Early interdisciplinary rehabilitation programme for whiplash associated disorders

Purpose : To assess the clinical outcomes of a multidisciplinary rehabilitation programme for early intervention of chronic whiplash associated disorders (WAD). The primary aim of the programme was to increase levels of activity and independence in patients suffering WAD.

Methods : Ninety subjects with purported chronic symptoms associated with whiplash associated disorder (WAD) were referred to a multi-centre multi-modal 5- and 8-week rehabilitation programme in 1997-1998, during which prospective and retrospective functional and psychological evaluations were conducted, the follow-up was to 6 months.

Results : Subjects indicated they were satisfied with the programme. Retrospective evaluation indicated increased ability to cope with and control pain and, to some extent, psychological aspects. The pain intensity in the neck and upper back were significantly decreased at 6 months follow-up. However, for most of the functional and psychological markers, no significant changes were found.

Conclusions : A multi-modal rehabilitation programme for the chronic suffering attributed to WAD had positive effects according to several aspects of the retrospective evaluations, but according to most of the aspects evaluated prospectively the programme does not appear to have significant benefits.     

Early interdisciplinary rehabilitation programme for whiplash associated disorders

Purpose : To assess the clinical outcomes of a multidisciplinary rehabilitation programme for early intervention of chronic whiplash associated disorders (WAD). The primary aim of the programme was to increase levels of activity and independence in patients suffering WAD. Methods : Ninety subjects with purported chronic symptoms associated with whiplash associated disorder (WAD) were referred to a multi-centre multi-modal 5- and 8-week rehabilitation programme in 1997-1998, during which prospective and retrospective functional and psychological evaluations were conducted, the follow-up was to 6 months. Results : Subjects indicated they were satisfied with the programme. Retrospective evaluation indicated increased ability to cope with and control pain and, to some extent, psychological aspects. The pain intensity in the neck and upper back were significantly decreased at 6 months follow-up. However, for most of the functional and psychological markers, no significant changes were found. Conclusions : A multi-modal rehabilitation programme for the chronic suffering attributed to WAD had positive effects according to several aspects of the retrospective evaluations, but according to most of the aspects evaluated prospectively the programme does not appear to have significant benefits.     

Quality of life in subgroups of individuals with whiplash associated disorders

Background: The term whiplash associated disorders (WAD) includes a wide range of complaints, with neck pain as predominating symptom. Living with long term pain influences quality of life. In previous studies of other chronic pain patients, subgrouping has been made according to thermal pain thresholds measured in quantitative sensory testing (QST). Aims: The aims of the present study are threefold, (1) to evaluate thermal pain thresholds and health related quality of life in WAD patients compared to healthy pain‐free individuals, (2) to explore whether subgrouping of the WAD patients is possible according to thermal pain thresholds over trapezius, and if so (3) to explore differences between the subgroups. Methods: Twenty‐six patients with WAD and 18 healthy pain‐free controls took part in the study. Thermal pain thresholds were measured in two sites (over the thenar and the trapezius muscle) using quantitative sensory testing (QST). Health related quality of life (HRQoL) was assessed using the SF‐36. The visual analogue scale was used to rate pain intensity and unpleasantness related to the experimental situation. Results: WAD patients are more sensitive to thermal pain, and scored lower on the SF‐36 in all scales when compared with healthy pain‐free individuals. After analyzing clusters (K‐means algorithm) two subgroups of WAD emerge, pain insensitive and pain sensitive. The pain insensitive group differed significantly from the pain sensitive group in the Role Emotional subscale of SF‐36 (p=0.025). Conclusions: Thermal pain hyperalgesia, especially for cold, seems to be a determinant for subgrouping WAD patients. These results support that such a classification of a heterogenous group could be of importance in tailoring treatment and early interventions.     

Head eye co-ordination and gaze stability in subjects with persistent whiplash associated disorders

Symptoms of dizziness, unsteadiness and visual disturbances are frequent complaints in persons with persistent whiplash associated disorders. This study investigated eye, head co-ordination and gaze stability in subjects with persistent whiplash (n?=?20) and asymptomatic controls (n?=?20). Wireless motion sensors and electro-oculography were used to measure: head rotation during unconstrained head movement, head rotation during gaze stability and sequential head and eye movements. Ten control subjects participated in a repeatability study (two occasions one week apart). Between-day repeatability was acceptable (ICC?>?0.6) for most measures. The whiplash group had significantly less maximal eye angle to the left, range of head movement during the gaze stability task and decreased velocity of head movement in head eye co-ordination and gaze stability tasks compared to the control group (p??0.55) between both unrestrained neck movement and neck pain and head movement and velocity in the whiplash group. Deficits in gaze stability and head eye co-ordination may be related to disturbed reflex activity associated with decreased head range of motion and/or neck pain. Further research is required to explore the mechanisms behind these deficits, the nature of changes over time and the tests' ability to measure change in response to rehabilitation.     

Cold hyperalgesia as a prognostic factor in whiplash associated disorders: A systematic review

ObjectiveTo review and critically evaluate the existing literature for the prognostic value of cold hyperalgesia in Whiplash Associated Disorders (WAD).MethodsEmbase, PsycINFO, and Medline databases were systematically searched (from inception to 20th September 2011) for prospective studies investigating a prognostic ability for cold hyperalgesia in WAD. Reference lists and lead authors were cross-referenced. Two independent reviewers selected studies, and consensus was achieved via a third reviewer. The risk of bias in identified studies was systematically evaluated by two reviewers using previously published guidance. The influences of seven potential covariates of cold hyperalgesia were considered. Quantitative synthesis was planned and homogeneity assessed. A modified Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to qualitatively assess trials.ResultsThe review screened 445 abstracts, from these 20 full text studies were retrieved and assessed for eligibility. Six prospective studies on four cohorts were identified and reviewed. Findings from all four cohorts supported cold hyperalgesia as a prognostic factor in WAD.ConclusionsThere is moderate evidence supporting cold hyperalgesia as a prognostic factor for long-term pain and disability outcome in WAD. Further validation of the strength of this relationship and the influence of covariates are required. The mechanism for this relationship is unknown.     

心理护理联合胃动力治疗仪对患者功能性消化不良合并心理障碍的影响

目的探讨心理护理联合胃动力治疗仪对功能性消化不良合并心理障碍患者的影响效果。方法收集本院72例功能性消化不良合并心理障碍患者按照是否愿意接受心理护理干预分为2组。对照组患者给予胃动力治疗仪加常规护理,实验组患者加施心理护理,比较2组患者干预前后FD症状、焦虑、抑郁、生活质量评分与护理满意度等。结果 2组患者干预后FD症状、焦虑、抑郁、躯体功能、心理功能、社会功能与物质功能评分较干预前均有变化,差异具有统计学意义(P0.01);2组患者干预后相关评分组间比较存在显著性差异,具有统计学意义(P0.01);实验组患者护理满意度评价显著性高于对照组,差异具有统计学意义(P0.01)。结论心理护理联合胃动力治疗仪对功能性消化不良合并心理障碍患者的影响效果显著,可提高满意度,具有借鉴性。     

Physical and psychological factors predict outcome following whiplash injury

Predictors of outcome following whiplash injury are limited to socio-demographic and symptomatic factors, which are not readily amenable to secondary and tertiary intervention. This prospective study investigated the predictive capacity of early measures of physical and psychological impairment on pain and disability 6 months following whiplash injury. Motor function (ROM; kinaesthetic sense; activity of the superficial neck flexors (EMG) during cranio-cervical flexion), quantitative sensory testing (pressure, thermal pain thresholds, brachial plexus provocation test), sympathetic vasoconstrictor responses and psychological distress (GHQ-28, TSK, IES) were measured in 76 acute whiplash participants. The outcome measure was Neck Disability Index scores at 6 months. Stepwise regression analysis was used to predict the final NDI score. Logistic regression analyses predicted membership to one of the three groups based on final NDI scores (<8 recovered, 10-28 mild pain and disability, >30 moderate/severe pain and disability). Higher initial NDI score (1.007-1.12), older age (1.03-1.23), cold hyperalgesia (1.05-1.58), and acute post-traumatic stress (1.03-1.2) predicted membership to the moderate/severe group. Additional variables associated with higher NDI scores at 6 months on stepwise regression analysis were: ROM loss and diminished sympathetic reactivity. Higher initial NDI score (1.03-1.28), greater psychological distress (GHQ-28) (1.04-1.28) and decreased ROM (1.03-1.25) predicted subjects with persistent milder symptoms from those who fully recovered. These results demonstrate that both physical and psychological factors play a role in recovery or non-recovery from whiplash injury. This may assist in the development of more relevant treatment methods for acute whiplash.     

Evaluation of an evidence based patient educational booklet for management of whiplash associated disorders

Objectives: This study aimed to develop and evaluate an evidence based educational booklet on whiplash associated disorders.

Methods: A comprehensive review of the available scientific evidence produced a set of unambiguous patient centred messages that challenge unhelpful beliefs about whiplash and promote an active approach to recovery. These messages were incorporated into a novel booklet, which was then evaluated qualitatively for end user acceptability and its ability to impart the intended messages, and quantitatively for its ability to improve beliefs about whiplash and what to do about it. The subjects comprised people attending accident and emergency or manipulative practice with a whiplash associated disorder, along with a sample of workers without a whiplash associated disorder (n = 142).

Results: The qualitative results showed that the booklet was considered easy to read, understandable, believable, and conveyed its key messages. Quantitatively, it produced a substantial statistically significant improvement in beliefs about whiplash among accident and emergency patients (mean 6.5, 95% CI 3.9 to 9.1, p<0.001), and among workers (mean 9.4, 95% CI 7.9 to 10.9, p<0.001), but the shift in the more chronic manipulation patients was substantially smaller (mean 3.3, 95% CI 0.5 to 6.1, p<0.05).

Conclusions: A rigorously developed educational booklet on whiplash (The Whiplash Book) was found acceptable to patients, and capable of improving beliefs about whiplash and its management; it seems suitable for use in the accident and emergency environment, and for wider distribution at the population level. A randomised controlled trial would be required to determine whether it exerts an effect on behaviour and clinical outcomes.

     

Psychosocial and socio-demographic factors associated with outcomes for patients undergoing rehabilitation for chronic whiplash associated disorders: A pilot study

Purpose. Identify psychosocial and socio-demographic factors (measured prior to treatment) that were associated with post-treatment self-perceived pain and disability and two secondary outcomes: psychological distress, and return to work in patients undergoing multidisciplinary rehabilitation for chronic whiplash associated disorders (WAD).

Method. Interviews were conducted with 28 patients with chronic WAD at entry to and completion of an intensive rehabilitation program, and a telephone interview was carried out three months later. Participants completed pain and disability, and psychological distress questionnaires, at baseline and at both follow-ups. They also completed psychosocial questionnaires and provided socio-demographic information. The effect of each of the independent variables on the outcomes was first evaluated by simple regressions, and then subsequently by multiple regression analysis.

Results. Higher baseline pain and disability predicted higher pain and disability at both follow-ups (p < 0.001), and higher psychological distress at program completion (p = 0.003). Younger age (p = 0.028) and higher baseline psychological distress (p = 0.002) were associated with higher psychological distress three months post-rehabilitation. Greater social support at work was prognostic of return to work at program completion (p = 0.04).

Conclusions. Baseline pain and disability was the only factor that affected pain and disability post-rehabilitation. Psychosocial factors played a role in the prognosis of psychological distress and return to work.     

The relationship between insurance claim closure and recovery after traffic injuries for individuals with whiplash associated disorders

Purpose: The purpose of this study was to determine if time to claim closure was similar to time to self-reported recovery in a no fault motor vehicle collision insurance system.

Method: A prospective cohort of traffic injured adults with a whiplash-associated disorder (WAD) was assembled. We excluded participants who applied for benefits after 42 days of the collision, who were in hospital for more than two days and participants who were not followed up at least once after their injury. Questionnaires were completed at baseline, six weeks, three-, six-, nine- and 12-months after the collision.

Results: The mean age of the cohort was 39 years and 66% were female. The mean number of days until claim closure and for self-reported recovery was 291days and 134 days, respectively. We found those who had their claim closed at each follow-up period had lower levels of disability and were more likely to report they were recovered than participants with open claims.

Conclusion: We conclude that time to claim closure could be used as an outcome measure in traffic collision; however, this measure should be used with caution since it over-estimates the true time to recovery.

• Implications for Rehabilitation

• Time to claim closure as an outcome measure for whiplash-associated disorders has been criticized in the literature because it is thought that closure is not reflective of the health status of the individual.

• We found that claim closure was associated with lower levels of disability, but the time to claim closure was significantly longer than the time to self-reported recovery.

• Time to claim closure may be used with caution as a “proxy” measure of recovery from an injury; however, it must be noted that it over-estimates the true time of recovery