Acute Whiplash-associated Disorders Research Articles

Higher Neck Pain Intensity and Pain Catastrophizing Soon After A Whiplash Injury Partially Explain the Presence of Persistent Headache: A Prospective Study.

To understand whether pain-related factors soon after a whiplash injury can explain the presence of chronic headache. A prospective study with a follow-up of 6 months was performed, including 42 patients with acute whiplash-associated disorders. Neck pain intensity, the Neck Disability Index, the Tampa Scale of Kinesiophobia, the Pain Catastrophizing Scale, and the Anxiety State-Trait Scale were assessed at baseline. Differences in clinical characteristics between those with and without headache at 6 months were determined. The relative risk of presenting with headache was evaluated. A logistic regression model was performed to assess which factors at baseline could explain the presence of headache at 6 months. At 6 months, one-third of the sample presented with chronic headache. Significant differences were found for several outcome measures when people with and without headache were compared ( P <0.001). The highest relative risk of presenting with headache was found for moderate/severe levels of pain catastrophizing during the acute phase (RR=15.00, 95% CI=3.93, 57.22). The level of neck pain intensity and pain catastrophizing at baseline partially explained the presence of headache at 6 months ( R2 =0.627). The risk of presenting with persistent headache attributed to a whiplash injury is increased when people present with higher neck pain intensity and pain catastrophizing soon after a whiplash injury. Evaluating neck pain intensity and pain catastrophizing at baseline may assist in identifying those more likely to develop chronic headache, potentially providing an opportunity for early targeted interventions.

Prognostic Factors of Perceived Disability and Perceived Recovery After Whiplash: A Longitudinal, Prospective Study With One-year Follow-up.

The understanding of the role that cognitive and emotional factors play in how an individual recovers from a whiplash injury is important. Hence, we sought to evaluate whether pain-related cognitions (self-efficacy beliefs, expectation of recovery, pain catastrophizing, optimism, and pessimism) and emotions (kinesiophobia) are longitudinally associated with the transition to chronic whiplash-associated disorders in terms of perceived disability and perceived recovery at 6 and 12 months. One hundred sixty-one participants with acute or subacute whiplash-associated disorder were included. The predictors were: self-efficacy beliefs, expectation of recovery, pain catastrophizing, optimism, pessimism, pain intensity, and kinesiophobia. The 2 outcomes were the dichotomized scores of perceived disability and recovery expectations at 6 and 12 months. Stepwise regression with bootstrap resampling was performed to identify the predictors most strongly associated with the outcomes and the stability of such selection. Baseline perceived disability, pain catastrophizing, and expectation of recovery were the most likely to be statistically significant, with an overage frequency of 87.2%, 84.0%, and 84.0%, respectively. Individuals with higher expectations of recovery and lower levels of pain catastrophizing and perceived disability at baseline have higher perceived recovery and perceived disability at 6 and 12 months. These results have important clinical implications as both factors are modifiable through health education approaches.

Usefulness of the DN4, S-LANSS, and painDETECT screening questionnaires to detect the neuropathic pain components in people with acute whiplash-associated disorders: a cross-sectional study.

Although the presence of neuropathic pain (NP) components has been reported in whiplash-associated disorders (WAD), no studies have analyzed the usefulness of NP screening questionnaires to detect NP components in WAD. This study aimed to assess the usefulness of 3 NP screening tools (Douleur Neuropathique 4 [DN4], self-administered Leeds Assessment of Neuropathic Symptoms and Signs [S-LANSS], and painDETECT questionnaire [PDQ]) to detect the presence of NP components in acute WAD. A cross-sectional study. Hospital. Of 188 eligible individuals, 50 people (68% women, mean age = 40.3 ± 12.5 years) with acute WAD (52% Grade III) were included. Specialized physicians initially screened participants for the presence of NP components according to clinical practice and international recommendations. After physician assessment, blinded investigators used NP screening questionnaires (DN4, S-LANSS, and PDQ) to assess participants within 2 weeks of their accident. The diagnostic accuracy of these tools was analyzed and compared with the reference standard (physicians' assessments). The 3 screening questionnaires showed excellent discriminant validity (area under the curve: ≥0.8), especially S-LANSS (area under the curve: 0.9; P < .001). DN4 demonstrated the highest sensitivity (87%), followed by S-LANSS (75%), while S-LANSS and PDQ showed the highest specificity (85% and 82%, respectively). These tools demonstrated a strong correlation with the reference standard (S-LANSS: rho = 0.7; PDQ: rho = 0.62; DN4: rho = 0.7; all, P < .001). The DN4, S-LANSS, and PDQ show excellent discriminant validity to detect the presence of NP components in acute WAD, especially S-LANSS. Initial screening with these tools might improve management of WAD.

Network analyses reveal the interaction between physical features, fear of movement and neck pain and disability in people with acute and chronic whiplash-associated disorders.

A network analysis can be used to quantitatively assess and graphically describe multiple interactions. This study applied network analyses to determine the interaction between physical and pain-related factors and fear of movement in people with whiplash-associated disorders (WAD) during periods of acute and chronic pain. Physical measurements, including pressure pain-thresholds (PPT) over neural structures, cervical range of motion, neck flexor and extensor endurance and the cranio-cervical flexion test (CCFT), in addition to subjective reports including the Tampa Scale of Kinesiophobia (TSK-11), Neck Disability Index (NDI) and neck pain and headache intensity, were assessed at baseline in 47 participants with acute WAD. TSK-11, NDI and pain intensity were assessed for the same participants 6 months later (n = 45). Two network analyses were conducted to estimate the associations between features at baseline and at 6 months and their centrality indices. Both network analyses revealed that the greatest weight indices were found for NDI and CCFT at baseline and for neck pain and headache intensity and NDI and TSK-11 at both time points. Associations were also found betweeen cervical muscle endurance and neck pain intensity in the acute phase. Cervical muscle endurance assesssed during the acute phase was also associated with NDI after 6 months - whereas PPT measured at baseline was associsated with headache intensity after 6 months. The strongest associations were found for headache and neck pain intensity and neck disability and fear of movement, both during acute pain and when mesured 6 months later. The extent of neck endurance and measures of PPT at baseline may be associated with neck disability and headache, respectively, 6 months after a whiplash injury. Through two network analyses, we evaluated the interaction between pain-related factors, fear of movement, neck disability and physical factors in people who had experienced a whiplash injury. We demonstrated that physical factors may be involved in the maintenance and development of chronic pain after a whiplash injury. Nevertheless, the strongest associations were found for headache and neck pain intensity and neck disability and fear of movement, both during acute and chronic phases.

Headache production during physical examination in patients with and without headache attributed to a whiplash injury: A case-control study

BackgroundProvocation of headache on physical examination of the neck may reflect a role of cervical structures in the presence of acute whiplash-associated headache (WAH). ObjectiveTo determine differences in headache provocation during physical tests in people with and without WAH after a whiplash injury. DesignCase-control study. MethodsForty-seven people with acute whiplash-associated disorders participated, 28 with WAH. Passive accessory intervertebral movement over the tubercle of C1, the spinous processes of C2-C3 and facet joints of C0-C4, the flexion-rotation test (FRT), manual palpation of cranio-cervical muscles and the upper limb neurodynamic test + cranio-cervical flexion were assessed bilaterally twice by a blinded examiner; headache provocation was determined. Cohen's kappa and Chi-squared were determined to evaluate the intra-rater reliability of test results and differences between groups, respectively. A logistic regression model was also performed. ResultsIntra-rater reliability of headache provocation was good or excellent for most tests. Significant differences between groups were found with higher positive tests in WAH for the assessment of C2 (68%), the most painful side of C0-C1 (57%), C1-C2 (75%) and C2-C3 (53%), most (79%) and least (25%) restricted sides of the FRT, and manual palpation of the most painful side for the trapezius (53%), masseter (50%) and temporalis (46%) muscles. Provocation of headache during the assessment of C2 and C1-C2 on the most painful side demonstrated the highest association with WAH. ConclusionMechanical provocation of headache is more frequent in people with WAH than in those without headache soon after a whiplash injury.

Baseline depressive symptoms do not moderate the association between baseline symptom severity and time to recovery in individuals with grade I-II whiplash-associated disorders: A secondary analysis of a randomised controlled trial.

This study investigated the moderating role of baseline depressive symptoms on the association between baseline pain severity and time to recovery in individuals with acute grade I-II whiplash-associated disorders (WAD). This is a secondary analysis of a randomised controlled trial investigating the effectiveness of a government-regulated rehabilitation guideline for the management of grade I-II WAD. Participants who completed baseline questionnaires for neck pain intensity and depressive symptoms and follow-up questionnaire on self-reported recovery were included in the analysis. Cox proportional hazards models were built, and hazard rate ratios were reported to describe the association between baseline neck pain intensity and time to self-reported recovery and to assess the effect modification of baseline depressive symptoms. 303 participants provided data for this study. Despite baseline level of depressive symptoms and neck pain intensity being independently associated with delayed recovery, the association between baseline neck pain intensity and time to recovery was not stronger for individuals with significant post-collision depressive symptoms (HRR = 0.91 (95%CI 0.79-1.04)) than for those without depressive symptoms (HRR = 0.92 (95%CI 0.83-1.02)). Baseline depressive symptoms are not an effect modifier of the association between baseline neck pain intensity and time to self-reported recovery in acute WAD.

Physical testing in patients with acute whiplash-associated disorders: A within session test-retest reliability study

BackgroundPeople with whiplash-associated disorders (WAD) commonly present with a variety of physical impairments. However, the reliability of physical tests has not been established for patients with acute WAD. ObjectiveTo assess test-retest reliability of different physical tests in acute WAD. DesignIntra-rater test-retest reliability. MethodsPatients with acute WAD were recruited. Physical tests were used to evaluate articular, muscular and neural systems in two blocks of measurements separated by 10 min. Bland-Altman plots were performed to assess intrarater agreement, which included calculation of the mean difference (d) between rates, the 95% CI for d, the standard deviation of the differences and the 95% limits of agreement. Reliability was calculated via the standard error of measurement, the minimal detectable change, percent of agreement, the intraclass-correlation coefficient, and kappa coefficient. Results47 patients participated. Test-retest reliability was excellent or good for almost all measures, except for extension ROM, ULTT for the radial nerve, and active cervical extension and upper cervical rotation performed in 4-point kneeling, which presented moderate reliability. Systematic bias was found in cervical ROM in flexion, left and right lateral-flexion, left and right rotation; left ULTT for radial nerve; right trapezius, suboccipitalis and temporalis muscles, left temporalis; C3, both sides of C1–C2, left C3–C4. ConclusionThe majority of physical tests achieved good or excellent test-retest intra-rater reliability when tested in patients with acute WAD. Findings must be considered with caution for those tests which demonstrated systematic bias. Additional research is warranted to evaluate inter-rater reliability.

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

ObjectivesTo determine if measures of cervical kinematics are altered in people with acute whiplash associated disorders (WAD) and secondarily, to examine whether kinematic variables are associated with self-reported outcomes. MethodsWe recruited people with acute WAD within 15 days after a motor vehicle collision and asymptomatic control participants. All participants performed active neck movements at a self-determined velocity. Maximal range of motion (ROM), peak and mean velocity of movement, smoothness of movement, and cervical joint position error were assessed. Moreover, self-reported measures of perceived pain and disability, pain catastrophising, and fear of movement were obtained. ResultsSixty people participated: 18 with acute WAD (mean age [SD] 38.7 [12.0]) and 42 as asymptomatic controls (mean age [SD] 38.4 [10.2]). Participants with acute WAD showed significantly decreased ROM in all movement directions (p < 0.0001). All participants with acute WAD showed a reduction in the mean and peak velocity of movement in all directions (p < 0.0001) and the number of velocity peaks was significantly higher (i.e., reduced smoothness of movement) in those with acute WAD in all directions (p < 0.0001). Repositioning acuity following cervical rotation was not significantly different between groups. Neck pain-related disability showed the largest number of significant associations with kinematic features, while fear of movement was not associated with measures of cervical kinematics. ConclusionsParticipants with acute WAD presented with altered cervical kinematics compared to asymptomatic participants. Several measures of cervical kinematics were associated with the level of pain and disability in people with acute WAD but not their fear of movement.

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

BackgroundWhipPredict, which includes prognostic factors of pain-related disability, age and hyperarousal symptoms, was developed and validated for prediction of outcome in people with whiplash associated disorders (WAD). Patient expectations of recovery was not an included factor, though is known to mediate outcomes. The aim of this study was to determine whether the addition of expectations of recovery could improve the accuracy of WhipPredict.MethodsTwo hundred twenty-eight participants with acute WAD completed questionnaires (WhipPredict and expectations of recovery) at baseline. Health outcomes (neck disability index (NDI) and Global Perceived Recovery (GPR)) were assessed at 6- and 12-months post injury. Cut-off points for expectations of recovery predictive of both full recovery (NDI ≤10 % , GPR ≥ 4) and poor outcome (NDI ≥30 % , GPR ≤ − 3) were determined, and multivariate logistic regression analyses were used to compare models with and without this variable.ResultsExpectations of recovery improved or maintained the accuracy of predictions of poor outcome (6-months: sensitivity 78 to 83%, specificity maintained at 79.5%; 12-months: sensitivity maintained at 80%, specificity 69 to 73%). The sensitivity of predictions of full recovery improved (6-months: 68 to 76%; 12-months: 57 to 81%), though specificity did not change appreciably at 6 months (80 to 81%) and declined at 12 (83 to 76%). ROC curves indicated a larger and more consistent improvement in model performance when expectations of recovery were added to the pathway predictive of full recovery.ConclusionsThe addition of expectations of recovery may improve the accuracy of WhipPredict, though further validation is required.

Higher Neck Pain Intensity and the Presence of Psychosocial Factors Are More Likely When Headache is Present after a Whiplash Injury: A Case-Control Study

Several factors such as neck pain intensity, disability, anxiety, depression, female sex, or a previous history of headache are associated with post-whiplash headache. However, the possible role of psychosocial factors contributing to the presence of headache or worsening of headache after a whiplash trauma remains unclear. To address this gap in knowledge, there is the need to assess psychosocial factors concerning headache shortly after a whiplash injury. To evaluate psychological features, pain and disability in people with acute whiplash associated disorders (WAD) and compare these features between those with and without headache. Case-control study. A secondary care traumatology center. Forty-seven people with acute WAD were recruited; 28 with headache, and 19 without. All participants completed self-reported questionnaires including Visual Analogue Scale (VAS) for neck pain intensity, the Neck Disability Index (NDI), Pain Catastrophizing Scale (PCS), Tampa Scale Kinesiophobia-11 (TSK-11), and State-Trait Anxiety Inventory. Neck pain intensity (P < .001), neck disability (P < 0.001), pain catastrophizing (P < .001), kinesiophobia (P < .001), and anxiety state (P = .007) and trait (P = .05) were higher in those with headache when compared to those without. In addition, high levels of neck pain (P = .025), moderate levels of neck disability (P < .001), moderate levels of pain catastrophizing (P = .015), and moderate (P = .002) and severe (P = .016) levels of kinesiophobia were related to the presence of headache. The level of neck pain intensity and disability, kinesiophobia, catastrophizing, and anxiety were all greater in people with acute WAD who presented with a headache compared to those without headache.

Are Measures of Physical Function of the Neck Region Associated With Poor Prognosis Following a Whiplash Trauma?: A Systematic Review.

The objective of this study was to synthesize the current evidence regarding the predictive ability of measures of physical function (PF) of the neck region and perceived PF on prognosis following a whiplash injury. Electronic databases were searched by 2 independent reviewers up to July 2020, including MEDLINE, EMBASE, CINAHL, PsycINFO, Scopus, and Web of Science as well as gray literature. Eligible studies were selected by 2 reviewers who then extracted and assessed the quality of evidence. Observational cohort studies were included if they involved participants with acute whiplash-associated disorders (WAD), followed for at least 3 months postinjury, and included objective measures of neck PF or self-reported measures of PF as prognostic factors. Data could not be pooled and therefore were synthesized qualitatively. Fourteen studies (13 cohorts) were included in this review. Low to very low quality of evidence indicated that initial higher pain-related disability and higher WAD grade were associated with poor outcome, while there was inconclusive evidence that neck range of motion, joint position error, activity of the superficial neck muscles, muscle strength/endurance, and perceived functional capacity are not predictive of outcome. The predictive ability of more contemporary measures of neck PF such as the smoothness of neck movement, variability of neck motion, and coactivation of neck muscles have not been assessed. Although initial higher pain-related disability and higher WAD grade are associated with poor outcome, there is little evidence available investigating the role of neck PF on prognosis following a whiplash injury.

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

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

Pregabalin vs placebo to prevent chronic pain after whiplash injury in at-risk individuals: results of a feasibility study for a large randomised controlled trial.

There are few effective treatments for acute whiplash-associated disorders (WADs). Early features of central sensitisation predict poor recovery. The effect of pregabalin on central sensitisation might prevent chronic pain after acute whiplash injury. This double blind, placebo-controlled randomised controlled trial examined feasibility and potential effectiveness of pregabalin compared with placebo for people with acute WAD. Twenty-four participants with acute WAD (<48 hours) and at risk of poor recovery (pain ≥5/10) were recruited from hospital emergency departments in Queensland, Australia, and randomly assigned by concealed allocation to either pregabalin (n = 10) or placebo (n = 14). Pregabalin was commenced at 75 mg bd, titrated to 300 mg bd for 4 weeks, and then weaned over 1 week. Participants were assessed at 5 weeks and 3, 6, and 12 months. Feasibility issues included recruitment difficulties and greater attrition in the placebo group. For the primary clinical outcome of neck pain intensity, attrition at 5 weeks was pregabalin: 10% and placebo: 36% and at 12 months was pregabalin: 10% and placebo: 43%. Pregabalin may be more effective than placebo for the primary clinical outcome of neck pain intensity at 3 months (mean difference: -4.0 [95% confidence interval -6.2 to -1.7]) on an 11-point Numerical Rating Scale. Effects were maintained at 6 months but not 12 months. There were no serious adverse events. Minor adverse events were more common in the pregabalin group. A definitive large randomised controlled trial of pregabalin for acute whiplash injury is warranted. Feasibility issues would need to be addressed with modifications to the protocol.

“I’ve learned to look at things in a different way”: exploring patients’ perspectives on participation in physiotherapist delivered integrated stress inoculation training and exercise for acute whiplash

Purpose To explore patient perspectives of the integrated intervention (intervention arm) of a recent randomised clinical trial that found clinically relevant and sustained benefits of a physiotherapist delivered integrated stress inoculation training (SIT) and exercise for people with acute whiplash-associated disorders (WAD) and at risk of poor recovery. Material and methods Twelve patients from the 53 who participated in the SIT and exercise arm of a randomised controlled trial (StressModex RCT) participated in semi-structured interviews. Data were analysed using inductive thematic analysis. Results Five main themes were identified: “balance between the physical and psychological components,” “dealing with stress,” “coping with the injury,” “pain relief and return to function,” and “elements enhancing therapeutic alliance.” Conclusions The majority of patients found the SIT techniques to be helpful in managing stress and pain, coping with their injury, and returning to function. The patients also found the exercises useful and acknowledged the importance of both the physical and the psychological aspects of whiplash injury. IMPLICATIONS FOR REHABILITATION Patients with acute WAD at risk of poor recovery welcomed the inclusion of psychological strategies as part of physiotherapy treatment. The patients nominated both the psychological (SIT) component and exercise as assisting them with their stress, pain, and recovery. Physiotherapists could consider including strategies targeting early stress responses in their management of patients with acute WAD.

Clinimetrics: Neck Disability Index.

The Neck Disability Index (NDI) is the most widely used assessment tool measuring disability due to acute and chronic neck pain or neck injury. 1 , 2 It has been recommended in both Australian and international guidelines as a suitable tool for the assessment of patients with acute whiplash-associated disorders and other neck pain. 345 It can also be used to monitor the effects of treatments over time and to classify chronic whiplash-associated disorder recovery status. 6The NDI is a modification of the Oswestry Low Back Pain Disability Index, 7 and consists of 10 items: pain intensity, personal care, lifting, reading, headaches, concentration, work, driving, sleeping and recreation. The patient rates the impact of their neck pain by ticking one of six boxes on a Likert scale. The tool takes approximately 5 to 10 minutes for the patient to self-administer and requires no special training. 2 The tool is free to access and can be printed from the Internet.

The Long-term Impact of Whiplash Injuries on Patient Symptoms and the Associated Degenerative Changes Detected Using MRI: A Prospective 20-year Follow-up Study Comparing Patients with Whiplash-associated Disorders with Asymptomatic Subjects.

A longitudinal, 20-year comparative study of patients with whiplash-associated disorders (WAD). The aim of this study was to clarify the long-term impact of WAD on patient symptoms and on magnetic resonance imaging (MRI) findings of the cervical spine, in comparison with asymptomatic volunteers. The long-term impact of WAD has not been fully elucidated. Between 1993 and 1996, we conducted a cross-sectional comparative study of 508 acute WAD patients and 497 asymptomatic volunteers, all of whom underwent MRI on cervical spine and physical examinations. For this 20-year follow-up comparative study, 75 WAD patients and 181 control subjects aged <60 years were recruited from the original cohort. The MRI findings, including discs' signal intensities, posterior disc protrusions, anterior dural compressions, spinal cord disc space narrowing, and foraminal stenoses, were evaluated using two to four numerical grades. The results of the WAD patients and control subjects were compared. In this follow-up, the prevalence of shoulder stiffness (72.0% vs. 45.9%), headache (24.0% vs. 12.2%), and arm pain (13.3% vs. 3.9%) were significantly greater in WAD patients than in control subjects. The multiregression analysis revealed that a history of WAD was associated with shoulder stiffness (odds ratio [OR]: 3.36), headache (OR: 2.39), and arm pain (OR: 3.82). Although MRI findings in WAD patients were more degenerated than in control subjects in the initial study, all MRI findings were similar at the 20-year follow-up. There were no significant correlations between clinical cervical symptoms and progression in each MR finding in either group. After 20 years, whiplash injuries significantly impacted the residual symptoms of shoulder stiffness, headache, and arm pain when compared with initially asymptomatic volunteers. The progression of degenerative changes in the cervical intervertebral discs after 20 years revealed no association with existing whiplash injuries, neither did the residual cervical-related symptoms.Level of Evidence: 3.

The mechanisms of effect of a physiotherapist-delivered integrated psychological and exercise intervention for acute whiplash-associated disorders: secondary mediation analysis of a randomized controlled trial

Integrated psychological and physical treatments can improve recovery for whiplash-associated disorders (WADs). Little is known about how these interventions work. To examine the mechanisms by which a physiotherapist-delivered integrated intervention for acute WAD improves health outcomes. Secondary analysis using structural equation modelling of a randomized controlled trial comparing integrated stress inoculation training and exercise to exercise alone for acute WAD. Outcomes were disability, pain self-efficacy, pain intensity, and health-related quality of life at 12 months. The intended intervention target and primary mediator, stress was tested in parallel with pain-related coping, an additional cognitive behavioral mediator that significantly improved at posttreatment (Model 1). Stress-related constructs that commonly co-occur with stress and pain were also tested as parallel mediators: depression and pain-related coping (Model 2); and posttraumatic stress and pain-related coping (Model 3). Reductions in stress mediated the effect of the integrated intervention on disability (β = -0.12, confidence interval [CI] = -0.21 to -0.06), pain self-efficacy (β = 0.09, CI = 0.02-0.18), pain (β = -0.12, CI = -0.21 to -0.06), and health-related quality of life (β = 0.11, CI = 0.04-0.21). There was an additional path to pain self-efficacy through pain-related coping (β = 0.06, CI = 0.01-0.12). Similar patterns were found in Models 2 and 3. Improvements in stress and related constructs of depression and posttraumatic stress, and pain-related coping were causal mechanisms of effect in a physiotherapist-delivered integrated intervention. As integrated interventions are growing in popularity, it is important to further personalize interventions for improved benefit.

Biomechanical contribution of the alar ligaments to upper cervical stability

Acute and chronic whiplash-associated disorders pose a significant healthcare burden due to chronic pain, which is associated with upper cervical instability resulting from ligamentous injury. No standard measure exists for diagnosing alar ligament injury and imaging findings vary widely. Multiple physical examination maneuvers are used to diagnose alar ligament injury including the C2 Spinous Kick, Flexion-Rotation, and Bending-Rotation tests. The objective of the current study was to determine the mechanical contribution of the alar ligaments to upper cervical stability and quantify the biomechanical changes seen during simulated clinical examinations after alar ligament injury. Eight cadaveric C0-C3 specimens were evaluated using a robotic testing system. Range of motion and moment at the end of intact specimen replay were the primary outcomes. Clinical examinations were simulated by rotation through two axes as performed during physical examination. Intact, unilateral and bilateral alar ligament injury states were tested. Unilateral alar ligament injury led to significant increases in lateral bending (12.0 ± 7.2%, p < 0.05), axial rotation (4.1 ± 2.4%, p < 0.05), and flexion-extension (5.3 ± 4.3%, p < 0.05) compared with intact specimens. The alar ligaments also contributed to resistance to intact motion in extension (13.4 ± 6.6%, p < 0.05), flexion (4.4 ± 2.2%, p < 0.05), axial rotation (19.3 ± 2.7%, p < 0.05), and lateral bending (16.0 ± 2.8%, p < 0.05). The C2 Spinous Kick Test showed the largest percentage change (−23.0 ± 14.8%), and the Bending-Rotation Test towards the side of injury significantly increased axial rotation by the largest absolute magnitude (5.5° ± 5.1°). Overall, quantifiable changes to motion measured during simulated physical examinations were found, but the ability of a clinician to feel these changes remains unknown.

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

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

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

IntroductionMitigating the transition from acute to chronic whiplash-associated disorders (WAD) is fundamental, and this could be achieved through early identification of individuals at risk. Several physical factors such as angular...