
To report the incidence, timing, and course of depressive symptoms after whiplash.
Evidence is conflicting about the frequency, time of onset, and course of depressive symptoms after whiplash.
Adults making an insurance claim or seeking health care for traffic-related whiplash were followed by telephone interview at 6 weeks, and 3, 6, 9, and 12 months post-injury. Depressive symptoms were assessed at baseline and at each follow-up.
Of the 5,211 subjects reporting no pre-injury mental health problems, 42.3% (95% confidence interval, 40.9-43.6) developed depressive symptoms within 6 weeks of the injury, with subsequent onset in 17.8% (95% confidence interval, 16.5-19.2). Depressive symptoms were recurrent or persistent in 37.6% of those with early post-injury onset. Pre-injury mental health problems increased the risk of later onset depressive symptoms and of a recurrent or persistent course of early onset depressive symptoms.
Depressive symptomatology after whiplash is common, occurs early after the injury, and is often persistent or recurrent. This suggests that, like neck pain and headache, depressed symptomatology is part of the cluster of acute whiplash symptoms. Clinicians should be aware of both physical and psychologic injuries after traffic collisions.
To test the reproducibility of the finding that early intensive care for whiplash injuries is associated with delayed recovery.
We analyzed data from a cohort study of 1,693 Saskatchewan adults who sustained whiplash injuries between July 1, 1994 and December 31, 1994. We investigated 8 initial patterns of care that integrated type of provider (general practitioners, chiropractors, and specialists) and number of visits (low versus high utilization). Cox models were used to estimate the association between patterns of care and time to recovery while controlling for injury severity and other confounders.
Patients in the low-utilization general practitioner group and those in the general medical group had the fastest recovery even after controlling for important prognostic factors. Compared with the low-utilization general practitioner group, the 1-year rate of recovery in the high-utilization chiropractic group was 25% slower (adjusted hazard rate ratio [HRR] 0.75, 95% confidence interval [95% CI] 0.54-1.04), in the low-utilization general practitioner plus chiropractic group the rate was 26% slower (HRR 0.74, 95% CI 0.60-0.93), and in the high-utilization general practitioner plus chiropractic combined group the rate was 36% slower (HRR 0.64, 95% CI 0.50-0.83).
The observation that intensive health care utilization early after a whiplash injury is associated with slower recovery was reproduced in an independent cohort of patients. The results add to the body of evidence suggesting that early aggressive treatment of whiplash injuries does not promote faster recovery. In particular, the combination of chiropractic and general practitioner care significantly reduces the rate of recovery.
This systematic literature review aims to assess the prognostic value of psychological factors in the development of late whiplash syndrome (LWS). We included prospective cohort studies that provided a baseline measure of at least one psychological variable and used outcome measures relating to LWS (i.e. pain or disability persisting 6 months post injury). A search of electronic databases (Pubmed, Medline, Cinahl, Embase and Psychinfo) up to August 2006 was done using a predetermined search strategy. Methodological quality was assessed independently by two assessors. Data extraction were carried out using a standardised data extraction form. Twenty-five articles representing data from 17 cohorts were included. Fourteen articles were rated as low quality with 11 rated as adequate quality. Meta-analysis was not undertaken due to the heterogeneity of prognostic factors, outcome measures and methods used. Results were tabulated and predefined criterion applied to rate the overall strength of evidence for associations between psychological factors and LWS. Data on 21 possible psychological risk factors were included. The majority of findings were inconclusive. Limited evidence was found to support an association between lower self-efficacy and greater post-traumatic stress with the development of LWS. No association was found between the development of LWS and personality traits, general psychological distress, wellbeing, social support, life control and psychosocial work factors. The lack of conclusive findings and poor methodological quality of the studies reviewed highlights the need for better quality research. Self-efficacy and post-traumatic distress may be associated with the development of LWS but this needs further investigation.
Hypersensitivity to a variety of sensory stimuli is a feature of persistent whiplash associated disorders (WAD). However, little is known about sensory disturbances from the time of injury until transition to either recovery or symptom persistence. Quantitative sensory testing (pressure and thermal pain thresholds, the brachial plexus provocation test), the sympathetic vasoconstrictor reflex and psychological distress (GHQ-28) were prospectively measured in 76 whiplash subjects within 1 month of injury and then 2, 3 and 6 months post-injury. Subjects were classified at 6 months post-injury using scores on the Neck Disability Index: recovered (<8), mild pain and disability (10-28) or moderate/severe pain and disability (>30). Sensory and sympathetic nervous system tests were also measured in 20 control subjects. All whiplash groups demonstrated local mechanical hyperalgesia in the cervical spine at 1 month post-injury. This hyperalgesia persisted in those with moderate/severe symptoms at 6 months but resolved by 2 months in those who had recovered or reported persistent mild symptoms. Only those with persistent moderate/severe symptoms at 6 months demonstrated generalised hypersensitivity to all sensory tests. These changes occurred within 1 month of injury and remained unchanged throughout the study period. Whilst no significant group differences were evident for the sympathetic vasoconstrictor response, the moderate/severe group showed a tendency for diminished sympathetic reactivity. GHQ-28 scores of the moderate/severe group were higher than those of the other two groups. The differences in GHQ-28 did not impact on any of the sensory measures. These findings suggest that those with persistent moderate/severe symptoms at 6 months display, soon after injury, generalised hypersensitivity suggestive of changes in central pain processing mechanisms. This phenomenon did not occur in those who recover or those with persistent mild symptoms.
Chronic whiplash-associated disorder (WAD) represents a major medical and psycho-social problem. The typical symptomatology presented in WAD is to some extent similar to symptoms of post traumatic stress disorder. In this study we examined if the acute stress reaction following a whiplash injury predicted long-term sequelae. Participants with acute whiplash-associated symptoms after a motor vehicle accident were recruited from emergency units and general practitioners. The predictor variable was the sum score of the impact of event scale (IES) completed within 10 days after the accident. The main outcome-measures were neck pain and headache, neck disability, general health, and working ability one year after the accident. A total of 737 participants were included and completed the IES, and 668 (91%) participated in the 1-year follow-up. A baseline IES-score denoting a moderate to severe stress response was obtained by 13% of the participants. This was associated with increased risk of considerable persistent pain (OR=3.3; 1.8-5.9), neck disability (OR=3.2; 1.7-6.0), reduced working ability (OR=2.8; 1.6-4.9), and lowered self-reported general health one year after the accident. These associations were modified by baseline neck pain intensity. It was not possible to distinguish between participants who recovered and those who did not by means of the IES (AUC=0.6). In conclusion, the association between the acute stress reaction and persistent WAD suggests that post traumatic stress reaction may be important to consider in the early management of whiplash injury. However, the emotional response did not predict chronicity in individuals.
Best evidence synthesis.
To perform a best evidence synthesis on the course and prognostic factors for neck pain and its associated disorders in Grades I-III whiplash-associated disorders (WAD).
Knowledge of the course of recovery of WAD guides expectations for recovery. Identifying prognostic factors assists in planning management and intervention strategies and effective compensation policies to decrease the burden of WAD.
The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) conducted a critical review of the literature published between 1980 and 2006 to assemble the best evidence on neck pain and its associated disorders. Studies meeting criteria for scientific validity were included in a best evidence synthesis.
We found 226 articles related to course and prognostic factors in neck pain and its associated disorders. After a critical review, 70 (31%) were accepted on scientific merit; 47 of these studies related to course and prognostic factors in WAD. The evidence suggests that approximately 50% of those with WAD will report neck pain symptoms 1 year after their injuries. Greater initial pain, more symptoms, and greater initial disability predicted slower recovery. Few factors related to the collision itself (for example, direction of the collision, headrest type) were prognostic; however, postinjury psychological factors such as passive coping style, depressed mood, and fear of movement were prognostic for slower or less complete recovery. There is also preliminary evidence that the prevailing compensation system is prognostic for recovery in WAD.
The Neck Pain Task Force undertook a best evidence synthesis to establish a baseline of the current best evidence on the course and prognosis for WAD. Recovery of WAD seems to be multifactorial.
Systematic Review.
To summarize evidence concerning physical prognostic factors for development of Late Whiplash Syndrome (LWS).
There have been 3 previous systematic reviews of prognosis of whiplash with conflicting findings. The Quebec Task Force concluded that high priority should be given to determining prognostic factors. Subsequently their review was updated by Cote et al (Spine 2001;26:E445-58) and most recently by Scholten-Peeters et al (Pain 2003;104:303-22).
We searched electronic databases from their inception to August 2006 using a prespecified search strategy. We included prospective cohort and case control studies that studied physical prognostic factors at baseline. Two independent reviewers selected articles, extracted data, and assessed quality. Meta-analysis was not performed due to the heterogeneity between studies. Instead, levels of evidence were generated by grouping similar findings from cohorts.
Thirty-eight articles from 26 cohorts were reviewed. The majority of articles (25 of 38) were rated as low quality. No studies were rated as high quality. Only a minority of studies used validated prognostic measures and/or outcome measures. High initial neck pain intensity, neck pain related disability, and cold hyperalgesia all had moderate evidence for an association with the development of LWS. No factor was rated as having strong evidence.
Pain has a central role to play as a prognostic factor for the development of LWS. Other physical factors commonly used in the clinical setting showed inconclusive evidence for their influence on prognosis. There is a need for improved quality of studies with consistent use of validated measures of all categories of prognostic factors and outcome. This may then provide a clearer understanding of prognosis of Whiplash Associated Disorders and therefore facilitate effective management of this costly problem.
Medically unexplained or functional somatic symptoms are prevalent in primary care, but general practitioners commonly find them difficult to treat. We focus on the conceptual issues and treatment from a primary care perspective, although the field is difficult to review because of the inconsistency and multiplicity of terminology used by different authors and specialties.
The training of general practitioners in management techniques has been hampered by an obsolete theoretical framework and outdated diagnostic systems. Epidemiological studies, however, indicate that valid, empirically based diagnostic criteria for functional disorders may be developed. Management studies in primary care have shown disappointing effects on patient outcome, but a lot may be gained by making the training programmes more sophisticated. Recently, stepped care approaches have been introduced but they need scientific evaluation.
There is an immediate need for a common language and a theoretical framework of understanding of functional symptoms and disorders across medical specialties, clinically and scientifically. Any names that presuppose a mind-body dualism (such as somatization, medically unexplained) ought to be abolished. The overall ambition for treatment is to offer patients with functional somatic symptoms the same quality of professional healthcare as we offer any other patient.
We conducted a systematic review and meta-analysis of prospective cohort studies of subjects with acute whiplash injuries. The aim was to describe the course of recovery, pain and disability symptoms and also to assess the influence of different prognostic factors on outcome. Studies were selected for inclusion if they enrolled subjects with neck pain within six weeks of a car accident and measured pain and/or disability outcomes. Studies were located via a sensitive search of electronic databases; Medline, Embase, CINAHL, Cochrane database, ACP Journal club, DARE and Psychinfo and through hand-searches of relevant previous reviews. Methodological quality of all studies was assessed using a six item checklist. Sixty-seven articles, describing 38 separate cohorts were included. Recovery rates were extremely variable across studies but homogeneity was improved when only data from studies of more robust methodological quality were considered. These data suggest that recovery occurs for a substantial proportion of subjects in the initial 3 months after the accident but after this time recovery rates level off. Pain and disability symptoms also reduce rapidly in the initial months after the accident but show little improvement after 3 months have elapsed. Data regarding the prognostic factors associated with poor recovery were difficult to interpret due to heterogeneity of the techniques used to assess such associations and the way in which they are reported. There was also wide variation in the measurement of outcome and the use of validated measures would improve interpretability and comparability of future studies.
A classification of injury and a follow-up schedule were proposed by the Quebec Task Force (QTF) in 1995. No general agreement about the clinical usefulness of the WAD-classification or of the suggested follow-up regimen exists. A series of 186 consecutive cases seen in the emergency room during the acute phase after a whiplash injury was prospectively studied for 1 year. All findings including history and physical findings were recorded using standardized QTF protocols. In one group follow-up visits were done according to the QTF regimen: at 1, 3, 6, 12 weeks and 1 year after the accident; in a control group no visit was scheduled. The outcome variable was neck pain at 1 year after the accident. After 1 year, 18% of the total number of patients had significant neck pain. Risk factors for chronic neck pain at 1 year after whiplash injury were: neck pain before the accident and a high degree of emotional distress at the time of the accident; both factors independently associated with a tenfold increased risk of developing chronic neck pain. Neither the WAD classification nor the QTF follow-up regimen could be linked to a better outcome. In this study the outcome was associated with patient-specific characteristics and not with physical signs of injury, the depth of the initial evaluation or the follow-up regimen.
To present an explanatory framework for understanding prognosis and illustrate it using data from a systematic review.
A framework including three phases of explanatory prognosis investigation was adapted from earlier work and a discussion of causal understanding was integrated. For illustration, prognosis studies were identified from electronic and supplemental searches of literature between 1966 and December 2006. We extracted characteristics of the populations, exposures, and outcomes and identified three phases of explanatory prognosis investigation: Phase 1, identifying associations; Phase 2, testing independent associations; and Phase 3, understanding prognostic pathways. The purpose of each phase is exploration, confirmation, and development of understanding, respectively.
It is important to consider a framework of explanatory prognosis studies for: (1) defining the study objectives, (2) presenting the study methods and data, and (3) interpreting and applying the results of the study.
When conducting and reporting prognosis studies, researchers should consider the approach to prognosis (explanatory or outcome prediction) and phase of investigation, use best methods to limit biases, report completely, and cautiously interpret results. Readers of health care research will then be better able to evaluate the goals and interpret and appropriately use the results of prognosis studies.