Whiplash-associated Disorders Grades Research Articles

The effect of a neck-specific exercise program on cervical kinesthesia for patients with chronic whiplash-associated disorders: a case-control study

IntroductionCervical kinesthesia is an important part of movement control and of great importance for daily function. Previous research on kinesthesia in whiplash-associated disorders (WAD) has focused on grades I-II. More research is needed on WAD grade III. The aim of this study was to investigate cervical kinesthesia in individuals with WAD grades II-III before and after a neck-specific exercise intervention and compare them to healthy controls.MethodsA prospective, case-control study with a treatment arm (n = 30) and a healthy control arm (n = 30) was conducted in Sweden. The WAD group received a neck-specific exercise program for 12 weeks. The primary outcome to evaluate kinesthesia was neck movement control (the Fly test). Secondary outcomes were neck disability, dizziness and neck pain intensity before and after the Fly test. Outcomes were measured at baseline and post-treatment. The control arm underwent measurements at baseline except for the dizziness questionnaire. A linear mixed model was used to evaluate difference between groups (WAD and control) and over time, with difficulty level in the Fly test and gender as factors.ResultsBetween-group analysis showed statistically significant differences in three out of five kinesthetic metrics (p = 0.002 to 0.008), but not for the WAD-group follow-up versus healthy control baseline measurements. Results showed significant improvements for the WAD-group over time for three out of five kinaesthesia metrics (p < 0.001 to 0.008) and for neck disability (p < 0.001) and pain (p = 0.005), but not for dizziness (p = 0.70).ConclusionsThe exercise program shows promising results in improving kinesthesia and reducing neck pain and disability in the chronic WAD phase. Future research might benefit from focusing on adding kinesthetic exercises to the exercise protocol and evaluating its beneficial effects on dizziness or further improvement in kinesthesia.Impact statementKinesthesia can be improved in chronic WAD patients without the use of specific kinesthetic exercises.Trial registrationClinicalTrials.gov (NCT03664934), first registration approved 11/09/2018.

Demonstration of transverse ligament on 3D SPACE MRI in whiplash-associated disorder and nontraumatic conditions.

This study aims to delineate the three-dimensional (3D) SPACE MRI findings of the transverse ligament (TL) in whiplash-associated disorder (WAD) patients, and to compare them with those from a nontraumatic group. A retrospective analysis was performed on cervical spine MRI scans obtained from 46 patients with WAD and 62 nontraumatic individuals. Clinical features, including the WAD grade and stage, were recorded. The TL's morphological grade and the symmetricity of the lateral atlantodental interval was assessed using axial 3D T2-SPACE images. The morphological grading was evaluated using a four-point scale: 0 = homogeneously low signal intensity with normal thickness, 1 = high signal intensity with normal thickness, 2 = reduced thickness, 3 = full-thickness rupture or indistinguishable from surrounding structures. Additionally, the number of cervical levels exhibiting degeneration was documented. When comparing the WAD and nontraumatic groups, a significant difference was observed in the proportion of high-grade TL changes (grade 2 or 3) and the number of degenerated cervical levels. Logistic regression analysis revealed that high-grade TL changes and a lower number of degenerative levels independently predicted the presence of WAD. Within the WAD group, the subset of patients with high-grade TL changes demonstrated a significantly higher mean age than the low-grade group (grade 0 or 1). High-grade morphological changes in the TL can be detected in patients with WAD through the use of 3D SPACE sequences. Clinical relevance statement 3D SPACE MRI could serve as an instrumental tool in the assessment of TL among patients with WAD. Integrating MRI findings with patient history and symptomology could facilitate the identification of potential ligament damage, and may help treatment and follow-up planning.

Neurofilament light protein as a cerebrospinal fluid marker after whiplash trauma

The purpose was to investigate if a whiplash trauma may cause an increased concentration of the Neurofilament Light (NFL) protein, and if so; is this related to the injury severity and the radiological findings? Adult car occupants, with neck problems after rear-end collisions, were investigated in a study on Whiplash-Associated Disorders (WAD) in 1997-2001. The study protocol included a neurological examination, plain radiography and MRT of the cervical spine, and a lumbar puncture for Cerebrospinal Fluid (CSF) within six weeks after the accident. Similar CSF samples were also taken three and twelve months later. All CSF samples were analyzed for NFL. Of 52 subjects who entered the study, 43 completed it. The WAD grade was I in two of the 43 cases, II in 13, and III in 28. No one had radiological signs, indicating injuries to the cervical spine or spinal cord. Six subjects showed an increased NFL concentration at the primary examination. This was judged to be caused by whiplash trauma in three of them (7%). There was no relation between an increased NFL concentration and the number of pathological changes on plain radiographs or MRT. Neither was there a relation between the NFL concentration and the WAD grade. An increased NFL concentration can be found in some WAD patients. It might be difficult to relate such an increase to clinical or radiological findings. Further studies should investigate NFL as a marker for injuries to the central nervous system in whiplash trauma, including minimal traumatic brain injuries.

Fatty infiltrate and neck muscle volume in individuals with chronic whiplash associated disorders compared to healthy controls – a cross sectional case–control study

BackgroundThe underlying pathophysiological mechanisms of chronic Whiplash Associated Disorders (WAD) are not fully understood. More knowledge of morphology is needed to better understand the disorder, improve diagnostics and treatments. The aim was to investigate dorsal neck muscle volume (MV) and muscle fat infiltration (MFI) in relation to self-reported neck disability among 30 participants with chronic WAD grade II-III compared to 30 matched healthy controls.MethodsMV and MFI at spinal segments C4 through C7 in both sexes with mild- to moderate chronic WAD (n = 20), severe chronic WAD (n = 10), and age- and sex matched healthy controls (n = 30) was compared. Muscles: trapezius, splenius, semispinalis capitis and semispinalis cervicis were segmented by a blinded assessor and analyzed.ResultsHigher MFI was found in right trapezius (p = 0.007, Cohen’s d = 0.9) among participants with severe chronic WAD compared to healthy controls. No other significant difference was found for MFI (p = 0.22–0.95) or MV (p = 0.20–0.76).ConclusionsThere are quantifiable changes in muscle composition of right trapezius on the side of dominant pain and/or symptoms, among participants with severe chronic WAD. No other statistically significant differences were shown for MFI or MV. These findings add knowledge of the association between MFI, muscle size and self-reported neck disability in chronic WAD.Trial registrationNA. This is a cross-sectional case–control embedded in a cohort study.

Comparative Effectiveness and Safety of Concomitant Treatment with Chuna Manual Therapy and Usual Care for Whiplash Injuries: A Multicenter Randomized Controlled Trial.

Objectives: We aimed to compare the effectiveness and safety of Chuna manual therapy combined with usual care to those of usual care alone for treating whiplash injuries. Design: A two-arm, parallel, assessor-blinded, multicenter pragmatic randomized clinical trial. Setting: Three hospitals in Korea. Participants: Overall, 132 participants between 19 and 70 years of age, involved in traffic accidents and treated at three hospitals in Korea, >2 but <13 weeks prior to enrollment, with neck pain consistent with whiplash-associated disorder grades I and II and a numeric rating scale score ≥5 were included. Interventions: Participants were equally and randomly allocated to the Chuna manual therapy and usual care (n = 66) or usual care (n = 66) groups and underwent corresponding treatment for three weeks. Primary and secondary outcome measures: The primary outcome was the number of days to achieve a 50% pain reduction. Secondary outcomes included areas under the 50% numeric rating scale reduction curve: pain, disability, quality of life, and safety. Results: The Chuna manual therapy + usual care group (23.31 ± 21.36 days; p = 0.01) required significantly fewer days to achieve 50% pain reduction compared to the usual care group (50.41 ± 48.32 days; p = 0.01). Regarding pain severity, functional index, and quality of life index, Chuna manual therapy and usual care were more effective than usual care alone. Safety was acceptable in both groups. Conclusions: In patients with subacute whiplash injury, Chuna manual therapy showed a rapid rate of recovery, high effectiveness, and safety.

Evaluation of implementation and effectiveness of neck-specific exercise for persistent disability and pain after whiplash injury: study protocol for a randomized controlled study using a hybrid 2 design

BackgroundPersistent pain and disability in whiplash-associated disorders (WAD) grades II and III are common. In two randomized controlled trials (RCTs) of neck-specific exercises (NSE), we have seen promising results in chronic WAD, with a sustained clinically important reduction in pain and disability. NSE can also be delivered through internet support (NSEIT) and a few visits to a physiotherapist, saving time and cost for both patients and providers. NSE have been shown to have positive effects in other neck pain disorders and we will evaluate the diffusion of the exercises to other patients. The aims of the proposed study are to evaluate an implementation strategy for NSEIT and NSE in primary health care and to evaluate the effectiveness of NSEIT and NSE in clinical practice.MethodsThe proposed study is a prospective cluster-randomized mixed-design study with hybrid 2 trial design. Reg. physiotherapists working in twenty physiotherapy clinics will be included. The primary implementation outcome is proportion of patients with neck pain receiving neck-specific exercise. Secondary outcomes are; physiotherapists attitudes to implementation of evidence-based practice, their self-efficacy and confidence in performing NSEIT/NSE, number of patients visits, and use of additional or other exercises or treatment. To further evaluate the implementation strategy, two qualitative studies will be performed with a sample of the physiotherapists. The primary outcome in the patient effectiveness evaluation is self-reported neck disability according to the Neck Disability Index (NDI). Secondary outcomes are pain intensity in the neck, arm, and head; dizziness; work- and health-related issues; and patient’s improvement or deterioration over time. All measurements will be conducted at baseline and at 3 and 12 months. Physiotherapists´ self-efficacy and confidence in diagnosing and treating patients with neck pain will also be evaluated directly after their instruction in NSEIT/NSE.DiscussionThis trial will evaluate the implementation strategy in terms of adoption of and adherence to NSEIT and NSE in clinical primary health care, and measure diffusion of the method to other patients. In parallel, the effectiveness of the method will be evaluated. The results may guide physiotherapists and health care providers to sustainable and effective implementation of effective exercise programs.Trial registrationThe randomized trial is registered on ClinicalTrials.gov, NCT05198258, initial release date January 20, 2022.

Associations Between Resting Heart Rate, Resting Blood Pressure, Psychological Variables and Pain Processing in Chronic Whiplash-Associated Disorder: A Cross-Sectional Study.

Autonomic nervous system dysfunction has been implicated in chronic whiplash-associated disorder (WAD). However, the relationship between autonomic variables (e.g., resting heart rate and blood pressure) and clinical factors in chronic WAD is not well understood. This study sought to examine the associations between resting heart rate, resting blood pressure, pain processing and psychological variables in chronic WAD and in pain-free controls. Secondary analysis of a cross-sectional study. University clinical research laboratory. Thirty-six people with chronic WAD Grade II (mean [SD] age 40.1 [14.6] years, 28 females) and 25 pain-free controls (35.6 [13.0] years, 17 females). Participants had resting heart rate, systolic and diastolic blood pressure measured. Pain processing measures comprised: (i) pain pressure threshold at the cervical spine, hand and leg, (ii) temporal summation at the cervical spine and hand, and (iii) conditioned pain modulation. Psychological outcomes included measures of kinesiophobia, pain catastrophizing and post-traumatic stress symptoms. Correlations between autonomic variables, pain processing and psychological variables were determined (P &lt; .05, 5% FDR). No significant correlations between autonomic and pain processing variables, or autonomic and psychological variables were found in the chronic WAD group. In the control group, diastolic blood pressure was positively correlated with cervical spine pressure pain threshold (r = 0.53, P = .007). An association between blood pressure and pain sensitivity was observed in the control group but not the chronic WAD group. Such an association appears to be disrupted in chronic WAD, which may infer involvement of autonomic pathways in the pathophysiology of this condition.

Nerve pathology and neuropathic pain after whiplash injury: a systematic review and meta-analysis.

There is no clear understanding of the mechanisms causing persistent pain in patients with whiplash associated disorder (WAD). The aim of this systematic review was to assess the evidence for nerve pathology and neuropathic pain in patients with WAD. EMBASE, PubMed, CINAHL (EBSCO), and MEDLINE were searched from inception to 1st September 2020. Study quality and risk of bias were assessed using the Newcastle-Ottawa Quality Assessment Scales. Fifty-four studies reporting on 390,644 patients and 918 controls were included. Clinical questionnaires suggested symptoms of predominant neuropathic characteristic in 34% of patients (range 25-75%). Mean prevalence of nerve pathology detected with neurological examination was 13% (0-100%) and 32% (10-100%) with electrodiagnostic testing. Patients independent of WAD severity (Quebec Task Force grades I-IV) demonstrated significantly impaired sensory detection thresholds of the index finger compared to controls, including mechanical (SMD 0.65 [0.30;1.00] p< 0.005), current (SMD 0.82 [0.25;1.39] p=0.0165), cold (SMD -0.43 [-0.73;-0.13] p=0.0204) and warm detection (SMD 0.84 [0.25;1.42] p=0.0200). Patients with WAD had significantly heightened nerve mechanosensitivity compared to controls upon median nerve pressure pain thresholds (SMD - 1.10 [-1.50;-0.70], p<0.0001) and neurodynamic tests (SMD 1.68 [0.92;2.44], p=0.0004). Similar sensory dysfunction and nerve mechanosensitivity was seen in WAD grade II, which contradicts its traditional definition of absent nerve involvement. Our findings strongly suggest a subset of patients with WAD demonstrate signs of peripheral nerve pathology and neuropathic pain. Although there was heterogeneity among some studies, typical WAD classifications may need to be reconsidered and include detailed clinical assessments for nerve integrity.

Impaired neck motor control in chronic whiplash and tension-type headache.

The purpose of this study is twofold, first to present a new method based on head laser tracking designed to measure head or hand movements and second to further investigate if patients suffering from chronic whiplash or tension-type headache have impaired motor control of neck muscles. A new laser tracking instrument was designed to measure the ability of a test person to track a reference point moving on the wall by a laser fixed to the forehead or held in the hand. The reference point to be tracked moves in runs of a circle or a square at three different speeds 10, 20, or 30cm/s. We used a 1×1×1m setup geometry to provide head movements well below pain release. Groups of 22 patients diagnosed with chronic whiplash-associated disorder grade 2, 19 patients diagnosed with chronic tension-type headache, and 37 control persons were compared. A small but highly significant dyscoordination of head movements was observed in both patient groups and in whiplash also of the hand. Our study presents a new method based on laser tracking for precision quantitative measurements of head or hand movements during standardized conditions. The results confirm that motor control of head movements is impaired in both chronic whiplash and tension-type headache, and in whiplash also of the hand. This suggests involvement of the central nervous system in the pathology of these diseases.

Combining Stress Management With Pain Neuroscience Education and Exercise Therapy in People With Whiplash-Associated Disorders: A Clinical Perspective

Individuals classified as having whiplash-associated disorder (WAD) grade II, which reflects approximately 93% of people with WAD who are commonly managed by health care professionals, exhibit both physical (eg, pain and disability) and psychological (eg, fear of movement, anxiety, posttraumatic stress) problems that, in approximately 50% of cases, persist beyond 3months. There is still much ongoing debate regarding factors predictive of poor recovery. The strongest associations have been found for high initial pain and disability following whiplash injury. In addition, a growing body of evidence supports the clinical importance of characteristic features, such as disturbed nociceptive processing (eg, local or general hyperalgesia to cold and mechanical stimuli), inefficient cognitions and beliefs about pain/movement/recovery, and posttraumatic stress symptoms, in the development and maintenance of physical and psychological manifestations in individuals with WAD. For this reason, the field shifted away from single interventions that mainly follow a biomedical approach, such as exercise therapy and activity programs, to gold standard multimodal care (at least 2 distinct therapeutic modalities given by 1 or more health care professionals) that acknowledges the biopsychological nature of WAD. To date, there exist several multimodal care approaches to managing WAD; however, for most, the efficacy has been found to be rather limited. One may argue that the limited success of some approaches can be attributed to the fact that they focused mainly on rehabilitating the physical symptoms (eg, pain, disability) rather than also the associated cognitive (eg, catastrophizing) and psychological (eg, posttraumatic stress symptoms) symptoms of the condition, leaving much room for improvement. In this article, current and previous evidence is used to explain why and how a comprehensive and multimodal treatment for people with WAD-consisting of a combination of pain neuroscience education, cognition-targeted exercise therapy, and stress management-can be applied in clinical practice.

Exercise, headache, and factors associated with headache in chronic whiplash: Analysis of a randomized clinical trial.

Background:Almost 40% of individuals with chronic whiplash-associated disorders (WAD) report headache after 5 years, making it one of the most common persistent symptoms besides neck pain, but randomized treatment studies are lacking. This study aimed to evaluate the effect of 3 different exercise approaches on headache in chronic WAD grades 2 and 3, and to identify potential factors associated with such headache, and whether they differ depending on 3 different aspects of such headache (current headache, maximum headache, or headache bothersomeness).Methods:This was an analysis of a randomized clinical trial of people with chronic WAD and headache (n = 188), who were randomized to either 12 weeks of neck-specific exercise without (NSE) or with a behavioral approach (NSEB) or physical activity prescription (PPA). Data were collected at baseline and at 3, 6, and 12 months. Physical and psychosocial factors were tested for association with headache. Multivariate regression models and linear mixed models were used.Results:The NSE/NSEB groups reported reduced headache both over time and compared to PPA. Up to 51% (NSE) and 61% (NSEB) reported at least 50% reduction in their headache at 12 months. The PPA group was not improved over time. Neck pain and dizziness were associated with headache regardless of aspect of headache. The only associated psychosocial factor was anxiety, which was associated with headache bothersomeness. Other factors were mainly physical, and up to 51% of the variance was explained.Conclusion:Headache in chronic WAD, may be reduced with neck-specific exercise with or without a behavioral approach. Chronic headache was associated with neck pain and dizziness regardless of aspect tested. Other factors associated with headache in chronic WAD were mainly physical rather than psychosocial.Trial registration number:Clinical Trials.gov, no: NCT015285

The role of non-rigid cervical collar in pain relief and functional restoration after whiplash injury: a systematic review and a pooled analysis of randomized controlled trials.

Whiplash injury (WI) represents a common diagnosis at every emergency department. Several investigations have been conducted to compare the different medical managements for non-surgical cases. However, the role of the immobilization with a non-rigid cervical collar (nRCC) for pain management and range of motion (RoM) preservation has not been completely clarified. We performed a systematic review of the randomized control trials (RCTs) and a pooled analysis in order to investigate the role of the nRCC for pain management, scored through the visual analogue scale (VAS) and the RoM, by comparing the use of a nRCC (for 1-2weeks) with a non-immobilization protocols, regardless of the association with physical therapy (PhT). Only patients with whiplash-associated disorders grade I-II were included. Due to a certain heterogeneity across the RCTs, follow-up period time range resetting was necessary in order to pool the data. A total of 141 papers were reviewed; 6 of them matched the inclusion criteria and were admitted to the final study. Pooled analysis showed that nRCC does not improve the outcome in terms of VAS score and RoM trends along the follow-up. Moreover, VAS and RoM trends seem to further improve at long-term follow-up in non-immobilization associated with PhT group. This pooled analysis of the available RCTs shows the absence of an advantage of the immobilization protocol with a nRCC after a WI. On the contrary, non-immobilization protocols show an overall better trend of pain relief and neck mobility recovery, regardless of the association of PhT. These slides can be retrieved under Electronic Supplementary Material.

Cervical Rotator Muscle Activity With Eye Movement at Different Speeds is Distorted in Whiplash.

People with whiplash-associated disorders (WADs) report difficulty with quick head movements and cervicoocular dysfunction. Changes in coordination between eye movement and neck muscle activity may be involved. To examine whether activity of superficial and deep neck muscles increases with eye movement when the head is held in a fixed position, whether this differs between directions and speed of eye movement, and whether this is modified in WAD. Convenience case series with unmatched controls. Research laboratory. Nine individuals with chronic WAD grade II and 11 pain-free controls. Electromyography (EMG) was recorded from muscles that could act to rotate the neck to the right (right obliquus capitis inferior [OI], multifidus [MF], splenius capitis [SC], and left sternocleidomastoid [SCM]) with intramuscular or surface electrodes in 9 WAD participants and 11 pain-free controls. Eyes were rotated without head movement to track slow and medium-speed targets to the right or left, and as fast as possible (FP). Amplitude of EMG. In controls, SCM and SC EMG increased with right gaze (all P's < .03). EMG of the deep OI muscle increased in both directions (P < .001). WAD involved counterintuitive greater activity of SCM with left rotation across speeds of eye movement (SC with slow movement, P < .036), decreased OI EMG with gaze left (P < .019), and no change in MF EMG (P < .6) in either gaze direction. For FP tasks, EMG of all muscles was greater than slower speeds in controls (all P's < .0001), but not WAD (all P's > .33). Coordination between neck muscle activity and eye movements with increasing speed is modified in WAD. Contrasting changes are present in deep and superficial neck muscles with implications for neck function that may explain some common WAD symptoms. IV.

Is a government-regulated rehabilitation guideline more effective than general practitioner education or preferred-provider rehabilitation in promoting recovery from acute whiplash-associated disorders? A pragmatic randomised controlled trial

ObjectiveTo evaluate the effectiveness of a government-regulated rehabilitation guideline compared with education and activation by general practitioners, and to a preferred-provider insurance-based rehabilitation programme on self-reported global recovery from acute...

The effect of three exercise approaches on health-related quality of life, and factors associated with its improvement in chronic whiplash-associated disorders: analysis of a randomized controlled trial

PurposeThe aim was to evaluate whether neck-specific exercise, with (NSEB) or without (NSE) a behavioural approach, improves health-related quality of life (HRQoL) compared to physical activity prescription (PPA) in chronic whiplash-associated disorders (WAD) grades 2 and 3. A secondary aim was to identify factors associated with HRQoL and HRQoL improvement following exercise interventions.MethodsThis is a secondary analysis of a multicentre randomized clinical trial. Participants (n = 216) with chronic WAD grades 2 and 3 were randomized to 12 weeks of PPA or physiotherapist-led NSE or NSEB. The EQ-5D 3L/EQ-VAS and SF-36v2 physical (PCS) and mental (MCS) component summaries were collected together with several neck-related and psychosocial outcomes at baseline, after 3, 6 and 12 months, and were analysed with linear mixed models (all time points) and multivariate linear regressions (baseline, 6 months).ResultsNSE/NSEB resulted in better outcomes than PPA (EQ-VAS and SF-36 PCS, both groups, p < 0.01) but not in a higher EQ-5D score. Improvement over time was seen in EQ-5D/EQ-VAS for the NSEB group (p < 0.01), and for NSE/NSEB as measured with the PCS (p < 0.01). Factors associated with baseline HRQoL and change to 6 months in HRQoL (R2 = 0.38–0.59) were both neck-related and psychosocial (e.g. depression, work ability).ConclusionNeck-specific exercise, particularly with a behavioural approach, may have a more positive impact on HRQoL than physical activity prescription in chronic WAD grades 2 and 3. HRQoL is however complex, and other factors also need to be considered. Factors associated with HRQL and improvements in HRQoL following exercise are multidimensional.Trial registration number: ClinicalTrials.gov, No. NCT01528579.

Adoption and use of guidelines for whiplash: an audit of insurer and health professional practice in New South Wales, Australia

BackgroundIn Australia, the New South Wales (NSW) State Insurance Regulatory Authority has been continuously developing and implementing clinical practice guidelines to address the health and economic burden from whiplash associated disorders (WAD). Despite this, it is uncertain the extent to which the guidelines are followed. This study aimed to determine insurer and health professional compliance with recommendations of the 2014 NSW clinical practice guidelines for the management of acute WAD; and explore factors related to adherence.MethodsThis was an observational study involving an audit of 288 randomly-selected claimant files from 4 insurance providers in NSW, Australia between March and October 2016. Data extracted included demographic, claim and injury details, use of health services, and insurer and health professional practices related to the guidelines. Analyses involved descriptive statistics and correlation analysis.ResultsMedian time for general practitioner medical consultation was 4 days post-injury and 25 days for physical treatment (e.g. physiotherapy). Rates of x-ray investigations were low (21.5%) and most patients (90%) were given active treatments in line with the guideline recommendations. The frequency of other practices recommended by the guidelines suggested lower guideline adherence in some areas such as; using the Quebec Task Force classification (19.9%); not using specialised imaging for WAD grades I and II (e.g. MRI, 45.8%); not using routine passive treatments (e.g. manual therapy, 94.0%); and assessing risk of non-recovery using relevant prognostic tools (e.g. Neck Disability Index, 12.8%). Over half of the claimants (59.0%) were referred to other professionals at 9–12 weeks post-injury, among which 31.2% were to psychologists and 68.8% to specialists (surgical specialists, 43.6%; WAD specialists, 20.5%). Legal representation and lodgment of full claim were associated with increased number of medical visits and imaging (ρ 0.23 to 0.3; p < 0.01).ConclusionThere is evidence of positive uptake of some guideline recommendations by insurers and health professionals; however, there are practices that are not compliant and might lead to poor health outcomes and greater treatment cost. Organisational, regulatory and professional implementation strategies may be considered to change practice, improve scheme performance and ultimately improve outcomes for people with WAD.

Factors associated with work ability following exercise interventions for people with chronic whiplash-associated disorders: Secondary analysis of a randomized controlled trial.

To investigate the efficacy of exercise interventions and factors associated with changes in work ability for people with chronic whiplash-associated disorders. Secondary analysis of a single-blind, randomized multi-centre controlled trial. Interventions were conducted in Swedish primary care settings. A total of 165 individuals with chronic whiplash-associated disorders grade II-III. Participants were randomly allocated to neck-specific exercise, neck-specific exercise with a behavioural approach, or prescribed physical activity interventions. Work ability was evaluated with the Work Ability Index at baseline, 3, 6 and 12 months. The neck-specific exercise with a behavioural approach intervention significantly improved work ability compared with the prescribed physical activity intervention (3 months, p = 0.03; 6 months, p = 0.01; 12 months, p = 0.01), and neck-specific exercise at 12 months (p = 0.01). Neck-specific exercise was better than the prescribed physical activity intervention at 6 months (p = 0.05). An increase in work ability from baseline to one year for the neck-specific exercise with a behavioural approach group (p< 0.01) was the only significant within-group difference. Higher self-rated physical demands at work, greater disability, greater depression and poorer financial situation were associated with poorer work ability (p<0.01). This study found that neck-specific exercise with a behavioural approach intervention was better at improving self-reported work ability than neck-specific exercise or prescribed physical activity. Improvement in work ability is associated with a variety of factors.

Predictors before and after multimodal rehabilitation for pain acceptance and engagement in activities at a 1-year follow-up for patients with whiplash-associated disorders (WAD)—a study based on the Swedish Quality Registry for Pain Rehabilitation (SQRP)

Background ContextStudies have shown that pain acceptance strategies related to psychological flexibility are important in the presence of chronic musculoskeletal pain. However, the predictors of these strategies have not been studied extensively in patients with whiplash-associated disorders (WAD). PurposeThe purpose of this study was to predict chronic pain acceptance and engagement in activities at 1-year follow-up with pain intensity, fear of movement, perceived responses from significant others, outcome expectancies, and demographic variables in patients with WAD before and after multimodal rehabilitation (MMR). Study designThe design of this investigation was a cohort study with 1-year postrehabilitation follow-up. Study settingThe subjects participated in MMR at a Swedish rehabilitation clinic during 2009–2015. Patient sampleThe patients had experienced a whiplash trauma (WAD grade I–II) and were suffering from pain and reduced functionality. A total of 386 participants were included: 297 fulfilled the postrehabilitation measures, and 177 were followed up at 1 year after MMR. Outcome measuresDemographic variables, pain intensity, fear of movement, perceived responses from significant others, and outcome expectations were measured at the start and after MMR. Chronic pain acceptance and engagement in activities were measured at follow-up. MethodsThe data were obtained from a Swedish Quality Registry for Pain Rehabilitation (SQRPR). ResultsOutcome expectancies of recovery, supporting and distracting responses of significant others, and fear of (re)injury and movement before MMR were significant predictors of engagement in activities at follow-up. Pain intensity and fear of (re)injury and movement after MMR significantly predicted engagement in activities at follow-up. Supporting responses of significant others and fear of (re)injury and movement before MMR were significant predictors of pain acceptance at the 1-year follow-up. Solicitous responses of significant others and fear of (re)injury and movement at postrehabilitation significantly predicted pain acceptance at follow-up. ConclusionFor engagement in activities and pain acceptance, the fear of movement appears to emerge as the strongest predictor, but patients' perceived reactions from their spouses need to be considered in planning the management of WAD.

Motor evoked potentials in patients with chronic whiplash-associated disorder grade II

Background and purposeIt is common belief that psychological problems influence the persistence of complains in patients with so-called mild whiplash-associated disorders (WADs). The usefulness of motor evoked potentials (MEPs) is investigated in patients with grade II WAD and remaining complains for more than 6 months. Patients and methodsTwenty consecutive patients, aged between 24 and 58 years, with persistent neck pain for months after a car accident were included. All patients had a magnetic resonance imaging (MRI) of the cervical spine and cord. Central (CMCT) and peripheral motor conduction times (PMCT) were evaluated by registration in the biceps brachii muscle (C5–C6) and in the abductor digiti minimi muscle (C7–C8–Th1). ResultsThirteen patients had prolonged CMCT or/and PMCT compared to 7 with normal values. On MRI discus bulging C5–C6, without abnormal signal changes in the cervical spinal cord was observed in 6 of the patients with disturbed MEPs compared to 3 without. Out of 7 patients, who had repeated MEPs after 6 months, 3 of them had an improvement of their conduction time. The patients with prolonged MEP conduction times were older than those with normal values (p=0.007). ConclusionsMEP examination has to be performed in all patients with persistent complains even in the absence of objective neurological signs and non-significant changes on imaging.

Association between pain extent and health status in whiplash associated disorders

Background. Whiplash associated disorders (WAD) are a complex phenomenon associated with relevant social and economic burdens. Many people with chronic WAD show widespread pain which can be observed from the patient’s pain drawing. No studies have evaluated the relation of pain extent to perceived pain and disability, financial status, general health and psychological status in individuals with chronic WAD. Purpose. To evaluate the relation of pain extent to a number of variables related to the patients’ perceived pain and disability, their financial status, general health and psychological status. Methods. A total of 205 individuals with chronic WAD grade 2 or 3 were selected. The main outcome measure was pain extent, extracted from the pain drawing. Pain extent was evaluated in relation to sex, age, educational level, insurance status and financial status. Multiple linear regression analysis was then used to verify whether pain extent was significantly associated with the other health indicators including perceived pain intensity and disability, health-related quality of life, pain catastrophizing, anxiety, depression and self-efficacy. Results: Pain extent was influenced by the sex of the participant (p<0.01) with larger pain extent in women compared to men (7.88±7.66 vs 5.40±6.44). People with unsettled insurance claims (p<0.05) and those with a worse financial situation (p<0.01) showed larger pain extent. Multiple linear regression models revealed that, when accounting for age, sex, education, insurance status, financial status and neck pain intensity, pain extent remained associated with perceived disability (p<0.01), depression (p<0.05), and self-efficacy (p<0.001). Conclusion: Women with chronic WAD, those with unsettled insurance claims and those with poorer financial status reported more widespread pain. When controlling for these factors, larger pain areas remained associated with perceived pain and disability, depression and self-efficacy. Implications: Pain drawings support the clinical evaluation of people with chronic WAD.