Whiplash-associated Disorders Research Articles

Measuring the impact of the French version of The Whiplash Book on both treatment approach and fear-avoidance beliefs among emergency physicians. A cluster randomized controlled trial.

BackgroundWhiplash-associated disorders have been the subject of much attention in the scientific literature and remain a major public health problem.ObjectiveMeasure the impact of a validated information booklet on the fear-avoidance beliefs of emergency physicians and their approach to management regarding the treatment of whiplash-associated disorders.MethodsA prospective cluster randomized controlled study conducted with a sample of emergency medicine physicians. Fear-avoidance beliefs were measured using The Whiplash Belief Questionnaire (WBQ) and Fear-Avoidance Beliefs Questionnaire (FABQ). We assessed the approach to management based on the prescription of pharmacological and non-pharmacological treatments based on the advice given to patients. The validated information booklet was the French version of The Whiplash Book. A set of questionnaires was sent to participants pre- and post-intervention. The experimental intervention was the provision of The Whiplash Book. The control arm did not receive any training or information.ResultsMean fears and beliefs scores on inclusion were high: WBQ = 19.09 (± 4.06); physical activity FABQ = 11.45 (± 4.73); work FABQ = 13.85 (± 6.70). Improvement in fear-avoidance beliefs scores being greater in the intervention group was further confirmed by the variation in WBQ (-20 [-32; -6] vs. -6 [-16; 9]; p = 0.06), physical activity FABQ (-70 [-86; -50] vs. -15 [-40; 11]; p < 0.001), and work FABQ (-40 [-71; 0] vs. 0 [-31; 50]; p = 0.02). The emergency physicians' initial approach to management was not consistent with current guidelines. Reading the French version of The Whiplash Book could contribute to changing their approach to management in several areas on intra-group analysis.ConclusionThe French version of The Whiplash Book positively influenced fear-avoidance beliefs among emergency physicians.

Small fibre pathology in chronic whiplash‐associated disorder: A cross‐sectional study

Mechanisms underpinning ongoing symptoms in chronic whiplash associated-disorder (WAD) are not well understood. People with chronic WAD can exhibit sensory dysfunction consistent with small nerve fibre pathology, including thermal hypoaesthesia and hyperalgesia. This study investigated small fibre structure and function in chronic WAD. Twenty-four people with chronic WAD (median [IQR] age 49 [15]years, 16 females) and 24 pain-free controls (50 [17]years, 16 females) were recruited. Intraepidermal nerve fibre density (IENFD) and dermal innervation were assessed by skin biopsy. This was performed at (a) the lateral index finger on the primary side of pain and (b) superior to the lateral malleolus on the contralateral side. Quantitative sensory testing was performed over the hand. The WAD group exhibited lower IENFD at the finger (WAD: median [IQR] 4.5 [4.9]fibres/mm; control 7.3 [3.9]; p=.010), but not the ankle (WAD: mean [SD] 7.3 [3.7]fibres/mm; control 9.3 [3.8]; p=.09). Dermal innervation was lower in the WAD group at the finger (WAD: median [IQR] 3.7 [2.8] nerve bundles/mm2 ; controls: 4.9 [2.1]; p=.017) but not the ankle (WAD: median [IQR] 2.1 [1.9] nerve bundles/mm2 ; controls: 1.8 [1.8]; p=.70). In the WAD group, hand thermal and light touch detection were impaired, and heat pain thresholds were lowered (p≤.037). Findings suggest small fibre structural and functional deficits in chronic WAD, implicating potential involvement of small fibre pathology. Our study found decreased intraepidermal nerve fibre density, reduced dermal innervation, thermal hypoaesthesia and hypersensitivity in people with chronic WAD, suggestive of small fibre pathology. This observation of peripheral nervous system pathology in chronic whiplash provides novel insights on mechanisms underpinning symptoms and challenges commonly held beliefs regarding this condition.

Relationships Between Context, Process, and Outcome Indicators to Assess Quality of Physiotherapy Care in Patients with Whiplash-Associated Disorders: Applying Donabedian's Model of Care.

BackgroundQuality indicators (QIs) are measurable elements of practice performance and may relate to context, process, outcome and structure. A valid set of QIs have been developed, reflecting the clinical reasoning used in primary care physiotherapy for patients with whiplash-associated disorders (WAD). Donabedian’s model postulates relationships between the constructs of quality of care, acting in a virtuous circle.AimTo explore the relative strengths of the relationships between context, process, and outcome indicators in the assessment of primary care physiotherapy in patients with WAD.Materials and MethodsData on WAD patients (N=810) were collected over a period of 16 years in primary care physiotherapy practices by means of patients records. This routinely collected dataset (RCD-WAD) was classified in context, process, and outcome variables and analyzed retrospectively. Clinically relevant variables were selected based on expert consensus. Associations were expressed, using zero-order, as Spearman rank correlation coefficients (criterion: rs >0.25 [minimum: fair]; α-value = 0.05).ResultsIn round 1, 62 of 85 (72.9%) variables were selected by an expert panel as relevant for clinical reasoning; in round 2, 34 of 62 (54.8%) (context variables 9 of 18 [50.0%]; process variables 18 of 34 [52.9]; outcome variables 8 of 10 [90.0%]) as highly relevant. Associations between the selected context and process variables ranged from 0.27 to 0.53 (p≤0.00), between selected context and outcome variables from 0.26 to 0.55 (p≤0.00), and between selected process and outcome variables from 0.29 to 0.59 (p≤0.00). Moderate associations (rs >0.50; p≤0.00) were found between “pain coping” and “fear avoidance” as process variables, and “pain intensity” and “functioning” as outcome variables.ConclusionThe identified associations between selected context, process, and outcome variables were fair to moderate. Ongoing work may clarify some of these associations and provide guidance to physiotherapists on how best to improve the quality of clinical reasoning in terms of relationships between context, process, and outcome in the management of patients with WAD.

There's Nothing Broken. You've Had a Whiplash, That's It: A Qualitative Study of Comorbid Posttraumatic Stress Disorder and Whiplash Associated Disorders.

Posttraumatic stress disorder (PTSD) symptoms are common in chronic Whiplash associated disorders (WAD) and have been found to be associated with higher levels of pain and disability. Theoretical frameworks have suggested that PTSD and pain not only coexist, but also mutually maintain one another. Although the comorbidity has been subject to increasing quantitative research, patients' experiences of the comorbidity and symptom interaction remain largely uninvestigated using qualitative methods. The present study set out to explore the potential relationship of PTSD and pain in people with WAD and properly assessed PTSD after motor vehicle accidents. A qualitative explorative study of eight individual face-to-face semistructured interviews were conducted. Interviews were recorded and transcribed verbatim and analyzed using framework analysis. Through the analysis, we developed three overarching themes. The first theme illustrated the complex and burdensome comorbidity with overlapping and transdiagnostic symptoms, whereas the second theme highlighted how several circumstances, some related to the health care system, could extend and amplify the traumatic response. The final theme illustrated symptom associations and interactions, particularly between pain and PTSD, both supporting and rejecting parts of the mutual maintenance framework. These findings underlined the great complexity and variability of the comorbidity and the traumatic event, but also emphasized how experiences of psyche and soma seem closely connected in these patients. The results provide support for the importance of thorough assessment by multidisciplinary teams, minimizing distress post-injury, and a critical approach to the idea of mutual maintenance between pain and PTSD.

Irritable bowel, chronic widespread pain, chronic fatigue and related syndromes are prevalent and highly overlapping in the general population: DanFunD

Prevalence of functional somatic syndromes (FSS) in the general population varies with observed overlap between syndromes. However, studies including a range of FSS are sparse. We investigated prevalence and characteristics of various FSS and the unifying diagnostic construct bodily distress syndrome (BDS), and identified mutual overlap of the FSS and their overlap with BDS. We included a stratified subsample of 1590 adults from a randomly selected Danish general population sample (n = 7493). Telephonic diagnostic interviews performed by three trained physicians were used to identify individuals with FSS and BDS. Prevalence of overall FSS was 9.3%; 3.8% for irritable bowel, 2.2% for chronic widespread pain, 6.1% for chronic fatigue, 1.5% for whiplash associated disorders, and 0.9% for multiple chemical sensitivity. Prevalence of BDS was 10.7% where 2.0% had the multi-organ type. FSS were highly overlapping with low likelihood of having a “pure” type. Diagnostic agreement of FSS and BDS was 92.0%. Multi-syndromatic FSS and multi-organ BDS were associated with female sex, poor health, physical limitations, and comorbidity. FSS are highly prevalent and overlapping, and multi-syndromatic cases are most affected. BDS captured the majority of FSS and may improve clinical management, making the distinction between multi- and mono-syndromatic patients easier.

Acupuncture for whiplash-associated disorder following road traffic collision: a physiotherapy service evaluation

Whiplash-associated disorder (WAD) is a common musculoskeletal condition that frequently occurs following a road traffic collision. Physiotherapy is often prescribed to help with the symptoms and injuries. Research evidence has demonstrated that acupuncture may be beneficial, but no studies have examined the routine clinical use of acupuncture by physiotherapists for treatment of WAD. Therefore, a physiotherapy service evaluation was conducted to examine the effects of acupuncture on WAD following a road traffic collision. This study involved 87 patients who attended a private physiotherapy practice following a road traffic collision after referral by their solicitor as part of a personal injury claim. Patients were included if they had been diagnosed with WAD (grades I-III) and received acupuncture as part of their treatment. An average of three sessions of acupuncture were received, which primarily involved needling of traditional acupuncture points and/or myofascial trigger points of the neck and upper/lower back. Pain significantly reduced (p < 0.001). Musculoskeletal outcome measures including neck disability index, Oswestry low back pain scale and Quick disabilities of the arm, shoulder and hand (Quick-DASH) scale also significantly improved (all p < 0.001). Adverse events were minor. The majority of the patients (n = 66) were able to return to full-work duties following treatment. Acupuncture appears to be an effective clinical treatment for WAD following a road traffic collision and should be considered by physiotherapists working with such patient groups.

A pilot study on the evaluation of eye, head, and trunk coordination in subjects with chronic whiplash during a target-tracking task - A driving context approach

BackgroundMotor vehicle accidents (MVA) are the most common causes of whiplash injuries. Difficulties with driving and changes in driving behavior are reported by subjects with chronic whiplash associated disorders (WAD). Proper eye and head coordination is required for driving tasks. Disturbances of eye and head coordination were found in these subjects with chronic WAD. ObjectivesThe objective of this pilot study is to evaluate eye, head and trunk coordination in subjects with chronic WAD due to MVA and healthy controls during a target-tracking task using a functionally oriented approach in the context of driving. DesignCross-sectional. MethodThe subjects performed target tracking tasks that reproduced eye and head movements required while driving. Head and trunk motion was captured using a motion capture system and eye movement was captured with an eye-tracker. Response time, time to target, and eye, head, and trunk contribution of movement were measured. Results/findingsSubjects with chronic WAD presented delayed response time and time to reach the targets with both eyes and head compared to the control group, and tended to compensate the lack of neck motion with increased eye motion. ConclusionsThis study shows indications of impairments of eye and head coordination in chronic WAD due to MVA when compared to healthy subjects. These alterations may have implications for driving safety.

Age-related changes to the craniocervical ligaments in asymptomatic subjects: a prospective MR study.

The craniocervical junction (CCJ) is a complex of bony and ligamentous structure stabilizing CCJ. Nearly one-third of all traumatic injuries to the cervical spine involve the CCJ. Only little literature is available on this topic, and most of the studies are focused on anatomy, biomechanics or ligamentous injury in whiplash-associated disorders. We conducted a prospective study to investigate age-related changes in the craniocervical ligaments. We included asymptomatic volunteers between 16 and 99years old who had no history of whiplash or other cervical trauma. Volunteers underwent a three-dimensional turbo spin-echo proton density-weighted sequence with variable flip-angle distribution focused on the craniocervical ligaments. The six main ligaments of the craniocervical junction were evaluated for grade of degeneration on a four-point scale by two independentreaders, blinded for age and sex. We included 102 volunteers. The mean age was 50.03 (16-94). Fifty-nine (58%) patients showed degeneration of at least one ligament of the CCJ. High-grade anomalous changes and multiligamentous involvement had a positive correlation with age (p < 0.001). The inter-rater agreement was fair to moderate, and the intra-rater agreement was moderate to substantial. The craniocervical ligaments show a variable degree of signal intensity and thickness in asymptomatic adults. We postulate that these changes can be due to normal aging or due to repetitive microtrauma. We propose a new grading system to evaluate changes to the craniocervical ligaments in asymptomatic volunteers. These slides can be retrieved under Electronic Supplementary Material.

Recovery despite everyday pain: Women's experiences of living with whiplash-associated disorder.

Living with whiplash-associated disorders (WAD) means living every day under the influence of pain and limitations. As the incidence of WAD and the related intensity of pain are somewhat higher among women than men, the aim of the present study was to describe women's experiences of living with WAD. A purposive sample of seven women participated in individual in-depth qualitative interviews, the transcripts of which were subjected to qualitative content analysis. The results of the analysis suggested six themes of women's experiences with WAD: living with unpredictable pain; trying to manage the pain; living with limitations; being unable to work as before; needing support and understanding; and learning to live with limitations. The findings showed that unpredictable pain limited women's strength to engage in activities of daily life and be as active as before. Support and understanding were important for their ability to manage changes in their daily lives. Pain considerably affects the daily lives of women with WAD, particularly by limiting their ability to perform activities and to enjoy their professional and social lives. As women with WAD need support with managing their daily lives, nurses and other healthcare personnel should adopt a person-centred approach, in order to support such women according to their individual needs and circumstances.

Critical considerations about the onset and epidemiology of whiplash associated disorders presented by the bone and joint decade 2000-2010 task force on neck pain

Critical considerations about the onset and epidemiology of whiplash associated disorders presented by the bone and joint decade 2000-2010 task force on neck pain

Characterizing the Mechanical Properties of Ectopic Axonal Receptive Fields in Inflamed Nerves and Following Axonal Transport Disruption

Radiating pain is a significant feature of chronic musculoskeletal pain conditions such as radiculopathies, repetitive motion disorders and whiplash associated disorders. It is reported to be caused by the development of mechanically-sensitive ectopic receptive fields along intact nociceptor axons at sites of peripheral neuroinflammation (neuritis). Since inflammation disrupts axonal transport, we have hypothesised that anterogradely-transported mechanically sensitive ion channels accumulate at the site of disruption, which leads to axonal mechanical sensitivity (AMS). In this study, we have characterised the mechanical properties of the ectopic axonal receptive fields in the rat and have examined the contribution of mechanically sensitive ion channels to the development of AMS following neuritis and vinblastine-induced axonal transport disruption. In both models, there was a positive force–discharge relationship and mechanical thresholds were low (∼9 mN/mm2). All responses were attenuated by Ruthenium Red and FM1-43, which block mechanically sensitive ion channels. In both models, the transport of TRPV1 and TRPA1 was disrupted, and intraneural injection of agonists of these channels caused responses in neurons with AMS following neuritis but not vinblastine treatment. In summary, these data support a role for mechanically sensitive ion channels in the development of AMS.

The effect of steroid treatment on whiplash associated syndrome: a controlled randomized prospective trial.

There is significant evidence in the literature that low or relatively low cortisol concentrations near the time of an accident are associated with more severe forms of whiplash-associated disorders. We hypothesized that treating patients that were involved in a motor vehicle accident with hydrocortisone would alleviate the incidence and severity of these disabling disorders. A prospective, randomized, double-blind, placebo-controlled clinical trial. Blunt trauma patients that underwent a motor vehicle crash were allocated into a study group that received a single bolus of hydrocortisone and a control group that received saline. The patients were followed for 1month. The incidence and severity of whiplash associated disorder, functional disturbances, and post-traumatic stress disorder were compared between the two groups. The analyses were repeated for sub-divisions into groups of high and low admission cortisol. The more severe forms of whiplash-associated disorders on the day of accident were associated with low cortisol levels; mean cortisol concentration of the lower grade of whiplash patients (13.09 ± 7.35µg%) was higher than that of whiplash syndrome of the severe forms (8.33 ± 3.45µg), p = 0.001. There were no differences between study and control groups regarding whiplash-associated disorders, functional tests, and severity of stress disorder 1month after the accident. Significant differences were evident between high and low cortisol sub-groups. Those who had low cortisol level on admission and received hydrocortisone had worse outcomes. Steroid treatment of patients with whiplash might be harmful to those who present with low cortisol concentrations (< 9.5μg/dL). Clinical Trials: Association between low cortisol levels and whiplash syndrome. Date of registration: March 18, 2014. Date the first participant was enrolled: May 10, 2014. NCT02090309. URL: https://clinicaltrials.gov/ct2/show/NCT02090309 .

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...

Psychometric properties of the global rating of change scales in patients with neck disorders: a systematic review with meta-analysis and meta-regression

ObjectiveThe purpose of this systematic review was to critically appraise and synthesise the psychometric properties of Global Rating of Change (GROC) scales for assessment of patients with neck pain.DesignSystematic review.Data...

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

Concussion in Combination With Whiplash-Associated Disorder May Be Missed in Primary Care: Key Recommendations for Assessment and Management.

Whiplash and concussion may have similar presenting symptoms, biomechanical mechanisms, and neurophysiological sequelae, but neither enjoys a gold standard diagnostic test. Guidelines for whiplash and concussion are developed and implemented separately. This disparate process may contribute to misdiagnosis, delay appropriate primary care management, and impair patient outcomes. In our clinical commentary, we present 3 cases where signs and symptoms consistent with whiplash were identified in primary care. Symptoms in all cases included neck pain, headache, dizziness, and concentration deficits, raising suspicion of coexisting postconcussion syndrome. All cases were referred for specialist physical therapy. Characteristics consistent with poor recovery in both whiplash and postconcussion syndrome were confirmed, and multidisciplinary management, drawing from both whiplash and concussion guidelines, was implemented. All patients reported improvement in activities of daily living after tailored management addressing both neck and head injury-related factors, suggesting that these conditions were not mutually exclusive. Self-reported outcomes included reductions in neck disability and postconcussion symptoms of between 20% and 40%. It may be appropriate for whiplash and concussion guidelines to be amalgamated, enhanced, and mutually recognized on a patient-by-patient basis. Primary health care professionals might consider minimum screening to identify postconcussion syndrome in patients following motor vehicle collision by administering questionnaires and assessing cranial nerve function, balance, and cognition. Management should then incorporate principles from both whiplash and concussion guidelines and harmonize with available imaging guidelines for suspected spine and head trauma. J Orthop Sports Phys Ther 2019;49(11):819-828. doi:10.2519/jospt.2019.8946.

Evaluation of a Novel Intervention to Improve Physical Activity for Adults with Whiplash Associated Disorders: Protocol for a Multiple-Baseline, Single Case Experimental Study

Half of individuals with a whiplash injury experience ongoing pain and disability. Many are insufficiently active for good health, increasing their risk of preventable morbidity and mortality, and compounding the effects of the whiplash injury. This paper describes a protocol for evaluating the efficacy of a physical activity promotion intervention in adults with whiplash associated disorders. A multiple-baseline, single case experimental design will be used to evaluate the effects of a physical activity (PA) intervention that includes evidence-based behaviour change activities and relapse prevention strategies for six adults with chronic whiplash. A structured visual analysis supplemented with statistical analysis will be used to analyse: accelerometer-measured PA, confidence completing PA in the presence of neck pain, and pain interference.

Recommendations For Core Outcome Domain Set For Whiplash-Associated Disorders (CATWAD).

Inconsistent reporting of outcomes in clinical trials of treatments for Whiplash-associated Disorders (WAD) hinders effective data pooling and conclusions that can be drawn about the effectiveness of tested treatments. The aim of this study was to provide recommendations for core outcome domains that should be included in clinical trials of WAD. A 3-step process was used: (1) A list of potential core outcome domains were identified from the published literature. (2) Researchers, health care providers, patients, and insurance personnel participated and rated the importance of each domain via a 3-round Delphi survey. A priori criteria for consensus were established. (3) Experts comprising researchers, health care providers, and a consumer representative participated in a multidisciplinary consensus meeting that made final decisions on the recommended core outcome domains. The literature search identified 63 potential core domains. A total of 223 participants were invited to partake in the Delphi surveys, with 41.7% completing round 1, 45.3% round 2, and 51.4% round 3. Eleven core domains met the criteria for inclusion across the entire sample. After the expert consensus meeting, 6 core domains were recommended: Physical Functioning, Perceived Recovery, Work and Social Functioning, Psychological Functioning, Quality of Life, and Pain. A 3-step process was used to recommend core outcome domains for clinical trials in WAD. Six core domains were recommended: Physical Functioning, Perceived Recovery, Work and Social Functioning, Psychological Functioning, Quality of Life, and Pain. The next step is to determine the outcome measurement instruments for each of these domains.