Practical guidelines for the prevention of chronic symptoms after a whiplash injury, based on published evidence

Recently, systematic reviews and evidence-based guidelines on whiplash have appeared, from which preventive recommendations can be derived. Fear of moving, catastrophic thoughts and avoidance of activity seem to play an important role in the transition from acute to chronic symptoms. Early reassurance and the advice to remain active can prevent the development of chronic symptoms following whiplash. In the acute and subacute phase, if there is still no recovery despite information designed to reduce anxiety, referral to a physiotherapist for active exercise therapy and management is indicated. In the chronic phase, depending on which factors play a role in the given patient, referral to active exercise therapy or a multi-disciplinary training programme may be considered.     

Validity of the Flemish working alliance inventory in a Dutch physiotherapy setting in patients with shoulder pain

Background: Working alliance is the interaction between the patient and therapist. It is a crucial part of the physiotherapeutic process. One instrument to measure working alliance is available in Dutch/Flemish language and validated in psychotherapy setting. Objective: This study aims to validate the Working Alliance Inventory Short-Form in a Dutch physiotherapy setting. Design: A prospective cohort study in primary-care physiotherapy. Method: To validate the Dutch/Flemish version of the working alliance inventory short-form (WAV-12) a RASCH analysis was used. Results: Sixty-six physiotherapists enrolled in total 389 patients with an average age of 50 years and a mean duration of shoulder pain of 33 weeks. A total of 274 patients filled in one or more items of the WAV-12. The WAV-12 showes good discriminative abilities and all items contributed to a one-dimensional construct. Due to the selective nature of the missing items, we believed rewording was necessary to make it more suitable to the physiotherapy setting. We performed a Delphi study and revised the WAV-12 into the PAS (Physio Alliance Scale). The validity of the revised version is unknown and is therefore not sufficiently strong to be implemented as a measurement tool. Limitations: The response rate for three items especially was low and we found ceiling effects in ten items. Conclusion: Although the measurement instrument shows good internal consistency and reliability, we made adjustments to the WAV-12 for Dutch physiotherapy setting.     

Evaluation of measurement properties of self-administered PROMs aimed at patients with non-specific shoulder pain and “activity limitations”: a systematic review

Objective

To critically appraise and compare the measurement properties of self-administered patient-reported outcome measures (PROMs) focussing on the shoulder, assessing “activity limitations.”

Study design

Systematic review. The study population had to consist of patients with shoulder pain. We excluded postoperative patients or patients with generic diseases. The methodological quality of the selected studies and the results of the measurement properties were critically appraised and rated using the COSMIN checklist.

Results

Out of a total of 3427 unique hits, 31 articles, evaluating 7 different questionnaires, were included. The SPADI is the most frequently evaluated PROM and its measurement properties seem adequate apart from a lack of information regarding its measurement error and content validity.

Conclusion

For English, Norwegian and Turkish users, we recommend to use the SPADI. Dutch users could use either the SDQ or the SST. In German, we recommend the DASH. In Tamil, Slovene, Spanish and the Danish languages, the evaluated PROMs were not yet of acceptable validity. None of these PROMs showed strong positive evidence for all measurement properties. We propose to develop a new shoulder PROM focused on activity limitations, taking new knowledge and techniques into account.

     

Lack of uniform diagnostic criteria for cervical radiculopathy in conservative intervention studies: a systematic review

Purpose

Cervical radiculopathy (CR) is a common diagnosis. It is unclear if intervention studies use uniform definitions and criteria for patient selection. Our objective was to assess the uniformity of diagnostic criteria and definitions used in intervention studies to select patients with CR.

Methods

We electronically searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE and CINAHL. Studies were included when evaluating conservative interventions in randomised clinical trials (RCTs) in patients with CR. Selection criteria and definitions for patients with CR were extracted and evaluated on their uniformity.

Results

Thirteen RCTs were included. Pain was used as an inclusion criterion in 11 studies. Inclusion based on the duration and location of pain varied between studies. Five studies used sensory symptoms in the arm as inclusion criterion. Four studies used cervical range of motion and motor disturbances as inclusion criteria, while reflex changes were used in two studies. Three studies included patients with a positive Spurling’s test and two studies used it within a cluster of provocation tests.

Conclusions

Criteria used to select patients with CR vary widely between different intervention studies. Selection criteria and test methods used are poorly described. There is consensus on the presence of pain, but not on the exact location of pain.     

Clinical classification of deformational plagiocephaly according to Argenta: a reliability study

The incidence of deformational plagiocephaly (DP) in primary health care is increasing. Patients are referred and treated by different practitioners. However, reliable and practical assessment tools in clinical practice are lacking. The clinical classification according to Argenta distinguishes 5 types of DP based on severity of asymmetry of the skull, ear position, and face. The aim of this study was to investigate the reliability of this clinical classification of DP. Twenty referred patients aged 0 to 1 year were classified for DP. Raters from 3 different professions (3 infant health care physicians, 3 pediatric physiotherapists, and 3 manual therapists) were used because these professionals are the first ones who see children with DP in clinical practise. Interrater and intrarater reliability was determined for the type of DP (I-V) and each characteristic clinical feature separately. There was a moderate overall interrater agreement for classifying DP (mean weighted kappa, 0.54), whereas intrarater agreement ranged from 0.60 to 0.85, indicating substantial to almost perfect agreement. Kappa scores of the first 4 clinical features of DP (occipital flattening, ear malposition, frontal bossing, and facial asymmetry) ranged from 0.45 to 0.57 for the interrater reliability and 0.47 to 1 for the intrarater reliability, except for 1 score of -0.14. Agreement for the fifth feature (vertical skull growth) was due to chance (kappa approximately 0). The classification according to Argenta is a moderately reliable method for classifying DP in clinical practice.     

One question might be capable of replacing the Shoulder Pain and Disability Index (SPADI) when measuring disability: a prospective cohort study

Questions

Is it possible to replace the Shoulder Pain and Disability Index (SPADI) with a single substitute question for people with shoulder pain, when measuring disability and how well does this substitute question perform as a predictor for recovery.

Design

A prospective cohort study.

Participants

A total of 356 patients with shoulder pain in primary care.

Analyses

Convergent, divergent, and “known” groups validity were assessed by using hypotheses testing. Responsiveness was assessed using the Receiver Operating Curve and hypothesis testing. In addition, we performed multivariate regression to assess if the substitute question showed similar properties as the SPADI and if it affected the model itself, using recovery as an outcome.

Results

The Spearman correlation coefficient between the total SPADI score and the substitute question was high, and moderate with the Shoulder Disability Questionnaire. The correlation between the substitute question and the EQ-5D-3L was low and the responsiveness was acceptable. The substitute question did not significantly contribute to both prognostic prediction models as opposed to the SPADI. Regardless all models showed poor to fair discrimination.

Conclusion

The single question is a reasonable substitute for the SPADI and can be used as a screening instrument for shoulder disability in primary clinical practice. It has slightly poorer predictive power and should therefore not be used for prognosis.

     

Prognostic factors for poor recovery in acute whiplash patients

The objective of our prospective inception cohort study was to identify prognostic factors for poor recovery in patients with whiplash-associated disorders grade 1 or 2 who still had neck pain and accompanying complaints 2 weeks after the accident. The study was carried out in a primary health care setting in The Netherlands and included 125 patients. The primary outcome measure was functional recovery defined in terms of neck pain intensity or work disability without medication use. The secondary outcome measures included neck pain intensity, work disability and sick leave. The outcomes were assessed at 4, 12 and 52 weeks after the accident. Prognostic factors were identified by logistic regression analyses. One year after the injury, 64% of the patients were recovered. Factors related to poor recovery were female gender, a low level of education, high initial neck pain, more severe disability, higher levels of somatisation and sleep difficulties. Neck pain intensity and work disability proved to be the most consistent predictors for poor recovery. The accuracy of the predictions of the prognostic models was high, meaning that the models adequately distinguished patients with poor recovery from those regarded as recovered. These findings add to the growing body of evidence, indicating that socio-demographic, physical and psychological factors affect short- and long-term outcome after whiplash injury. Our findings also indicate that care providers can easily identify patients at risk for poor recovery with a visual analogue scale for initial pain intensity and work-related activities.     

Value of physical tests in diagnosing cervical radiculopathy: a systematic review

Background Context

In clinical practice, the diagnosis of cervical radiculopathy is based on information from the patient's history, physical examination, and diagnostic imaging. Various physical tests may be performed, but their diagnostic accuracy is unknown.