Review article: Methodology for the ‘rapid review’ series on musculoskeletal injuries in the emergency department Neck exercises, physical and cognitive behavioural-graded activity as a treatment for adult whiplash patients with chronic neck pain: Design of a randomised controlled trial Pain Thresholds and Tenderness in Neck and Head Following Acute Whiplash Injury: A Prospective Study Predictors of persistent neck pain after whiplash injury 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 Similar factors predict disability and posttraumatic stress disorder trajectories after whiplash injury 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 Derivation of a clinical prediction rule to identify both chronic moderate/severe disability and full recovery following whiplash injury Chronic neck pain and whiplash: a case-control study of the relationship between acute whiplash injuries and chronic neck pain. Differential development of sensory hypersensitivity and a measure of spinal cord hyperexcitability following whiplash injury Clinical assessment of prognostic factors for long-term pain and handicap after whiplash injury: a 1-year prospective study. Development in pain and neurologic complaints after whiplash Managing Injuries of the Neck Trial (MINT): design of a randomised controlled trial of treatments for whiplash associated disorders Are early MRI findings correlated with long-lasting symptoms following whiplash injury? A prospective trial with 1-year follow-up Manual therapy and exercise for neck pain: A systematic review. Managing Injuries of the Neck Trial (MINT): a randomised controlled trial of treatments for whiplash injuries. Psychological Factors and the Development of Chronic Whiplash–associated Disorder(s): A Systematic Review Handicap after acute whiplash injury Compensation claim lodgement and health outcome developmental trajectories following whiplash injury: A prospective study Headache, Neck Pain, and Neck Mobility After Acute Whiplash Injury: A Prospective Study The burden and determinants of neck pain in workers: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Does the presence of sensory hypersensitivity influence outcomes of physical rehabilitation for chronic whiplash? – A preliminary RCT A prospective cohort study of the outcome of acute whiplash injury in Greece.
Musculoskeletal injuries are a common presentation to the ED , with significant costs involved in the management of these injuries , variances in care within the ED and associated morbidity . A series of rapid review papers were completed to guide best practice for the assessment and management of common musculoskeletal injuries presenting to the ED . This paper presents the methodology used across the rapid review s. PubMed , CINAHL , EMBASE , TRIP and the grey literature , including relevant organisational websites , were search ed in 2015 . The search was repeated consistently for each topic area ( injuries of the foot and ankle , knee , h and and wrist , elbow , shoulder , lumbar spine and cervical spine ) . English- language primary studies , systematic review s and guidelines that were published in the last 10 years and addressed acute musculoskeletal injury management were considered for inclusion . Data extraction of each included article was conducted , followed by a quality appraisal . The extracted data from each article was synthesis ed to group similar evidence together . For each rapid review , the evidence has been organised in a way that a clinician can direct their attention to a specific component of the clinical cycle of care in the ED , such as the assessment , diagnostic tests , management and follow-up considerations from ED . The series of rapid review s are design ed to foster evidence -based practice within the ED , targeting the injuries most commonly presenting . The review s provide clinicians in EDs with rapid access to the best current evidence , which has been synthesis ed and organised to assist decision-making Background Many patients suffer from chronic neck pain following a whiplash injury . A combination of cognitive , behavioural therapy with physiotherapy interventions has been indicated to be effective in the management of patients with chronic whiplash-associated disorders . The objective is to present the design of a r and omised controlled trial ( RCT ) aim ed at evaluating the effectiveness of a combined individual physical and cognitive behavioural- grade d activity program on self-reported general physical function , in addition to neck function , pain , disability and quality of life in patients with chronic neck pain following whiplash injury compared with a matched control group measured at baseline and 4 and 12 months after baseline . Methods / Design The design is a two-centre , RCT - study with a parallel group design . Included are whiplash patients with chronic neck pain for more than 6 months , recruited from physiotherapy clinics and an out-patient hospital department in Denmark . Patients will be r and omised to either a pain management ( control ) group or a combined pain management and training (intervention)group . The control group will receive four educational sessions on pain management , whereas the intervention group will receive the same educational sessions on pain management plus 8 individual training sessions for 4 months , including guidance in specific neck exercises and an aerobic training programme . Patients and physiotherapists are aware of the allocation and the treatment , while outcome assessors and data analysts are blinded . The primary outcome measures will be Medical Outcomes Study Short Form 36 ( SF36 ) , Physical Component Summary ( PCS ) . Secondary outcomes will be Global Perceived Effect ( -5 to + 5 ) , Neck Disability Index ( 0 - 50 ) , Patient Specific Functioning Scale ( 0 - 10 ) , numeric rating scale for pain bothersomeness ( 0 - 10 ) , SF-36 Mental Component Summary ( MCS ) , TAMPA scale of Kinesiophobia ( 17 - 68 ) , Impact of Event Scale ( 0 - 45 ) , EuroQol ( 0 - 1 ) , craniocervical flexion test ( 22 mmHg - 30 mmHg ) , joint position error test and cervical range of movement . The SF36 scales are scored using norm-based methods with PCS and MCS having a mean score of 50 with a st and ard deviation of 10 . Discussion The perspectives of this study are discussed , in addition to the strengths and weaknesses . Trial registration The study is registered in http://www . Clinical Trials.gov identifier NCT01431261 Objective of the investigation : In a 6-month prospect i ve study of 141 consecutive acute whiplash-injured participants , and 40 acute , ankle-injured controls , pain and tenderness in the neck/head , and at a distant control site , were measured . Basic procedures : Muscle palpation and pressure algometry in five head/neck muscle-pairs were performed after 1 week and 1 , 3 and 6 months after injury . Algometry was performed at a distant control site . Main findings : Whiplash-injured patients had lowered pressure-pain-detection thresholds and higher palpation-score initially in the neck/head , but the groups were similar after 6 months , and the control site was not sensitized . Principal conclusion : Focal , but not generalized , sensitization to musculoskeletal structure is present until 3 months , but not 6 months , after whiplash injury , and probably does not play a major role in the development of late whiplash syndrome . Pressure algometry and palpation are useful clinical tools in the evaluation of neck and jaw pain in acute whiplash injury Objective : To establish the aetiological influences of  persistent neck pain following a motor vehicle collision and to construct a model for use in the emergency department for identifying patients at high risk of persistent symptoms . Design : Prospect i ve cohort study . Patients recruited from hospital emergency departments were sent a question naire to gather information on various exposures . They were followed up at 1 , 3 , and 12 months to identify those with persistent symptoms . Main outcome measure : Persistent neck pain ( pain at 1 , 3 , and 12 months after collision ) . Results : The baseline survey included 765 patients . Subsequently , 480 completed a question naire at each follow up time point , of whom 128 ( 27 % ) reported neck pain on each occasion . Few collision specific factors predicted persistent neck pain . In contrast , a high level of general psychological distress , pre-collision history of widespread body pain , type of vehicle , whiplash associated symptoms , and initial neck disability best predicted the persistence of symptoms . Furthermore , these factors , in combination , accounted for more than a fivefold increase in the risk of persistent neck pain . Conclusion : The greatest predictors of persistent neck pain following a motor vehicle collision relate to psychological distress and aspects of pre-collision health rather than to various attributes of the collision itself . With these factors , and those relating to initial injury severity , it is possible to identify a subgroup of patients presenting with neck pain with the highest risk of persistent symptoms . Thus , it is possible to identify whiplash patients with a poor prognosis and to provide closer follow up and specific attention to management in these individuals 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 & NA ; Distinct developmental trajectories for neck disability and posttraumatic stress disorder ( PTSD ) symptoms after whiplash injury have recently been identified . This study aim ed to identify baseline predictors of membership to these trajectories and to explore their dual development . In a prospect i ve study , 155 individuals with whiplash were assessed at < 1 month , 3 , 6 , and 12 months postinjury . Outcomes at each time point were assessed according to the Neck Disability Index and the Posttraumatic Stress Diagnostic Scale . Baseline predictor variables were age , gender , initial pain ( based on a visual analogue scale [ VAS ] ) , pressure pain thresholds ( PPT ) , cold pain thresholds ( CPT ) , and sympathetic vasoconstrictor responses . Group‐based trajectory analytical techniques were used to parameterise the optimal trajectories and to identify baseline predictors . A dual trajectory analysis was used to explore probabilities of conditional and joint trajectory group membership . CPT ⩾ 13 ° C ( OR = 26.320 , 95 % CI = 4.981–139.09 ) , initial pain level ( VAS ) ( OR = 4.3 , 95 % CI = 4.98–139.1 ) , and age ( OR = 1.109 , 95 % CI = 1.043–1.180 ) predicted a chronic/severe disability trajectory . The same baseline factors also predicted chronic moderate/severe PTSD ( CPT ⩾ 13 ° C , OR = 9.7 , 95%CI = 2.22–42.44 ; initial pain level [ VAS ] : OR = 2.13 , 95 % CI = 1.43–3.17 ; age : OR = 1.07 , 95 % CI = 1.01–1.14 ) . There was good correspondence of trajectory group for both disability and PTSD . These findings support the proposal of links between the development of chronic neck related disability and PTSD after whiplash injury . Developmental trajectories of disability and posttraumatic stress disorder ( PTSD ) after whiplash injury are mostly in synchrony , and similar factors predict their membership . This suggests links between the development of chronic neck pain‐related disability and PTSD 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 Summary A clinical prediction rule comprising relevant biopsychosocial factors was derived to predict both  chronic moderate/severe disability and full recovery following whiplash injury . Abstract Recovery following a whiplash injury is varied : approximately 50 % of individuals fully recover , 25 % develop persistent moderate/severe pain and disability , and 25 % experience milder levels of disability . Identification of individuals likely to develop moderate/severe disability or to fully recover may help direct therapeutic re sources and optimise treatment . A clinical prediction rule ( CPR ) is a research ‐generated tool used to predict outcomes such as likelihood of developing moderate/severe disability or experiencing full recovery from whiplash injury . The purpose of this study was to assess the plausibility of developing a CPR . Participants from 2 prospect i ve , longitudinal studies that examined prognostic factors for poor functional recovery following whiplash injury were used to derive this tool . Eight factors , previously identified as predictor variables of poor recovery , were included in the analyses : initial neck disability index ( NDI ) , initial neck pain ( visual analogue scale ) , cold pain threshold , range of neck movement , age , gender , presence of headache , and posttraumatic stress symptoms ( Posttraumatic Diagnostic Scale [ PDS ] ) . An increased probability of developing chronic moderate/severe disability was predicted in the presence of older age and initially higher levels of NDI and hyperarousal symptoms ( PDS ) ( positive predictive value [ PPV ] = 71 % ) . The probability of full recovery was increased in younger individuals with initially lower levels of neck disability ( PPV = 71 % ) . This study provides initial evidence for a CPR to predict both chronic moderate/severe disability and full recovery following a whiplash injury . Further research is needed to vali date the tool , determine the acceptability of the proposed CPR by practitioners , and assess the impact of inclusion in practice The authors undertook a case-control study of chronic neck pain and whiplash injuries in nine states in the United States to determine whether whiplash injuries contributed significantly to the population of individuals with chronic neck and other spine pain . Four hundred nineteen patients and 246 controls were r and omly enrolled . Patients were defined as individuals with chronic neck pain , and controls as those with chronic back pain . The two groups were surveyed for cause of chronic pain as well as demographic information . The two groups were compared using an exposure-odds ratio . Forty-five per cent of the patients attributed their pain to a motor vehicle accident . An OR of 4.0 and 2.1 was calculated for men and women , respectively . Based on the results of the present study , it reasonable to infer that a significant proportion of individuals with chronic neck pain in the general population were originally injured in a motor vehicle accident & NA ; Widespread sensory hypersensitivity is present in acute whiplash and is associated with poor recovery . Decreased nociceptive flexion reflex ( NFR ) thresholds ( spinal cord hyperexcitability ) are a feature of chronic whiplash but have not been investigated in the acute to chronic injury stage . This study compared the temporal development of sensory hypersensitivity and NFR responses from soon after injury to either recovery or to transition to chronicity . It also aim ed to identify predictors of persistent spinal cord hyperexcitability . Pressure and cold pain thresholds , NFR responses ( threshold and pain VAS )  were prospect ively measured in 62 participants at <3 weeks , 3 and 6 months post whiplash injury and in 22 healthy controls on two occasions a month apart . Pain levels and psychological distress ( GHQ‐28 ; IES ) were measured at baseline . Whiplash participants were classified at 6 months post‐injury using the Neck Disability Index : recovered ( ≤8 % ) , mild pain and disability ( 10–28 % ) or moderate/severe pain and disability ( ≥30 % ) . All whiplash groups  demonstrated spinal cord hyperexcitability ( lowered NFR thresholds ) at 3 weeks post‐injury . This hyperexcitability persisted in those with moderate/severe symptoms at 6 months but resolved in those who recovered or reported lesser symptoms at 6 months . In contrast generalized sensory hypersensitivity ( pressure and cold ) was only ever present in those with persistent moderate/severe symptoms and remained unchanged throughout the study period . This suggests different mechanisms underlie sensory hypersensitivity and NFR responses . In multivariate analyses only initial NDI scores ( p = 0.003 ) were a unique predictor of persistent spinal cord hyperexcitability indicating possible ongoing peripheral nociception following whiplash injury BACKGROUND AND PURPOSE Physical mechanisms are the possible factors involved in the development and maintenance of long-term h and icaps after acute whiplash injury . This study prospect ively examined the role of active neck mobility , cervical and extra-cervical pains , as well as non-painful complaints after a whiplash injury as predictors for subsequent h and icap . METHODS Consecutive acute whiplash patients ( n = 688 ) were interviewed and examined by a study nurse after the median of 5 days after injury , and divided into a high- or a low-risk group by an algorithm based on pain intensity , number of non-painful complaints and active neck mobility [ active cervical range of motion ( CROM ) ] . All 458 high-risk patients and 230 low-risk patients received mailed question naires after 3 , 6 and 12 months . Two examiners examined all high-risk patients ( n = 458 ) and 41 consecutive low-risk patients at median 11 , 109 , 380 days after injury . The main outcome measures were : h and icaps , severe headaches , neck pain and neck disability . RESULTS The relative risk for a 1-year disability increased by 3.5 with initial intense neck pain and headaches , by 4.6 times with reduced CROM and by four times with multiple non-painful complaints . CONCLUSION Reduced active neck mobility , immediate intense neck pain and headaches and the presence of multiple non-painful complaints are the important prognostic factors for a 1-year h and icap after acute whiplash Objective : To prospect ively examine the course of pain and other neurologic complaints in patients with acute whiplash injury and in controls with acute ankle injury . Methods : Patients with acute whiplash ( n = 141 ) and ankle-injured controls ( n = 40 ) were consecutively sample d , and underwent interview and examination after 1 week and 1 , 3 , 6 , and 12 months . Outcome measures were pain intensity , pain frequency , and associated symptoms . Results : Initial overall pain intensity above lower extremities ( pain in neck , head , shoulder-arm , and low back ) was similar in patients with whiplash ( median Visual Analogue Scale [VAS]0–100 of 20 [ 25th and 75th percentile , 4 , 39 ] ) and ankle-injured controls ( median VAS0–100 of 15 [ 5 , 34 ] ) . Whiplash-injured patients reported median overall VAS0–100 pain intensity above lower extremities of 23 ( 12 , 40 ) after 11 days and 14 ( 12 , 40 ) after 1 year . Controls reported pain intensity of 0 ( 0 , 4 ) after 12 days and 0 ( 0 , 9 ) after 1 year . Reported overall pain frequency above lower extremities was 96 % after 11 days and 74 % after 1 year in whiplash-injured patients and 33 % after 12 days and 47 % after 1 year in controls . Associated neurologic symptoms were two to three times more common after whiplash injury . Correlation was found between pain intensity and associated symptoms in whiplash-injured patients but not controls . Conclusion : Pain occurs with high frequency but low intensity after whiplash and ankle injury . Associated neurologic symptoms were not correlated to pain in ankle-injured controls , but were correlated to pain in patients with whiplash injury . Persistent symptoms in whiplash-injured patients may be caused by both specific neck injury – related factors and nonspecific post-traumatic reactions . Disability was only encountered in the whiplash group Background A substantial proportion of patients with whiplash injuries develop chronic symptoms . However , the best treatment of acute injuries to prevent long-term problems is uncertain . A stepped care treatment pathway has been proposed , in which patients are given advice and education at their initial visit to the emergency department ( ED ) , followed by review at three weeks and physiotherapy for those with persisting symptoms . MINT is a two-stage r and omised controlled trial to evaluate two components of such a pathway : 1 . use of The Whiplash Book versus usual advice when patients first attend the emergency department ; 2 . referral to physiotherapy versus reinforcement of advice for patients with continuing symptoms at three weeks . Methods Evaluation of the Whiplash Book versus usual advice uses a cluster r and omised design in emergency departments of eight NHS Trusts . Eligible patients are identified by clinicians in participating emergency departments and are sent a study question naire within a week of their ED attendance . Three thous and participants will be included . Patients with persisting symptoms three weeks after their ED attendance are eligible to join an individually r and omised study of physiotherapy versus reinforcement of the advice given in ED . Six hundred participants will be r and omised . Follow-up is at 4 , 8 and 12 months after their ED attendance . Primary outcome is the Neck Disability Index ( NDI ) , and secondary outcomes include quality of life and time to return to work and normal activities . An economic evaluation is being carried out . Conclusion This paper describes the protocol and operational aspects of a complex intervention trial based in NHS emergency and physiotherapy departments , evaluating two components of a stepped-care approach to the treatment of whiplash injuries . The trial uses two r and omisations , with the first stage being cluster r and omised and the second individually r and omised Neck pain is the cardinal symptom following whiplash injuries . The trauma mechanism could theoretically lead to both soft tissue and bone injury that could be visualised by means of MRI . From previous quite small trials it seems that MRI does not demonstrate significant tissue damage . Large prospect ively followed cohorts are needed to identify possible clinical ly relevant MRI findings . The objective of this trial was to evaluate ( 1 ) the predictive value of cervical MRI  after whiplash injuries and ( 2 ) the value of repeating MRI examinations after 3 months including sequences with flexion and extension of the cervical spine . Participants were included after rear-end or frontal car collisions . Patients with fractures or dislocations diagnosed by st and ard procedures at the emergency unit were not included .  MRI scans of the cervical spine were performed at baseline and repeated after 3 months . Clinical follow-ups were performed after 3 and 12 months . Outcome parameters were neck pain , headache , neck disability and working ability .  A total of 178 participants had a cervical MRI scan on average 13 days after the injury . Traumatic findings were observed in seven participants . Signs of disc degeneration were common and most frequent at the C5–6 and C6–7 levels . Findings were not associated with outcome after 3 or 12 months . The population had no considerable neck trouble prior to the whiplash injury and the non-traumatic findings represent findings to be expected in the background population . Trauma-related MRI findings are rare in a whiplash population screened for serious injuries in the emergency unit and not related to a specific symptomatology . Also , pre-existing degeneration is not associated with prognosis Manual therapy is often used with exercise to treat neck pain . This cervical overview group systematic review up date assesses if manual therapy , including manipulation or mobilisation , combined with exercise improves pain , function/disability , quality of life , global perceived effect , and patient satisfaction for adults with neck pain with or without cervicogenic headache or radiculopathy . Computerized search es were performed to July 2009 . Two or more authors independently selected studies , abstract ed data , and assessed method ological quality . Pooled relative risk ( pRR ) and st and ardized mean differences ( pSMD ) were calculated . Of 17 r and omized controlled trials included , 29 % had a low risk of bias . Low quality evidence suggests clinical ly important long-term improvements in pain ( pSMD-0.87(95 % CI:-1.69,-0.06 ) ) , function/disability , and global perceived effect when manual therapy and exercise are compared to no treatment . High quality evidence suggests greater short-term pain relief [ pSMD-0.50(95 % CI:-0.76,-0.24 ) ] than exercise alone , but no long-term differences across multiple outcomes for (sub)acute/chronic neck pain with or without cervicogenic headache . Moderate quality evidence supports this treatment combination for pain reduction and improved quality of life over manual therapy alone for chronic neck pain ; and suggests greater short-term pain reduction when compared to traditional care for acute whiplash . Evidence regarding radiculopathy was sparse . Specific research recommendations are made OBJECTIVES To examine the clinical effectiveness of a stepped care approach over a 12-month period after an acute whiplash injury ; to estimate the costs and cost-effectiveness of each strategy including treatments and subsequent health-care costs ; and to gain participants ' perspective on experiencing whiplash injury , NHS treatment , and recovery within the context of the Managing Injuries of the Neck Trial ( MINT ) . DESIGN Two linked , pragmatic , r and omised controlled trials . In Step 1 , emergency departments ( EDs ) were cluster r and omised to usual care advice ( UCA ) or The Whiplash Book advice (WBA)/active management advice . In Step 2 , participants were individually r and omised to either a single session of advice from a physiotherapist or a physiotherapy package of up to six sessions . An economic evaluation and qualitative study were run in parallel with the trial . SETTING Twelve NHS trusts in Engl and comprising 15 EDs . PARTICIPANTS People who attended EDs with an acute whiplash injury of whiplash-associated disorder grade s I-III were eligible for Step 1 . People who had attended EDs with whiplash injuries and had persistent symptoms 3 weeks after ED attendance were eligible for Step 2 . INTERVENTIONS In Step 1 , the control intervention was UCA and the experimental intervention was a psycho-educational intervention ( WBA/active management advice ) . In Step 2 the control treatment was reinforcement of the advice provided in Step 1 and the experimental intervention was a package of up to six physiotherapy treatments . MAIN OUTCOME The primary outcome was the Neck Disability Index ( NDI ) , which measures severity and frequency of pain and symptoms , and a range of activities including self-care , driving , reading , sleeping and recreation . Secondary outcomes included the mental and physical health-related quality -of-life ( HRQoL ) subscales of the Short Form question naire-12 items ( SF-12 ) and the number of work days lost . RESULTS A total of 3851 patients were recruited to Step 1 of the trial . 1598 patients attending EDs were r and omised to UCA , and 2253 were r and omised to WBA/active management . Outcome data were obtained at 12 months for 70 % and 80 % of participants at Step 1 and Step 2 , respectively . The majority of people recovered from the injury . Eighteen per cent of the Step 1 cohort had late whiplash syndrome . There was no statistically or clinical ly significant difference observed in any of the outcomes for participants attending EDs r and omised to UCA or active management advice [ difference in NDI 0.5 , 95 % confidence interval ( CI ) -1.8 to 2.8 ] . In Step 2 the physiotherapy package result ed in improvements in neck disability at 4 months compared with a single advice session , but these effects were small at the population level ( difference in NDI -3.2 , 95 % CI -5.8 to -0.7 ) . The physiotherapy package was accompanied by a significant reduction in the number of work days lost at 4-month follow-up ( difference -40.2 , 95 % CI -44.3 to -35.8 ) . CONCLUSIONS MINT suggests that enhanced psycho-educational interventions in EDs are no more effective than UCA in reducing the burden of acute whiplash injuries . A physiotherapy package provided to people who have persisting symptoms within the first 6 weeks of injury produced additional short-term benefits in neck disability compared with a single physiotherapy advice session . However , from a health-care perspective , the physiotherapy package was not cost-effective at current levels of willingness to pay . Both experimental treatments were associated with increased cost with no discernible gain in health-related quality of life . However , an important benefit of the physiotherapy package was a reduction in work days lost ; consequently , the intervention may prove cost-effective at the societal level . TRIAL REGISTRATION Current Controlled Trials IS RCT N33302125 . FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol . 16 , No. 49 . See the HTA programme website for further project information Objectives : To assess which psychological factors are important in the development of chronic whiplash symptoms . Methods : Search es were conducted across PubMed , CINAHL , Scopus , and PsychINFO up until March 2017 . Studies were included if they investigated psychological prognostic factors in association with recovery from a whiplash injury . Studies also had to be prospect i ve , cohort , follow-up or observational studies , have a 6 month follow-up and published in English . Quality assessment s were conducted by 2 independent review ers . Thirty-one articles were included investigating 34 psychological factors . Results : Poor expectations of recovery , posttraumatic stress symptoms and passive coping emerged as the most consistent prognostic factors of chronic neck pain and /or disability after a whiplash injury . Anxiety , travel anxiety , depression , personality , precollision distress , general psychological distress , and avoidance behavior were not associated with chronic whiplash problems Background : Exposure to a whiplash injury implies a risk for development of chronic disability and h and icap , with reported frequencies ranging from 0 % to 50 % in follow-up studies . The exact risk for development of chronic whiplash syndrome is not known . Objective : To prospect ively determine the sensitivity and specificity of five possible predictors for h and icap following a whiplash injury . Methods : In a 1-year prospect i ve study of persons with acute whiplash injury ( n = 141 ) and control subjects who had acute ankle distortion ( n = 40 ) , pain intensity , number of nonpainful neurologic complaints , cervical mobility , workload during extension and flexion of the neck , and results of psychometric assessment were recorded . The consecutively sample d injured persons were assessed with structured and semistructured question naires , and underwent neurologic examination after 1 week and 1 , 3 , 6 , and 12 months . After 3 to 4 years , participants with whiplash injury were question ed about legal issues . Results : After 1 year , 11 ( 7.8 % ) persons with whiplash injury had not returned to usual level of activity or work . The best single estimator of h and icap was the cervical range-of-motion test , which had a sensitivity of 73 % and a specificity of 91 % ( p < 0.01 , Cox regression analysis ) . Accuracy and specificity increased to 94 % and 99 % when combined with pain intensity and other complaints . This increase was gained at the expense of a reduced sensitivity . Initiation of lawsuit within first month after injury did not influence recovery . Conclusion : The cervical range-of-motion test has a high sensitivity in prediction of h and icap after acute whiplash injury . The value of cervical range-of-motion test is further improved by additional recording of symptoms and pain intensity & NA ; This study aim ed to identify distinctive trajectories for pain/disability and posttraumatic stress disorder ( PTSD ) symptoms following whiplash injury and to examine the effect of injury compensation cl aim lodgement on the trajectories . In a prospect i ve study , 155 individuals with whiplash were assessed at < 1 month , 3 , 6 and 12 months post injury . Outcomes at each time point were Neck Disability Index ( NDI ) and the Posttraumatic Stress Diagnostic Scale ( PDS ) . Group‐based trajectory analytical techniques were used to identify outcome profiles . The analyses were then repeated after including third party compensation cl aim lodgment as a binary time‐changing covariate . Three distinct NDI trajectories were determined : ( 1 ) Mild : mild or negligible pain/disability for the entire 12 months ( 45 % ) , ( 2 ) Moderate : initial moderate pain/disability that decreased to mild levels by 3 months ( 39 % ) and ( 3 ) Chronic‐severe : severe pain/disability persisting at moderate/severe levels for 12 months ( 16 % ) . Three distinct PTSD trajectories were also identified : ( 1 ) Resilient : mild symptoms throughout ( 40 % ) , ( 2 ) Recovering : initial moderate symptoms declining to mild levels by 3 months ( 43 % ) and ( 3 ) Chronic moderate‐severe : persistent moderate/severe symptoms throughout 12 months ( 17 % ) . Cl aim su bmi ssion had a detrimental effect on all trajectories ( p < 0.001 ) except for the Chronic‐severe NDI trajectory ( p = 0.098 ) . Following whiplash injury , there are distinct pathways of recovery for pain/ disability and PTSD symptoms . Management of whiplash should consider the detrimental association of compensation cl aim with psychological recovery and recovery of those with mild to moderate pain/disability levels . However , cl aim lodgement has no significant association with a more severe pain and disability trajectory Study Design . A 6-month prospect i ve study of neck mobility in patients with acute whiplash injury and a control group with acute ankle distortion  was conducted . Objectives . To assess active  neck mobility  after acute whiplash and ankle distortion injuries , and to relate neck mobility to headache , neck pain , and speed of car at the time of collision . Summary of background data . A major problem after whiplash injury is restriction of neck mobility immediately subsequent to trauma . It is , however , unclear whether neck mobility changes after the acute injury are related to the associated headache and neck pain . Methods . Cervical range of neck motion , neck pain , and headache were assessed after 1 week , then 1 , 3 , and 6 months after injury in 141 patients with acute whiplash injury , and in 40 patients with acute nonsport ankle distortion .  Results . Patients with whiplash injury had significantly reduced flexion , extension , lateral flexion , and rotation of the neck immediately after injury , as compared with patients with ankle distortion injury . Neck mobility , however , was similar in the two groups after 3 months . In patients with whiplash injury , neck pain and neck mobility were found to be related inversely to reported headache and neck mobility . Neck mobility was not significantly related to a difference in car speed at the time of collision . Conclusions . Neck mobility is reduced immediately after , but not 3 months after , a whiplash trauma . Headache and neck mobility are related inversely and neck pain and neck mobility are related inversely during the first 6 months after acute whiplash injury STUDY DESIGN Systematic review and best evidence synthesis . OBJECTIVES To describe the prevalence and incidence of  neck pain and disability in workers ; to identify risk factors for neck pain in workers ; to propose an etiological diagram ; and to make recommendations for future research . SUMMARY OF BACKGROUND DATA Previous review s of the etiology of neck pain in workers relied on cross-sectional evidence . Recently published cohorts and r and omized trials warrant a re- analysis of this body of research . METHODS We systematic ally search ed Medline for literature published from 1980 - 2006 . Retrieved articles were review ed for relevance . Relevant articles were critically appraised . Articles judged to have adequate internal validity were included in our best evidence synthesis . RESULTS One hundred and nine papers on the burden and determinants of neck pain in workers were scientifically admissible . The annual prevalence of neck pain varied from 27.1 % in Norway to 47.8 % in Québec , Canada . Each year , between 11 % and 14.1 % of workers were limited in their activities because of neck pain . Risk factors associated with neck pain in workers include age , previous musculoskeletal pain , high quantitative job dem and s , low social support at work , job insecurity , low physical capacity , poor computer workstation design and work posture , sedentary work position , repetitive work and precision work . We found preliminary evidence that gender , occupation , headaches , emotional problems , smoking , poor job satisfaction , awkward work postures , poor physical work environment , and workers ' ethnicity may be associated with neck pain . There is evidence that interventions aim ed at modifying workstations and worker posture are not effective in reducing the incidence of neck pain in workers . CONCLUSION Neck disorders are a significant source of pain and activity limitations in workers . Most neck pain results from complex relationships between individual and workplace risk factors . No prevention strategies have been shown to reduce the incidence of neck pain in workers Abstract Patients with chronic whiplash associated disorders present with varied sensory , motor and psychological features . In this first instance it was question ed whether a multimodal program of physical therapies was an appropriate management to be broadly prescribed for these patients when it was known that some would have sensory features suggestive of a notable pain syndrome . A r and omised controlled trial was conducted with 71 participants with persistent neck pain following a motor vehicle crash to explore this question . Participants were r and omly allocated to receive either a multimodal physiotherapy program ( MPT ) or a self‐management program ( SMP ) ( advice and exercise ) . In the r and omisation process , participants were stratified according to the presence or not of widespread mechanical or cold hyperalgesia . The intervention period was 10 weeks and outcomes were assessed immediately following treatment . Even with the presence of sensory hypersensitivity in 72.5 % of subjects , both groups reported some relief of neck pain and disability ( Neck Disability Index ) and it was superior in the group receiving multimodal physiotherapy ( p = 0.04 ) . Post‐hoc observations however suggested that relief was marginal in the subgroup with both widespread mechanical and cold hyperalgesia . Further research is required to test the validity of this sub‐group observation and to test the effect of the intervention in the long term OBJECTIVE An earlier pilot study suggested that the late whiplash syndrome is uncommon in Greece . The purpose of the present study is to extend the evaluation to a larger sample , and include the prevalence of specific symptoms in the evaluation . METHODS In a prospect i ve , cohort study , a total of 180 accident victims were consecutively recruited following Emergency ward presentation .  A st and ard question naire asked about neck pain , headache , shoulder pain , limb numbness or pain , and dizziness . Accident victims were followed for 6 months . RESULTS In the initial 4 weeks after the accident , accident victims reported neck pain , headache , shoulder pain , arm numbness or pain , and dizziness , but at 4 weeks more than 90 % had recovered from these , the remainder of the subjects having minor symptoms ( not requiring therapy ) , and returning to their pre-accident state of health ( which included minor symptoms ) . There were no cases of chronic disability . CONCLUSION In Greece , symptoms after an acute whiplash injury are self-limiting , brief , and do not appear to evolve into the so-called late whiplash syndrome
Consistent evidence was found to support the use of ' red flags ' to screen for serious pathologies , judicious use of imaging through clinical decision rule application and promotion of functional exercise coupled with advice and reassurance .
Neck pain and whiplash injuries are a common presentation to the ED , and a frequent cause of disability globally .
This rapid review investigated best practice for the assessment and management of musculoskeletal neck pain in the ED .