Are non-steroidal anti-inflammatory drugs effective for the management of neck pain and associated disorders, whiplash-associated disorders, or non-specific low back pain? A systematic review of systematic reviews by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration Physiotherapist-delivered stress inoculation training integrated with exercise versus physiotherapy exercise alone for acute whiplash-associated disorder (StressModex): a randomised controlled trial of a combined psychological/physical intervention Are Work Disability Prevention Interventions Effective for the Management of Neck Pain or Upper Extremity Disorders? A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration Implementation of a guideline-based clinical pathway of care to improve health outcomes following whiplash injury (Whiplash ImPaCT): protocol of a randomised, controlled trial. Coping and Recovery in Whiplash-associated Disorders: Early use of Passive Coping Strategies is Associated With Slower Recovery of Neck Pain and Pain-related Disability Are People With Whiplash-Associated Neck Pain Different From People With Nonspecific Neck Pain? Dysfunctional pain inhibition in patients with chronic whiplash-associated disorders: an experimental study Protocol for an economic evaluation alongside the University Health Network Whiplash Intervention Trial: cost-effectiveness of education and activation, a rehabilitation program, and the legislated standard of care for acute whiplash injury in Ontario Prospective Ten-Year Follow-up Study Comparing Patients With Whiplash-Associated Disorders and Asymptomatic Subjects Using Magnetic Resonance Imaging A Randomized Controlled Trial of Cognitive-behavioral Therapy for the Treatment of PTSD in the Context of Chronic Whiplash Does acupuncture activate endogenous analgesia in chronic whiplash-associated disorders? A randomized crossover trial. The role of fear of movement in subacute whiplash-associated disorders grades I and II Acute whiplash-associated disorders (WAD): the effects of early mobilization and prognostic factors in long-term symptomatology Is there a relationship between whiplash-associated disorders and concussion in hockey? A preliminary study A Randomized Controlled Trial of an Educational Intervention to Prevent the Chronic Pain of Whiplash Associated Disorders Following Rear-End Motor Vehicle Collisions Characterization of Acute Whiplash-Associated Disorders The Development of Sensory Hypoesthesia After Whiplash Injury A new clinical test for cervicocephalic kinesthetic sensibility: "the fly". Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: A pilot randomised controlled trial. A Combination of Gestalt Therapy, Rosen Body Work, and Cranio Sacral Therapy did not help in Chronic Whiplash-Associated Disorders (WAD) - Results of a Randomized Clinical Trial Multidimensional associative factors for improvement in pain, function, and working capacity after rehabilitation of whiplash associated disorder: a prognostic, prospective outcome study Changes in Pain, Disability, and Muscle Activation Patterns in Chronic Whiplash Patients After Ambulant Myofeedback Training A three-group study, internet-based, face-to-face based and standard- management after acute whiplash associated disorders (WAD) – choosing the most efficient and cost-effective treatment: study protocol of a randomized controlled trial
Abstract Purpose To evaluate the effectiveness of non-steroidal anti-inflammatory drugs ( NSAIDs ) for the management of neck pain and associated disorders ( NAD ) , whiplash-associated disorders , and non-specific low back pain ( LBP ) with or without radiculopathy . Methods We systematic ally search ed six data bases from 2000 to 2014 . R and om pairs of independent review ers critically appraised eligible systematic review s using the Scottish Intercollegiate Guidelines Network criteria . We included systematic review s with a low risk of bias in our best evidence synthesis . Results We screened 706 citations and 14 systematic review s were eligible for critical appraisal . Eight systematic review s had a low risk of bias . For recent-onset NAD , evidence suggests that intramuscular NSAIDs lead to similar outcomes as combined manipulation and soft tissue therapy . For NAD ( duration not specified ) , oral NSAIDs may be more effective than placebo . For recent-onset LBP , evidence suggests that : ( 1 ) oral NSAIDs lead to similar outcomes to placebo or a muscle relaxant ; and ( 2 ) oral NSAIDs with bed rest lead to similar outcomes as placebo with bed rest . For persistent LBP , evidence suggests that : ( 1 ) oral NSAIDs are more effective than placebo ; and ( 2 ) oral NSAIDs may be more effective than acetaminophen . For recent-onset LBP with radiculopathy , there is inconsistent evidence on the effectiveness of oral NSAIDs versus placebo . Finally , different oral NSAIDs lead to similar outcomes for neck and LBP with or without radiculopathy . Conclusions For NAD , oral NSAIDs may be more effective than placebo . Oral NSAIDs are more effective than placebo for persistent LBP , but not for recent-onset LBP . Different oral NSAIDs lead to similar outcomes for neck pain and LBP Objective There are few effective treatments for acute whiplash-associated disorders ( WAD ) . Early symptoms of postinjury stress predict poor recovery . This r and omised controlled trial ( StressModex ) investigated whether physiotherapist-led stress inoculation training integrated with exercise is more effective than exercise alone for people with acute WAD . Methods 108 participants ( < 4 weeks ) at risk of poor recovery ( moderate pain-related disability and hyperarousal symptoms ) were r and omly assigned by concealed allocation to either physiotherapist-led stress inoculation training and guideline -based exercise ( n=53 ) or guideline -based exercise alone ( n=55 ) . Both interventions comprised 10 sessions over 6 weeks . Participants were assessed at 6 weeks and at 6 and 12 months postr and omisation . Analysis was by intention to treat using linear mixed models . Results The combined stress inoculation training and exercise intervention was more effective than exercise alone for the primary outcome of pain-related disability at all follow-up points . At 6 weeks , the treatment effect on the 0–100 Neck Disability Index was ( mean difference ) −10 ( 95 % CI −15.5 to −4.48 ) , at 6 months was −7.8 ( 95 % CI −13.8 to −1.8 ) and at 12 months was −10.1 ( 95 % CI −16.3 to −4.0 ) . A significant benefit of the stress inoculation and exercise intervention over exercise alone was also found for some secondary outcomes . Conclusion A physiotherapist-led intervention of stress inoculation training and exercise result ed in clinical ly relevant improvements in disability compared with exercise alone — the most commonly recommended treatment for acute WAD . This contributes to the case for physiotherapists to deliver an early psychological intervention to patients with acute WAD who are otherwise at high risk of a poor outcome . Trial registration number ACTRN12614001036606 Abstract Purpose We conducted a systematic review to critically appraise and synthesize literature on the effectiveness of work disability prevention ( WDP ) interventions in workers with neck pain , whiplash-associated disorders ( WAD ) , or upper extremity disorders . Methods We search ed electronic data bases from 1990 to 2012 . R and om pairs of independent review ers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria . Scientifically admissible studies were summarized and synthesized following best- evidence synthesis methodology . Results Of the 6,359 articles retrieved , 16 r and omized controlled trials were eligible for critical appraisal and five were admissible . We found that a return-to-work coordination program ( including workplace-based work hardening ) was superior to clinic-based work hardening for persistent rotator cuff tendinitis . Workplace high-intensity strength training and workplace advice had similar outcomes for neck and shoulder pain . Mensendieck/Cesar postural exercises and strength and fitness exercises had similar outcomes for non-specific work-related upper limb complaints . Adding a brief job stress education program to a workplace ergonomic intervention was not beneficial for persistent upper extremity symptoms . Adding computer-prompted work breaks to ergonomic adjustments and workplace education benefited workers ’ recovery from recent work-related neck and upper extremity complaints . Conclusions At present , no firm conclusions can be drawn regarding the effectiveness of WDP interventions for managing neck pain , WAD , and upper extremity disorders . Our review suggests a return-to-work coordination program is more effective than clinic-based work hardening . Also , adding computer-prompted breaks to ergonomic and workplace interventions benefits workers ’ recovery . The current quality of evidence does not allow for a definitive evaluation of the effectiveness of ergonomic interventions INTRODUCTION Whiplash-associated disorders ( WAD ) are a huge worldwide health and economic burden . The propensity towards developing into chronic , disabling conditions drives the rise in health and economic costs associated with treatment , productivity loss and compulsory third party insurance cl aims . Current treatments fail to address the well-documented heterogeneity of WAD and often result in poor outcomes . A novel approach is to evaluate whether the care provided according to the estimated risk of poor prognosis improves health outcomes while remaining cost-effective . RESEARCH QUESTIONS ( 1 ) Does a guideline -based clinical pathway of care improve health outcomes after whiplash injury compared to usual care ? ( 2 ) Does risk of recovery have a differential effect on health outcomes for the clinical pathway of care ? ( 3 ) Is the clinical pathway of care intervention cost-effective ? ( 4 ) What are the variations in professional practice between usual care and the clinical pathway of care ? DESIGN Multi-centre , r and omised , controlled trial conducted over two Australian states : Queensl and and New South Wales . PARTICIPANTS AND SETTING 236 people with WAD ( grade I-III , within 6 weeks of injury ) and their primary healthcare providers . INTERVENTION A clinical pathway of care , with care matched to the predicted risk of poor recovery . Participants at low risk of ongoing pain and disability ( hence , predicted to fully recover ) will receive up to three sessions of guideline -based advice and exercise with their primary healthcare provider . Participants at medium/high risk of developing ongoing pain and disability will be referred to a specialist ( defined as a practitioner with expertise in whiplash ) who will conduct a more in-depth physical and psychological assessment . As a result , the specialist will liaise with the original primary healthcare provider and determine one of three further pathways of care . CONTROL Usual care provided by the primary healthcare provider that is based on clinical judgment . MEASUREMENTS Primary ( global rating of change and neck-related disability ) and secondary ( self-efficacy , pain intensity , general health and disability and psychological health ) outcomes will be collected using vali date d scales . Direct ( eg , professional care , transportation costs , time spent for care , co-payments ) and indirect ( eg , lost economic productivity ) costs will be obtained through an electronic cost diary . Health and cost outcomes will be assessed at baseline , 3 , 6 and 12 months after r and omisation . Professional practice outcomes will be evaluated through question naires completed by healthcare providers and their patients at 3 months . PROCEDURE Potential participants ( patients ) will be identified through emergency departments , primary health clinics and advertisements . Eligible participants will complete baseline assessment s and will be categorised into low or medium/high risk of poor recovery using a clinical prediction rule . After this assessment , participants will be r and omly allocated to either a  control group ( n=118 ) or intervention group ( n=118 ) , stratified by risk subgroup and treatment site . The participants ' nominated primary healthcare providers will be informed of their involvement in the trial . Consent will be obtained from the primary healthcare providers to participate and to obtain information about professional practice . Participants in the intervention group will additionally have access to an interactive website that provides information about whiplash and recovery relative to their risk category . ANALYSIS Analysis will be conducted on an intention-to-treat basis . Outcomes will be analysed independently through cross-sectional analyses using generalised linear models methods , with an appropriate link function , to test for an intervention effect , adjusted for the baseline values . The risk category will be tested for its association with treatment effect by adding risk group to the regression equation . Cost-effectiveness will be calculated using utility weights and the result ing measure will be cost per quality -adjusted life year ( QALY ) saved . Professional practice outcomes will be analysed using descriptive statistics . DISCUSSION This research is significant as it will be the first study to address the heterogeneity of whiplash by implementing a clinical pathway of care that matches evidence -based interventions to projected risk of poor recovery . The results of this trial have the potential to change clinical practice for WAD , thereby maximising treatment effects , improving patient outcomes , reducing costs and maintaining the compulsory third party system Objective : Coping is shown to affect outcomes in chronic pain patients ; however , few studies have examined the role of coping in the course of recovery in whiplash-associated disorders ( WAD ) . The purpose of this study was to determine the predictive value of coping style for 2 key aspects of WAD recovery , reductions in neck pain , and in disability . Methods : A population -based prospect i ve cohort study design was used to study 2986 adults with traffic-related WAD . Participants were assessed at baseline , 6 weeks , and 4 , 8 , and 12 months postinjury .  Coping  was measured at 6 weeks using the Pain Management Inventory  , and neck pain recovery was assessed at each subsequent follow-up , using a 100 mm  visual analogue scale ( VAS ) . Disability was assessed at each follow-up using the Pain Disability Index ( PDI ) . Pain recovery was defined as a VAS score of 0 to 10 ; disability recovery was defined as a PDI score of 0 to 4 . Data analysis used multivariable Cox proportional hazards models . Results : Those using high versus low levels of passive coping at 6 weeks postinjury experienced 28 % slower pain recovery and 43 % slower disability recovery . Adjusted hazard rate ratios for pain recovery and disability recovery were 0.72 ( 95 % CI , 0.59 - 0.88 ) and 0.57 ( 95 % CI , 0.41 - 0.78 ) , respectively . Active coping was not associated with recovery of neck pain or disability . Conclusions : Passive coping style predicts neck pain and self-assessed disability recovery . It may be beneficial to assess and improve coping style early in WAD Study Design Secondary analysis of a prospect i ve cohort study with cross-sectional and longitudinal analyses . Background The clinical importance of a history of whiplash-associated disorder ( WAD ) in people with neck pain remains uncertain . Objective To compare people with WAD to people with nonspecific neck pain , in terms of their baseline characteristics and pain and disability outcomes over 1 year . Methods Consecutive patients with neck pain who presented to a secondary -care spine center answered a comprehensive self-report question naire and underwent a physical examination . Patients were classified into a group of either those with WAD or those with nonspecific neck pain . We compared the outcomes of baseline characteristics of the 2 groups , as well as pain intensity and activity limitation at follow-ups of 6 and 12 months . Results A total of 2578 participants were included in the study . Of these , 488 ( 19 % ) were classified as having WAD . At presentation , patients with WAD were statistically different from patients without WAD for almost all characteristics investigated . While most differences were small ( 1.1 points on an 11-point pain-rating scale and 11 percentage points on the Neck Disability Index ) , others , including the presence of dizziness and memory difficulties , were substantial . The between-group differences in pain and disability increased significantly ( P<.001 ) over 12 months . At 12-month follow-up , the patients with WAD had on average approximately 2 points more pain and 17 percentage points more disability than those with nonspecific neck pain . Conclusion People referred to secondary care with WAD typically had more self-reported pain and disability and experienced worse outcomes than those with nonspecific neck pain . Caution is required when interpreting the longitudinal outcomes due to lower-than-optimal follow-up rates . Level of Evidence Prognosis , level 2 . J Orthop Sports Phys Ther 2016;46(10):894 - 901 . Epub 3 Sep 2016 . doi:10.2519/jospt.2016.6588 Inefficient endogenous pain inhibition , in particular impaired conditioned pain modulation ( CPM ) , may disturb central pain processing in patients with chronic whiplash-associated disorders ( WAD ) . Previous studies revealed that abnormal central pain processing is responsible for a wide range of symptoms in patients with chronic WAD . Hence , the present study aim ed at examining the functioning of descending pain inhibitory pathways , and in particular CPM , in patients with chronic WAD . Thirty-five patients with chronic WAD and 31 healthy controls were subjected to an experiment evaluating CPM . CPM was induced by an inflated occlusion cuff and evaluated by comparing temporal summation ( TS ) of  pressure pain prior to and during cuff inflation . Temporal summation was provoked by means of 10 consecutive pressure pulses at upper and lower limb location . Pain intensity of first , fifth , and 10th pressure pulse was rated . During heterotopic noxious conditioning stimulation , TS of pressure pain was significantly depleted among healthy controls . In contrast , TS was quite similar prior to and during cuff inflation in chronic WAD , providing evidence for dysfunctional CPM in patients with chronic WAD . The present study demonstrates a lack of endogenous pain inhibitory pathways , and in particularly CPM , in patients with chronic WAD , and hence provides additional evidence for the presence of central sensitization in chronic WAD Background Whiplash injury affects 83 % of persons in a traffic collision and leads to whiplash-associated disorders ( WAD ) . A major challenge facing health care decision makers is identifying cost-effective interventions due to lack of economic evidence . Our objective is to compare the cost-effectiveness of : 1 ) physician-based education and activation , 2 ) a rehabilitation program developed by Aviva Canada ( a group of property and casualty insurance providers ) , and 3 ) the legislated st and ard of care in the Canadian province of Ontario  : the Pre-approved Framework Guideline for Whiplash developed by the Financial Services Commission of Ontario . Methods / Design The economic evaluation will use participant-level data from the University Health Network Whiplash Intervention Trial and will be conducted from the societal perspective over the trial 's one-year follow-up . Re source use ( costs ) will include all health care goods and services , and benefits provided during the trial 's 1-year follow-up . The primary health effect will be the quality -adjusted life year . We will identify the most cost-effective intervention using the incremental cost-effectiveness ratio and incremental net-benefit . Confidence ellipses and cost-effectiveness acceptability curves will represent uncertainty around these statistics , respectively . A budget impact analysis will assess the total annual impact of replacing the current legislated st and ard of care with each of the other interventions . An expected value of perfect information will determine the maximum research expenditure Canadian society should be willing to pay for , and inform priority setting in , research of WAD management . Discussion Results will provide health care decision makers with much needed economic evidence on common interventions for acute whiplash management . Trial Registration http:// Clinical Trials.govidentifierNCT00546806[Trial registry date : October 18 , 2007 ; Date first patient was r and omized : February 27 , 2008 Study Design . A prospect i ve 10-year follow-up study of patients with whiplash-associated disorders ( WAD ) and asymptomatic volunteers . Objective . To clarify long-term impact of whiplash injury on patient 's symptoms and on magnetic resonance imaging ( MRI ) findings of the cervical spine . Summary of Background Data . Long-term prognosis of WAD has not been fully eluci date d. Methods . Between 1993 and 1996 , we conducted cross-sectional comparative study of 508 acute WAD patients and 497 asymptomatic volunteers , all of whom underwent MRI of the cervical spine .  For this follow-up study , 133 WAD patients and 223 control subjects were recruited again . All participants underwent follow-up MRI and physical examination , and answered to question naires regarding neck symptoms . Evaluation of MRI included decrease in signal intensity of discs , posterior disc protrusion , disc space narrowing , and foraminal stenosis using 2 to 4 numerical grade s. Increase in the numerical grade s by one or more was considered to be progression of degenerative changes . Results . Progression of decrease in signal intensity was observed in 109 WAD patients ( 82.0 % ) , and 132 control subjects ( 59.2 % ) , ( age , sex adjusted odds ratio [ OR ] : 3.06 ) , posterior disc protrusion in 101 ( 75.9 % ) and in 155 ( 69.5 % ) ( OR = 1.46 ) , disc space narrowing in 33 ( 24.8 % ) and in 59 ( 26.5 % ) ( OR = 0.98 ) , and foraminal stenosis in 6 ( 4.5 % ) , and in 20 ( 9.0 % ) ( OR = 0.52 ) , respectively . Neck pain was observed in 34 WAD patients ( 25.6 % ) and 22 control subjects ( 9.9 % ) ( P < 0.0001 ) . There was no statistically significant correlation between neck pain and progression in each MR finding in either group . Conclusion . The results of this study suggest that , although some WAD patients are more likely to suffer from long-lasting neck pain , MRI findings can not explain the symptoms Objectives : Whiplash-associated disorders ( WAD ) are common and involve both physical and psychological impairments . Research has shown that persistent posttraumatic stress symptoms are associated with poorer functional recovery and physical therapy outcomes .  Trauma-focused cognitive-behavioral therapy ( TF-CBT ) has shown moderate effectiveness in chronic pain sample s. However , to date , there have been no clinical trials within WAD . Thus , this study will report on the effectiveness of TF-CBT in individuals meeting the criteria for current chronic WAD and posttraumatic stress disorder ( PTSD ) . Method : Twenty-six participants were r and omly assigned to either TF-CBT or a waitlist control , and treatment effects were evaluated at posttreatment and 6-month follow-up using a structured clinical interview , self-report question naires , and measures of physiological arousal and sensory pain thresholds . Results : Clinical ly significant reductions in PTSD symptoms were found in the TF-CBT group compared with the waitlist at post assessment , with further gains noted at the follow-up . The treatment of PTSD was also associated with clinical ly significant improvements in neck disability , physical , emotional , and social functioning and physiological reactivity to trauma cues , whereas limited changes were found in sensory pain thresholds . Discussion : This study provides support for the effectiveness of TF-CBT to target PTSD symptoms within chronic WAD . The finding that treatment of PTSD result ed in improvements in neck disability and quality of life and changes in cold pain thresholds highlights the complex and interrelating mechanisms that underlie both WAD and PTSD . Clinical implication s of the findings and future research directions are discussed BACKGROUND Many patients with chronic pain , including those with chronic whiplash-associated disorders ( WAD ) , show features of central sensitization . R and omized trials examining whether treatments are able to influence the process of central sensitization in patients with chronic WAD are emerging . Therefore , the present study aim ed at examining whether acupuncture results in activation of endogenous analgesia and relief in symptoms in patients with chronic WAD . METHODS In this r and omized crossover pilot trial with blinded assessors , each patient ( n = 39 ) received two treatment sessions of identical duration , with acupuncture and relaxation therapy r and omly crossed over in visit 2 . Primary outcome measurement included immediate activation of endogenous analgesia i.e. , pressure pain sensitivity and conditioned pain modulation . Secondary outcome measurements included pain relief and reduced disability level . RESULTS Local pressure pain sensitivity at baseline and during conditioned pain modulation decreased significantly more following acupuncture compared with relaxation ( time × group interactions : p < 0.001 ) , both in the neck and at a site distinct from the painful region . When comparing the effects of acupuncture versus relaxation , no differences were observed on conditioned pain modulation , temporal summation of pressure pain , neck disability or symptom severity ( all p-values > 0.05 ) . CONCLUSION It was shown that one session of acupuncture treatment results in acute improvements in pressure pain sensitivity in the neck and calf of patients with chronic WAD .  Acupuncture had no effect on conditioned pain modulation or temporal summation of pressure pain . Both acupuncture and relaxation appear to be well-tolerated treatments for people with chronic WAD . These findings suggest that acupuncture treatment activates endogenous analgesia in patients with chronic WAD Summary Fear of movement plays and important role in individuals with subacute whiplash‐associated disorders and it should be directly targeted in treatment . ABSTRACT Fear and avoidance of activity may play a role in fostering disability in  whiplash‐associated disorders ( WAD ) . This study examined the role of fear after WAD and assessed the effectiveness of 3 treatments targeting fear . People still symptomatic from WAD grade I‐II injuries approximately 3 months previously ( n = 191 ) completed question naires ( eg , Neck Disability Index [ NDI ] ) and were r and omized to 1 of the treatments : ( 1 ) informational booklet ( IB ) describing WAD and the importance of resuming activities , ( 2 ) IB + didactic discussion s ( DD ) with clinicians reinforcing the booklet , and ( 3 ) IB + imaginal and direct exposure desensitization ( ET ) to feared activities . DD and ET participants received three 2‐hour treatment sessions . Absolute improvements in NDI were in predicted direction ( ET = 14.7 , DD = 11.9 , IB = 9.9 ) . ETs reported significantly less posttreatment pain severity compared with the IB ( Mean = 1.5 vs 2.3 , P < .001 , d = 0.6 ) and DD ( M = 1.5 vs 2.0 , P = .039 , d = 0.6 ) groups . Reduction in fear was the most important predictor of improvement in NDI ( β = 0.30 , P < .001 ) , followed by reductions in pain ( β = 0.20 , P = .003 ) and depression ( β = 0.18 , P = .004 ) . The mediational analysis confirmed that fear reduction significantly mediated the effect of treatment group on outcome . Results highlight the importance of fear in individuals with subacute WAD and suggest the importance of addressing fear via exposure therapy and /or educational interventions to improve function Objective : To compare two different home exercise programmes for patients with acute whiplash-associated disorders ( WAD ) . A further aim was to describe the initial prognostic variables related to self-reported pain at six months follow-up . Design : A r and omized treatment study with a follow-up period of six months . Setting s : The study was undertaken in an orthopaedic clinic at a university hospital . Subjects : A total of 59 symptomatic ( neck pain , stiffness , etc . ) patients with acute whiplash injury . Interventions : Patients were r and omized to a regular treatment group ( RT group ) and an additional-exercise treatment group ( AT group ) . Main outcome measures : Pain Disability Index ( PDI ) , Self-Efficacy Scale ( SES ) , Coping Strategies Question naire ( CSQ ) , neck range of motion ( ROM ) , head posture , kinaesthetic sensibility , visual analogue scale ( VAS ) . Results : Patients given an additional exercise did not improve more than patients with regular treatment . Only one CSQ item , ‘ Ability to decrease pain ' , showed a significant difference between the groups in its pattern of change over time : the AT group had a significant increase between three and six months whilst values in the RT group decreased . Nonsymptomatic patients at six months follow-up were characterized by initially better self-efficacy , lower disability and significantly different patterns in the use of ‘ behavioural coping strategies ' when compared with symptomatic patients . The nonsymptomatic patients also reported more frequent training than symptomatic patients , i.e. they complied better with the treatment regime . Conclusion : This home exercise programme , including training of neck and shoulder ROM , relaxation and general advice seems to be sufficient treatment for acute WAD patients when used on a daily basis . Additionally , patients reporting low self-efficacy and high disability levels may profit from more attention initially , as these psychological factors are significant predictors of pain at long-term follow-up Primary objective : To examine the relationship between the occurrence of  whiplash-associated disorders and concussion symptoms in hockey players . Research design : Prospect i ve cohort observational study to examine the relationship between whiplash associated disorders and concussion in actual hockey play . Methods and procedures : Twenty hockey teams were followed prospect ively for one season . Team therapists completed acute and 7–10 day follow-up evaluation question naires for all of the players who received either a whiplash mechanism or a concussion . Main outcomes and results : 183 players were registered for this study ; 13 received either a whiplash mechanistic injury or a concussion injury . Initial injuries ranged from WAD I to WAD III and all subjects reported concussion symptoms . Only three subjects reported full resolution of bothWAD and concussion symptoms at the 7–10 day follow-up evaluation . Conclusions : There is a strong association between whiplash induced neck injuries and the symptoms of concussion in hockey injuries . Both should be evaluated when dealing with athletes/ patients suffering from either injury Study Design . Concealed allocation , multicenter , single-blind , r and omized controlled clinical trial . Objective . To assess the efficacy of an educational video in the tertiary prevention of persistent WAD symptoms following rear-end motor vehicle collisions ( MVCs ) . Summary of Background Data . Whiplash-associated disorders ( WAD ) are an important and costly health problem . There is a lack of high quality evidence surrounding efficacy of treatments for WAD . Existing research supports active interventions and early return to regular activities . Methods . Consecutive patients presenting to four tertiary care emergency departments following rear-end MVCs were eligible . Following informed consent , patients were allocated , using central r and omization , to receive an educational video plus usual care or usual care alone . The video provided reassurance , and advice about posture , return to regular activities , exercises , and pain-relief methods . Data were collected by telephone using st and ardized question naires . The primary outcome was presence of Persistent WAD Symptoms at 24 weeks postinjury , based on the frequency and severity of neck , shoulder , or upper back pain . The absolute difference in proportion of patients with persistent WAD symptoms and rate ratios were calculated . Changes in pain scores were compared using the Mann-Whitney U test . Results . The  intervention ( n = 206 ) and control ( n = 199 ) groups were similar at baseline ( mean age 38.4 years ; 64 % female ) . Overall , the proportion of subjects with Persistent WAD Symptoms decreased from 89.1 % at baseline to 33.6 % at 24 weeks after injury . At 24 weeks , the proportion of subjects with persistent WAD symptoms in the intervention group was 7.9 % ( 95 % CI , −2.0 , 17.8 ) lower than the control group . The median improvement in pain score at 24 weeks was 3 for the intervention group and 2 for the control group ( P = 0.016 ) . Conclusion . The presence of persistent WAD symptoms following simple rear-end MVCs was high in this sample . The video group demonstrated a trend toward less severe WAD symptoms . We recommend evaluating other educational interventions that could reduce WAD symptoms Study Design . An experimental study of motor and sensory function and psychological distress in subjects with acute whiplash injury . Objectives . To characterize acute whiplash injury in terms of motor and sensory systems dysfunction and psychological distress and to compare subjects with higher and lesser levels of pain and disability . Summary of Background Data . Motor system dysfunction , sensory hypersensitivity , and psychological distress are present in chronic whiplash associated disorders ( WAD ) , but little is known of such factors in the acute stage of injury . As higher levels of pain and disability in acute WAD are accepted as signs of poor outcome , further characterization of this group from those with lesser symptoms is important . Material s and Methods .  Motor function ( cervical range of movement [ ROM ] , joint position error [ JPE ] ; activity of the superficial neck flexors [ EMG ] during a test of cranio-cervical flexion ) , quantitative sensory testing ( pressure , thermal pain thresholds , and responses to the brachial plexus provocation test ) , and psychological distress ( GHQ-28 , TAMPA , IES ) were measured in 80 whiplash subjects ( WAD II or III ) within 1 month of injury , as were 20 control subjects . Results . Three subgroups were identified in the cohort using cluster analysis based on the Neck Disability Index : those with mild , moderate , or severe pain and disability . All whiplash groups demonstrated decreased ROM and increased EMG compared with the controls ( all P < 0.01 ) . Only the moderate and severe groups demonstrated greater JPE and generalized hypersensitivity to all sensory tests ( all P < 0.01 ) . The three whiplash subgroups demonstrated evidence of psychological distress , although this was greater in the moderate and severe groups . Measures of psychological distress did not impact on between group differences in motor or sensory tests . Conclusions . Acute whiplash subjects with higher levels of pain and disability were distinguished by sensory hypersensitivity to a variety of stimuli , suggestive of central nervous system sensitization occurring soon after injury . These responses occurred independently of psychological distress . These findings may be important for the differential diagnosis of acute whiplash injury and could be one reason why those with higher initial pain and disability demonstrate a poorer outcome Objectives ( 1 ) To investigate the development of hypoesthesia from soon after the whiplash injury to 6 months postinjury and ( 2 ) to determine differences in detection thresholds between those with initial features of poor recovery and those without these signs . Methods Fifty-two participants with acute whiplash-associated disorders ( WAD ) ( < 1 mo ) were classified as either “ high-risk ” ( n=17 ; Neck Disability Index > 30 ; sensory hypersensitivity ) or “ low risk ” ( n=35 ; without these signs ) .  Detection thresholds to electrical , thermal , and vibration stimuli and psychological distress were prospect ively measured within 1 month of injury and then 3 and 6 months postinjury . Detection thresholds were also measured in the 38 controls . Results Both WAD groups showed hypoesthesia ( vibration , electrical , and cold ) at 1 month postinjury . Vibration and electrocutaneous hypoesthesia persisted to 3 and 6 months only in the high-risk WAD group . Heat detection thresholds were not different between the groups at 1 month postinjury but were elevated in the high-risk group at 3 and 6 months . Both WAD groups were distressed at 1 month but this decreased by 3 months in the low-risk group . The differences in the Impact of Event Scale did not impact on any of the sensory measures . Discussion Sensory hypoesthesia is a feature of acute WAD but persists only in those at higher risk of poor recovery . These findings suggest the involvement of the central inhibitory mechanisms that may be sustained by ongoing nociception OBJECTIVE To investigate the reliability and discriminative ability of a new test design ed to detect accuracy of neck movements . DESIGN Repeated- measures . Case-control . SETTING University musculoskeletal research clinic in Icel and . PARTICIPANTS Twenty women ( mean age + /- st and ard deviation [ SD ] , 30.8+/-9.1 y ; range , 18 - 49 y ) with chronic whiplash-associated disorders ( WAD ) grade s I and II ( duration , 6 mo-6 y ) , with current pain score on a visual analog scale of 46.8+/-21.8 , and a disability score on the Northwick Park Neck Pain Disability Index of 45%+/-14 % . Twenty asymptomatic women ( mean age + /- SD , 29.3+/-8.6 y ; range , 18 - 48 y ) with no history of whiplash or insidious onset neck pain served as controls . INTERVENTION A slowly moving object appeared on a computer screen and traced an unpredictable movement path that the subjects were required to follow by moving their heads . Three r and omly ordered movement patterns were tested . MAIN OUTCOME MEASURE A new software program connected to a 3Space Fastrak system  was used to measure the mean absolute error ( in millimeters ) of 3 trials in each movement pattern . RESULTS The mean differences ( + /-2 SD ) between days 1 and 2 were.01+/-.64 mm for the asymptomatic group and .33+/-1.80 mm for the WAD group . The between-day intraclass correlation coefficients were between.60 and .77 for the asymptomatic group and .79 and .86 for the WAD group . Repeated- measures analysis of variance revealed a significant difference between groups ( P=.02 ) . The Tukey post hoc test showed significant between-group differences for each movement pattern ( P</=.05 ) . In each successive trial , a slight improvement for the asymptomatic group and a slight worsening for the WAD group were detected . CONCLUSIONS Better reliability was detected for the asymptomatic group than for the WAD group . The test could discriminate between the asymptomatic group versus the chronic WAD group Sensory hypersensitivity indicative of augmented central pain processing is a feature of chronic whiplash associated disorders ( WAD ) . This study investigated the immediate effects of a cervical spine manual therapy ( SMT ) technique on measures of central hyperexcitability . In a r and omised , single blind , clinical trial , 39 participants with chronic WAD were r and omly assigned to a cervical SMT ( lateral glide ) or manual contact intervention . The Neck Disability Index ( NDI ) and GHQ-28 were administered at baseline . Pressure pain thresholds ( PPTs ) , thermal pain thresholds ( TPTs ) and Nociceptive Flexion Reflex ( NFR ) responses ( threshold and VAS of pain ) were measured pre and post intervention . There was a significantly greater increase in NFR threshold following SMT compared to the manual contact intervention ( p = 0.04 ) . PPTs at the cervical spine increased following both SMT ( mean + /- SE : 24.1 + /- 7.3 % ) and manual contact ( 21 + /- 8.4 % ) with no difference between interventions . There was no difference between interventions for pain ratings with the NFR test , PPTs at the Median Nerve or Tibialis Anterior , heat or cold TPT . SMT may be effective in reducing spinal hyperexcitability in chronic WAD The chronic state of whiplash-associated disorder ( WAD ) might be understood as a somatization of existential pain . Intervention aim ed to improve quality of life ( QOL )  seemed to be a solution for such situations . The basic idea behind the intervention was holistic , restoring quality of life and relationship with self , in order to diminish tension in the locomotion system , especially the neck . A psychosomatic theory for WAD is proposed . Our treatment was a short 2-day course with teachings in philosophy of life , followed by 6 to 10 individual sessions in gestalt psychotherapy and body therapy ( Rosen therapy and Cranio Sacral therapy ) , followed by a 1-day course approximately 2 months later , closing the intervention . Two independent institutions did the intervention and the assessment s. In a r and omized , clinical ly controlled setting , 87 chronic WAD patients were included with a median duration of 37 months from their whiplash accidents . One patient never started . Forty-three had the above intervention ( female/male = 36/7 , ages 22—49 , median 37 years ) and another 43 were assigned to a nontreated control group ( female/male = 35/8 , ages 1848 , median 38 ) . Six had disability pension and 27 had pending medicolegal issues in each group . Effect variables were pain in neck , arm , and /or head ; measures of quality of life and daily activities ; as well as general physical or mental health . Wilcoxon test for between-groups comparisons with intention-to-treat analyses was conducted ; the square curve paradigm testing for immediate improvements of health and quality of life was also used . The groups were comparable at baseline . From the intervention group , 11 dropped out during the intervention ( 4 of those later joined the follow-up investigation ) , 22 of the remaining 32 graduated the course , and 35 of the 43 controls did as well . Approximately 3 months later , we found no clinical ly relevant or significant increase in any effect measure . The above version of a quality of life intervention based on alternative therapy had no effect on patients with chronic WAD Background Whiplash associated disorders ( WAD ) have dramatic consequences for individual and public health . Risk factors for better and worse outcomes are important to optimize management . This study aim ed to determine short- and mid-term associative co-factors of neck pain relief , improved physical functioning , and improved working capacity ( dependent variables ) in patients suffering from whiplash associated disorder who participated in a st and ardized , inpatient pain management program .  Methods Naturalistic , observational , prospect i ve cohort study . Outcome was measured by st and ardized assessment instruments . Co-factors covered sociodemographics , comorbidities , social participation , affective health , and coping abilities . Stepwise , multivariate linear regression analysis was performed at discharge and at the 6-month follow-up . Results All regression models explained high proportions of variance ( 53.3 % – 72.1 % ) . The corresponding baseline level was significantly associated with a change in every dependent variable ( explained variances : 11.4%-56.7 % ) . Pain relief significantly depended on improved function and vice-versa ( 3.4%-14.8 % ) . Improved ability to decrease pain was associated with pain relief at discharge ( 9.6 % ) . Functional improvement was associated with decreased catastrophizing ( 19.4 % ) at discharge and decreased depression ( 20.5 % ) at the 6 month follow-up . Conclusions Pain relief , improved physical function and working capacity were associated with each other . Improved coping ( catastrophizing and ability to decrease pain ) and reduced depression may act as important predictors for pain relief and improved function . These findings offer toe-holds for optimized therapy of chronic WAD Objective The aim of this exploratory study was to investigate changes in pain , disability , and muscle activation patterns in patients with chronic whiplash-associated disorder ( WAD ) after 4 weeks of myofeedback training . Methods Eleven WAD patients received ambulatory myofeedback training  , during which upper trapezius muscle activation and relaxation were continuously recorded and processed for 4 weeks . Feedback was provided when muscle relaxation was insufficient . Pain in neck , shoulders , and upper back ( Visual Analogue Scale ) , disability ( Neck Disability Index ) , and muscle activation patterns during rest , typing , and stress tasks ( surface electromyography ) were assessed before and after the 4 weeks of training . Results Pain intensity decreased after 4 weeks of training . Clinical ly relevant changes were found with regard to pain in the neck and upper back region ( 55 % of the patients ) , right shoulder ( 64 % ) , and left shoulder ( 18 % ) . A trend for decreased disability was found which was clinical ly relevant in 36 % of the patients . A remarkable reduction was found in the Neck Disability Index items concerning headache and lifting weights . Overall , muscle activation was lower and muscle relaxation was higher after the training period with the largest differences during rest . Clinical ly relevant changes in surface electromyography parameters were found in a minority of patients . Conclusion Four weeks of ambulant training may be beneficial in reducing pain and disability levels and normalizing muscle activation patterns in chronic WAD patients . A r and omized-controlled study is recommended to further explore the effects of myofeedback training Background The management of Whiplash Associated Disorders is one of the most complicated challenges with high expenses for the health care system and society . There are still no general guidelines or scientific documentation to unequivocally support any single treatment for acute care following whiplash injury . The main purpose of this study is to try a new behavioural medicine intervention strategy at acute phase aim ed to reduce the number of patients who have persistent problems after the whiplash injury . The goal is also to identify which of three different interventions that is most cost-effective for patients with Whiplash Associated Disorders . In this study we are controlling for two factors . First , the effect of behavioural medicine approach is compared with st and ard care . Second , the manner in which the behavioural medicine treatment is administered , Internet or face-to-face , is evaluated in it 's effectiveness and cost-effectiveness . Methods / Design The study is a r and omized , prospect i ve , experimental three-group study with analyses of cost-effectiveness up to two-years follow-up . Internet – based programme and face-to-face group treatment programme are compared to st and ard-treatment only . Patient follow-ups take place three , six , twelve and 24 months , that is , short-term as well as long-term effects are evaluated . Patients will be enrolled via the emergency ward during the first week after the accident . Discussion This new self-help management will concentrate to those psychosocial factors that are shown to be predictive in long-term problems in Whiplash Associated Disorders , i.e. the importance of self-efficacy , fear of movement , and the significance of catastrophizing as a coping strategy for restoring and sustaining activities of daily life . Within the framework of this project , we will develop , broaden and evaluate current physical therapy treatment methods for acute Whiplash Associated Disorders . The project will contribute to the creation of a cost-effective  behavioural medicine approach to management of acute Whiplash Associated Disorders . The results of this study will answer an important question ; on what extent and how should these patients be treated at acute stage and how much does the best management cost . Trial registration numberCurrent Controlled Trials IS RCT
For workers with persistent neck and shoulder pain , evidence supports mixed supervised and unsupervised high-intensity strength training or advice alone ( grade s I-III NAD ) .
A multimodal approach including manual therapy , self-management advice , and exercise is an effective treatment strategy for both recent-onset and persistent neck pain
OBJECTIVE The objective was to develop a clinical practice guideline on the management of neck pain-associated disorders ( NADs ) and whiplash-associated disorders ( WADs ) .
This guideline replaces 2 prior chiropractic guidelines on NADs and WADs .