Whiplash-associated Disorders Research Articles

Pathology and Treatment of Traumatic Cervical Spine Syndrome: Whiplash Injury.

Traumatic cervical syndrome comprises the various symptoms that occur as a result of external force such as that of a traffic accident. In 1995, the Quebec Task Force on whiplash-associated disorders (WAD) formulated the Quebec classification, with accompanying clinical practice guidelines. These guidelines were in accordance with the stated clinical isolated or combined symptoms of the syndrome: neck pain, headaches, dizziness, numbness of head or face, eye pain, vision loss, double vision, tinnitus, hearing loss, nausea, and numbness and/or weakness of extremities. In recent years, cerebrospinal fluid hypovolemia or fibromyalgia has been recognized as a major notable cause of a variety of symptoms, although many clinical questions remain regarding the pathology of this syndrome. Therefore, its diagnosis and treatment should be conducted extremely carefully. While the Quebec classification and its guidelines are very useful for the normalization and standardization of symptoms of traumatic cervical syndrome, in the future, we would like to see the emergence of new guidelines that better address the diversity of this disease.

Cervical extension traction as part of a multimodal rehabilitation program relieves whiplash-associated disorders in a patient having failed previous chiropractic treatment: a CBP® case report.

[Purpose] To present the case of the non-surgical restoration of cervical lordosis in a patient suffering from chronic whiplash syndrome including chronic neck pain and daily headaches resulting from previous whiplash. [Subject and Methods] A 31 year old female presented with a chief complaint of chronic neck pain and headaches for 12 years, correlating temporally with a sustained whiplash. These symptoms were not significantly relieved by previous chiropractic spinal manipulative therapy. The patient had cervical hypolordosis and was treated with Chiropractic BioPhysics® protocol including extension exercises, manual adjustments and cervical extension traction designed to increase the cervical lordosis. [Results] The patient received 30 treatments over approximately 5-months. Upon re-assessment, there was a significant increase in global C2–C7 lordosis, corresponding with the reduction in neck pain and headaches. [Conclusion] This case adds to the accumulating evidence that restoring lordosis may be key in treating chronic whiplash syndrome. We suggest that patients presenting with neck pain and/or headaches with cervical hypolordosis be treated with a program of care that involves cervical extension traction methods to restore the normal cervical lordosis.

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.

Few promising multivariable prognostic models exist for recovery of people with non-specific neck pain in musculoskeletal primary care: a systematic review.

Which multivariable prognostic model(s) for recovery in people with neck pain can be used in primary care? Systematic review of studies evaluating multivariable prognostic models. People with non-specific neck pain presenting at primary care. Baseline characteristics of the participants. Recovery measured as pain reduction, reduced disability, or perceived recovery at short-term and long-term follow-up. Fifty-three publications were included, of which 46 were derivation studies, four were validation studies, and three concerned combined studies. The derivation studies presented 99 multivariate models, all of which were at high risk of bias. Three externally validated models generated usable models in low risk of bias studies. One predicted recovery in non-specific neck pain, while two concerned participants with whiplash-associated disorders (WAD). Discriminative ability of the non-specific neck pain model was area under the curve (AUC) 0.65 (95% CI 0.59 to 0.71). For the first WAD model, discriminative ability was AUC 0.85 (95% CI 0.79 to 0.91). For the second WAD model, specificity was 99% (95% CI 93 to 100) and sensitivity was 44% (95% CI 23 to 65) for prediction of non-recovery, and 86% (95% CI 73 to 94) and 55% (95% CI 41 to 69) for prediction of recovery, respectively. Initial Neck Disability Index scores and age were identified as consistent prognostic factors in these three models. Three externally validated models were found to be usable and to have low risk of bias, of which two showed acceptable discriminative properties for predicting recovery in people with neck pain. These three models need further validation and evaluation of their clinical impact before their broad clinical use can be advocated. PROSPERO CRD42016042204. [Wingbermühle RW, van Trijffel E, Nelissen PM, Koes B, Verhagen AP (2018) Few promising multivariable prognostic models exist for recovery of people with non-specific neck pain in musculoskeletal primary care: a systematic review. Journal of Physiotherapy 64: 16-23].

Validity and Responsiveness of the Pain Self-Efficacy Questionnaire in Patients With Neck Pain Disorders.

Study Design Longitudinal clinimetric study. Background Pain self-efficacy predicts poor recovery and mediates the relationship between pain and disability in patients with neck pain disorders (NPDs). The Pain Self-Efficacy Questionnaire (PSEQ) is a frequently used instrument to measure pain self-efficacy; however, its measurement properties have never been evaluated in a group of patients with NPDs. Objectives This study aimed to assess validity and responsiveness of the PSEQ in patients with NPDs. Methods Patients with NPDs (n = 161) were included. Confirmatory and exploratory factor analysis was used to assess structural validity. Twelve hypotheses on expected correlations with other instruments were formulated a priori to assess construct validity. Responsiveness was evaluated in 146 patients with NPDs who underwent multimodal rehabilitation by testing 12 hypotheses on expected effect sizes, area under the curve, and correlations with change in other instruments. Results Factor analyses showed that the PSEQ is a unidimensional instrument with moderate construct validity and responsiveness (50% to 75% of hypotheses met). Validity was consistent when analyzed separately for patients with whiplash-associated disorders and idiopathic neck pain, and responsiveness was better in patients with idiopathic neck pain. Conclusion The PSEQ is a unidimensional measure of pain self-efficacy in patients with NPDs, as found by previous studies in other populations. Nevertheless, in contrast with previous studies, its construct validity and responsiveness were found to be suboptimal in NPDs, suggesting that the content validity of the PSEQ and of the comparator instruments used in this study should be better assessed. J Orthop Sports Phys Ther 2018;48(3):204-216. Epub 19 Dec 2017. doi:10.2519/jospt.2018.7605.

Thoracic dysfunction in whiplash associated disorders: a systematic review

Background Research investigating Whiplash Associated Disorder (WAD) has largely focused on the cervical spine yet symptoms can be widespread. Thoracic spine pain prevalence is reported ~66%; perhaps unsurprising given the forceful stretch/eccentric loading of posterior structures of the spine, and the thoracic spine’s contribution to neck mobility/function. Approximately 50% WAD patients develop chronic pain and disability resulting in high levels of societal and healthcare costs. It is time to look beyond the cervical spine to fully understand anatomical dysfunction in WAD and provide new directions for clinical practice and research. Purpose To evaluate the scope and nature of dysfunction in the thoracic region in patients with WAD. Methods A systematic review and data synthesis was conducted according to a pre-defined, registered (PROSPERO, CRD42015026983) and published protocol. All forms of observational study were included. A sensitive topic-based search strategy was designed from inception to 1/06/16. Databases, grey literature and registers were searched using a study population terms and key words derived from scoping search. Two reviewers independently searched information sources, assessed studies for inclusion, extracted data and assessed risk of bias. A third reviewer checked for consistency and clarity. Extracted data included summary data: sample size and characteristics, outcomes, and timescales to reflect disorder state. Risk of bias was assessed using the Newcastle-Ottawa Scale. Data were tabulated to allow enabling a semi-qualitative comparison and grouped by outcome across studies. Strength of the overall body of evidence was assessed using a modified GRADE. Results Thirty eight studies (n>50,000) which were conducted across a range of countries were included. Few authors responded to requests for further data (5 of 9 contacted). Results were reported in the context of overall quality and were presented for measures of pain or dysfunction and presented, where possible, according to WAD severity and time point post injury. Key findings include: 1) high prevalence of thoracic pain (>60%); higher for those with more severe presentations and in the acute stage, 2) low prevalence of chest pain (<22%), 3) evidence of thoracic outlet syndrome, with some association to and involvement of the brachial plexus, 4) muscle dysfunction in the form of heightened activity of the sternocleidomastoid or delayed onset of action of the serratus anterior, 5) high prevalence of myofascial pain and trigger points in the scalene muscles, sternocleidomastoid and mid/lower fibres of trapezius muscle (48–65%), and 6) inconclusive evidence of altered thoracic posture or mobility. Conclusions Considerable evidence supports thoracic pain and dysfunction in patients with WAD, involving primarily nerves and muscles. Notwithstanding the low/very low level of evidence from this review, our findings do support a more extensive clinical evaluation of patients presenting with WAD. Additional high quality research is required to further characterise dysfunction across other structures in the thoracic region, including but not limited to the thoracic spine (mobility and posture) and thoracic muscles (stiffness, activation patterns). In turn this may inform the design of clinical trials targeting such dysfunction.

COMT genotype and non-recovery after a whiplash injury in a Northern European population

BackgroundThe COMT (Catechol-O-Methyl Transferase) gene may influence a person’s vulnerability to develop long-term pain and some COMT single nucleotide polymorphisms (SNPs) may associate with patterns of acute or chronic pain. Many patients with whiplash-associated disorders (WADs) suffer from long-term pain and other related symptoms, but it is less known if genetic factors play a role in the recovery process. The primary aim of this study was to evaluate whether self-reported non-recovery, including pain, was related to COMT genotype in patients with WAD. The secondary aim was to investigate whether or not background factors, including mental health, were related to genotype and non-recovery.MethodsA total of 133 patients with neck pain after a whiplash trauma were included. Background factors were collected and blood samples were taken during the acute phase after the accident. DNA was isolated from blood and used to genotype the SNPs rs6269, rs4633, rs4818 and rs4680 in the COMT gene; additionally haplotypes were estimated and haplogenotypes inferred. The patients were followed up after 12 months and asked to rate their recovery including pain, mental health and quality of life.ResultsThe overall reported non-recovery rate at 12 months was 44% with no significant differences in distribution of the COMT haplotypes. High levels of self-reported pain (OR 7.2) and anxiety (OR 4.4) after the accident were associated with non-recovery, but not related to the haplotypes. None of the other background factors were related to the haplotypes or non-recovery.ConclusionNo association between self-reported non-recovery or pain levels and COMT haplotypes in patients with acute whiplash injuries could be detected. Independent replications are necessary to discard the hypothesis that COMT haplotypes do not influence non-recovery or pain levels in patients with acute whiplash injuries. High levels of initial pain and anxiety were associated with non-recovery, thereby confirming previously published reports.

Widespread pain is associated with greater perceived pain and disability, but not with psychological features in patients with cervical radiculopathy

Purpose: People with cervical radiculopathy (CR) present with varying pain extent indicative of an interplay of differing pain mechanisms. A widespread distribution of perceived pain may reflect central sensitisation and could be associated with poorer psychological functioning as seen in other conditions such as individuals with whiplash associated disorders (WAD). No studies have evaluated the relation of pain extent to perceived pain and disability, general health and psychological status in individuals with CR.

Prospective cluster-randomised double-blind pilot and feasibility trial of an active behavioural physiotherapy intervention for acute whiplash associated disorder (WAD)II

Prospective cluster-randomised double-blind pilot and feasibility trial of an active behavioural physiotherapy intervention for acute whiplash associated disorder (WAD)II

Cervico-thoracic myofascial pain in whiplash-associated disorders: a systematic review

Purpose: With the highest incidence of whiplash injuries in Europe, consultations for whiplash-associated disorder (WAD) in the UK cost the NHS ∼£8 million a year. Despite this, a third of the injured individuals remain moderately disabled at 12 months. Although research has mainly focused on the neck, pain is found in adjacent regions with thoracic pain prevalence reported to be 65.5%. With the whiplash mechanism of injury involving strain load on myofascial tissue spanning both the neck and the thorax, further consideration of the impact on tissues in adjacent regions offers novel directions for future research.

Neck-specific exercises with internet-based support compared to neck-specific exercises at a physiotherapy clinic for chronic whiplash-associated disorders: study protocol of a randomized controlled multicentre trial

BackgroundGlobally, neck pain is the fourth most common condition associated with longer periods of living with disability. Annually, approximately 0.3% of the population of Western countries undergo whiplash trauma, and half of those individuals will develop chronic problems with high costs for the individual and society. Evidence for chronic whiplash-associated disorders (WAD) treatment is scarce, though neck-specific training at a physiotherapy clinic twice a week for 12 weeks has demonstrated good results. More efficient, flexible rehabilitation with reduced waiting times and lower costs is needed, ideally replacing lengthy on-site treatment series by healthcare providers. Internet-based care has been shown to be a viable alternative for a variety of diseases and interventions, but studies are lacking on Internet-based interventions for individuals with chronic neck problems. The aim of the trial described here is to compare the effects of an Internet-based neck-specific exercise programme to the same exercises performed at a physiotherapy clinic in regards to self-reported and clinical measures, as well as cost-effectiveness.MethodsThis prospective, randomized controlled trial will involve 140 participants. Measurements will be made at baseline, 3 months (end of treatment), and 15 months (12 months after end of intervention) and will include ratings of pain, disability, satisfaction with care, work ability, quality of life, and cost-effectiveness.DiscussionThe study results may contribute to the development of a more effective rehabilitation, flexible and equal care, shorter waiting times, increased availability, and lower costs for healthcare and society.Trial registrationClinicalTrials.gov Protocol ID: NCT03022812, initial release 12/20/2016.

Management of Whiplash Associated Disorders in Australian general practice

BackgroundWhiplash Associated Disorders (WAD) are common and costly, and are usually managed initially by general practitioners (GPs). How GPs manage WAD is largely unstudied, though there are clinical guidelines. Our aim was to ascertain the rate of management (percentage of encounters) of WAD among patients attending Australian general practice, and to review management of these problems, including imaging, medications and other treatments.MethodsWe analysed data from 2013 to 2016 collected by different random samples of approximately 1000 general practitioners (GPs) per year. Each GP collected data about 100 consecutive consultations for BEACH (Bettering the Evaluation and Care of Health), an Australian national study of general practice encounters.Main outcome measures were: the proportion of encounters involving management of WAD; management including imaging, medications and other treatments given; appropriateness of treatment assessed against published clinical guidelines.ResultsOf 291,100 encounters from 2919 GP participants (a nationally representative sample), WAD were managed at 137 encounters by 124 GPs (0.047%). Management rates were 0.050% (females) and 0.043% (males). For 63 new cases (46%), 19 imaging tests were ordered, most commonly neck/cervical spine x-ray (52.6% of tests for new cases), and neck/cervical spine CT scan (31.6%). One or more medications were prescribed/supplied for 53.3% of WAD. NSAIDs (11.7 per 100 WAD problems) and compound analgesics containing paracetamol and opioids (10.2 per 100 WAD problems) were the commonest medications used by GPs overall. Paracetamol alone was used in 8 per 100 WAD problems. The most frequent clinical/procedural treatments for WAD were physical medicine/rehabilitation (16.1 per 100 WAD problems), counselling (6.6), and general advice/education (5.8).ConclusionsGPs refer about 30% of new cases for imaging (possibly overutilising imaging), and prescribe a range of drugs, approximately 22% of which are outside clinical guidelines. These findings suggest a need for further education of GPs, including indications for imaging after whiplash injury, identification of those more likely to develop chronic WAD, and medication management guidelines. WAD carry a large personal and economic burden, so the impact of improvements in GP management is potentially significant.

Pain extent predicts the outcome following a programme of neck specific exercise in patients with chronic whiplash-associated disorders

Pain extent predicts the outcome following a programme of neck specific exercise in patients with chronic whiplash-associated disorders

Referral to specialist physiotherapists in the management of whiplash associated disorders: Perspectives of healthcare practitioners

BackgroundGuidelines for whiplash associated disorders (WAD) recommend early referral to specialists (e.g. specialist physiotherapists) of people who are not recovering. This recommendation is a key component of a proposed clinical pathway of care for WAD. ObjectiveTo explore healthcare practitioners' opinions about referral to specialist physiotherapists of people with WAD at high risk of non-recovery. DesignQualitative descriptive study. MethodsSix focus groups were conducted among primary care allied-health practitioners (n = 16) and specialist physiotherapists (n = 12) in New South Wales and Queensland, Australia. Discussions were audio recorded and transcribed for thematic analysis. ResultsTen themes were generated from analysis. Practitioners appeared to have good knowledge of indicators for referral; however, referrals were often made to the medical practitioner, less commonly to specialist physiotherapists. There was general support for referral to specialist physiotherapists, which was deemed as a viable alternative for people who are not recovering. Practitioners, however, had differing views about the attributes of a specialist physiotherapist and referral timeframe. A number of factors have been identified to influence the referral process and practitioners expressed specific expectations of the desired outcomes of referral as well as considerations for specialist management approaches. There was strong support for a collaborative approach in management that involved the referring practitioner. ConclusionResults support the feasibility of referral to specialist physiotherapists despite limited uptake in practice and recognised barriers to referral. These findings have implications for further study and adopting strategies to facilitate effective implementation and translation of the proposed pathway into primary care practice.

Tactile acuity is reduced in people with chronic neck pain

BackgroundTactile acuity deficits have been demonstrated in a range of persistent pain conditions and may reflect underlying cortical re-organisation. ObjectiveThis study aimed to determine whether tactile acuity is impaired in people with chronic neck pain relative to controls, and whether deficits relate to pain location, duration and intensity. MethodsIn this cross-sectional study, 20 people with chronic neck pain (5 idiopathic neck pain; 15 whiplash-associated disorder) and 20 pain-free controls underwent two-point discrimination (TPD) testing at the neck, back and arm, and point-to-point (PTP) and graphesthesia tests of tactile acuity at the neck and arm. ResultsLinear mixed effects models demonstrated a significant group*body region interaction for TPD, Graphesthesia and PTP tests (Ps < 0.001), with post hoc tests showing impaired TPD in people with neck pain relative to controls at the neck, low back, and arm (P ≤ 0.001). Graphesthesia and PTP was also impaired at the neck (P < 0.001) but not the arm (P ≥ 0.48). TPD correlated with intensity and duration of pain (Pearson's r = 0.48, P < 0.05; Pearson's r = 0.77, P < 0.01). There was no sig difference between the two neck pain groups for any tactile acuity measure (TPD: P = 0.054; Graphesthesia; P = 0.67; Point to Point: P = 0.77), however, low power limited confidence in this comparison. ConclusionPeople with chronic neck pain demonstrated tactile acuity deficits in painful and non-painful regions when measured using the TPD test, with the magnitude of deficits appearing greatest at the neck. The study also revealed a positive relationship between TPD and pain intensity/duration, further supporting the main study finding.

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.

Decreased Regional Grey Matter Volume in Women with Chronic Whiplash-Associated Disorders: Relationships with Cognitive Deficits and Disturbed Pain Processing

Background: Patients with chronic whiplash-associated disorders (CWAD) are characterized by pain of traumatic origin, cognitive deficits, and central sensitization (CS). Previous neuroimaging studies revealed altered grey matter volume (GMV) in mild traumatic brain injury patients and chronic pain conditions also characterized by CS. It can therefore be hypothesized that GMV alterations also play a role in the persistent complaints of CWAD. However, brain alterations remain poorly investigated in these patients. Objectives: This study examined regional GMV alterations in patients with CWAD compared to patients with non-traumatic chronic idiopathic neck pain (CINP), who normally do not show CS at a group level, and healthy controls. Additionally, in both patient groups, relationships between regional GMV and measures of cognition as well as pain processing were assessed. Study Design: A cross-sectional case-control study. Setting: This study was performed at the Department of Rehabilitation Sciences and Physiotherapy of Ghent University in cooperation with the Ghent Institute for Functional and Metabolic Imaging. Methods: Ninety-three women (28 healthy controls, 34 CINP patients, and 31 CWAD patients) were enrolled. First, T1-weighted magnetic resonance images (MRIs) were acquired to examine GMV alterations in the brain regions involved in processing cognition and pain. Next, cognitive performance, pain cognitions, and CS symptoms were assessed. Finally, hyperalgesia and conditioned pain modulation efficacy were examined. Results: Regional GMV of the right lateral orbitofrontal cortex, left supramarginal cortex, and left posterior cingulate cortex was decreased in CWAD patients compared to healthy controls (P = 0.023; P = 0.012; P = 0.047, respectively). Additionally, GMV of the right superior parietal cortex and left posterior cingulate cortex was decreased in CWAD patients compared to CINP patients (P = 0.008; P = 0.035, respectively). Decreased regional GMV correlated with worse cognitive performance, higher maladapted pain cognitions, CS symptoms, and hyperalgesia in CWAD patients (rs = -0.515 to -0.657; P &lt; 0.01). In CINP patients, decreased regional GMV correlated only with worse cognitive performance (rs = -0.499 to -0.619; P &lt; 0.01), and no GMV differences compared with the controls could be revealed. Limitations: No conclusions about the causality of the observed relationships can be drawn. Conclusions: These results provide the first evidence for reduced GMV in cortical regions involved in processing cognition and pain in patients with CWAD. Accordingly, it is recommended that therapy approaches for CWAD patients should address the brain and take into account neuroplasticity of the central nervous system (CNS). Key words: Whiplash injuries, neck pain, magnetic resonance imaging, grey matter, cognitive dysfunction, pain catastrophizing, central sensitization

Lateral atlantoaxial joint meniscoid volume in individuals with whiplash associated disorder: A case-control study

BackgroundLateral atlantoaxial (LAA) joints are established sources of nociceptive input in chronic whiplash associated disorder (WAD). These joints contain intra-articular meniscoids that may be damaged in whiplash trauma. LAA joint meniscoid morphology has not been investigated comprehensively in a chronic WAD population, and it is unclear whether morphological differences exist compared to a pain-free population. ObjectivesThis study examined LAA joint meniscoid volume in individuals with chronic WAD who report pain in a distribution consistent with LAA joint pain. DesignCase-control study. MethodFourteen individuals with chronic WAD with pain in an LAA joint distribution (mean [SD] age 38.1 [10.8] years; six female) and 14 age- and sex-matched pain-free controls (38.0 [10.5] years) underwent cervical spine magnetic resonance imaging. LAA joint images were inspected for meniscoids; meniscoid volume was calculated in mm3 and as a percentage of articular cavity volume. Symptom duration, location and intensity were recorded. Data were analysed using paired t-tests, Wilcoxon signed-rank testing, Spearman's rank testing, linear and logistic regression (α < 0.05). ResultsVentral and dorsal meniscoids (n = 112) were found in each LAA joint. Greater dorsal meniscoid volume as a percentage of articular cavity volume was associated with higher pain intensity (odds ratio 1.48, p = 0.03; likelihood ratio test chi-square2 = 6.64, p = 0.04), however no significant differences existed between meniscoid volumes of WAD and control participants. ConclusionsFindings indicate a potential link between dorsal LAA joint meniscoid volume and pain, suggesting larger meniscoid size may have pathoanatomical significance in WAD.

Is Preexisting Cervical Disk Degeneration a Prognostic Factor in Whiplash-associated Disorders?

This is a retrospective control study. We aimed to determine whether preexisting cervical disk degeneration is a prognostic factor in Whiplash-associated disorder (WAD). WAD is a common injury of traffic accident and has a broad range of prognoses. Although numerous studies have investigated prognostic factors in WAD, few have evaluated the effect of preexisting disk degeneration. This study involved 45 consecutive patients with grade I or II WAD having advanced disk degeneration (at least 1 disk of Miyazaki grade≥III on magnetic resonance imaging) and a control cohort of 52 patients with no or mild disk degeneration (all disks having Miyazaki grades≤II). Clinical assessment included pain severity (assessed by the visual analog scale), neck pain-related disability (assessed by the neck disability index), and physical and mental health condition [assessed by the short-form 36 (SF-36) physical composite score and SF-36 mental composite score, respectively]. Changes in each parameter were evaluated at baseline and at 3-month, 6-month, and 1-year follow-ups and compared between the 2 groups. There were no differences between the 2 groups regarding demographics and baseline outcome parameters (all P>0.05). There were also no differences in improvement in visual analog scale for neck pain, neck disability index, SF-36 physical composite score, or SF-36 mental composite score between the 2 groups (all P>0.05) for each visit. The number of claim closures was significantly lower among patients with advanced degeneration than among controls at 6-month and 1-year follow-ups (P=0.004 and 0.006, respectively). In the present study, the clinical presentation and prognosis of WAD were not affected by preexisting disk degeneration. However, claim closure was delayed in patients with preexisting disk degeneration. These results suggest that misunderstanding of disk degeneration on magnetic resonance imaging may create persistent illness and lead to continued compensation in WAD.

Information needs of patients with whiplash associated disorders: A Delphi study of patient beliefs

BackgroundWhiplash associated disorders (WAD) result in significant personal and economic costs. Patient education and reassurance are recommended treatments for acute WAD but the information needs of patients have not been investigated. ObjectivesTo determine what information whiplash-injured patients believe is important to help recovery in the acute stage of injury. DesignA Delphi design survey series with three rounds. MethodThirty-three participants who had sustained a whiplash injury within the last three years were invited to participate. Participants were asked to provide five statements, in response to an open-ended question, regarding what they believed was the most important information to provide to patients following a whiplash injury. Nineteen patients responded and 85 statements were collected and reviewed independently by two of the authors to remove duplicates. The importance of the remaining items was rated by the participants in the second survey round. Items rated by >50% of participants as important were included in the third survey round. To be deemed key information, >80% of participants had to rate an item as important in this final round. ResultsEighteen items met the criteria for key information. These points addressed four areas: assessment and treatment, recovery and symptoms, patient attitudes during treatment and relationships with health practitioners. ConclusionsThe key information points endorsed by patients in this study may provide useful information to constitute a basis for reassurance and education provided to patients with WAD. The results also suggest that improved relationships between patients with whiplash and health practitioners is required.