Brain Connectivity Predicts Chronic Pain in Acute Mild Traumatic Brain Injury.

OBJECTIVES: Previous studies have established the role of the cortico-mesolimbic and descending pain modulation systems in chronic pain prediction. Mild traumatic brain injury (mTBI) is an acute pain model where chronic pain is prevalent and complicated for prediction. In this study, we set out to study whether functional connectivity (FC) of the nucleus accumbens (NAc) and the periaqueductal gray matter (PAG) is predictive of pain chronification in early-acute mTBI. METHODS: To estimate FC, resting-state functional magnetic resonance imaging (fMRI) of 105 participants with mTBI following a motor vehicle collision was acquired within 72 hours post-accident. Participants were classified according to pain ratings provided at 12-months post-collision into chronic pain (head/neck pain ≥30/100, n = 44) and recovery (n = 61) groups, and their FC maps were compared. RESULTS: The chronic pain group exhibited reduced negative FC between NAc and a region within the primary motor cortex corresponding with the expected representation of the area of injury. A complementary pattern was also demonstrated between PAG and the primary somatosensory cortex. PAG and NAc also shared increased FC to the rostral anterior cingulate cortex (rACC) within the recovery group. Brain connectivity further shows high classification accuracy (area under the curve [AUC] = .86) for future chronic pain, when combined with an acute pain intensity report. INTERPRETATION: FC features obtained shortly after mTBI predict its transition to long-term chronic pain, and may reflect an underlying interaction of injury-related primary sensorimotor cortical areas with the mesolimbic and pain modulation systems. Our findings indicate a potential predictive biomarker and highlight targets for future early preventive interventions. ANN NEUROL 2022;92:819-833.

Genetic impact of blood C-reactive protein levels on chronic spinal & widespread pain.

PURPOSE: Causal mechanisms underlying systemic inflammation in spinal & widespread pain remain an intractable experimental challenge. Here we examined whether: (i) associations between blood C-reactive protein (CRP) and chronic back, neck/shoulder & widespread pain can be explained by shared underlying genetic variants; and (ii) higher CRP levels causally contribute to these conditions. METHODS: Using genome-wide association studies (GWAS) of chronic back, neck/shoulder & widespread pain (N = 6063-79,089 cases; N = 239,125 controls) and GWAS summary statistics for blood CRP (Pan-UK Biobank N = 400,094 & PAGE consortium N = 28,520), we employed cross-trait bivariate linkage disequilibrium score regression to determine genetic correlations (rG) between these chronic pain phenotypes and CRP levels (FDR < 5%). Latent causal variable (LCV) and generalised summary data-based Mendelian randomisation (GSMR) analyses examined putative causal associations between chronic pain & CRP (FDR < 5%). RESULTS: Higher CRP levels were genetically correlated with chronic back, neck/shoulder & widespread pain (rG range 0.26-0.36; P ≤ 8.07E-9; 3/6 trait pairs). Although genetic causal proportions (GCP) did not explain this finding (GCP range - 0.32-0.08; P ≥ 0.02), GSMR demonstrated putative causal effects of higher CRP levels contributing to each pain type (beta range 0.027-0.166; P ≤ 9.82E-03; 3 trait pairs) as well as neck/shoulder pain effects on CRP levels (beta [S.E.] 0.030 [0.021]; P = 6.97E-04). CONCLUSION: This genetic evidence for higher CRP levels in chronic spinal (back, neck/shoulder) & widespread pain warrants further large-scale multimodal & prospective longitudinal studies to accelerate the identification of novel translational targets and more effective therapeutic strategies.

The effects of physical exercise on structural, functional, and biochemical brain characteristics in individuals with chronic whiplash-associated disorder: A pilot randomized clinical trial.

BACKGROUND: Exercise for people with whiplash associated disorder (WAD) induces hypoalgesic effects in some, but hyperalgesic effects in others. We investigated the exercise-induced neurobiological effects of aerobic and strengthening exercise in individuals with chronic WAD. METHODS: Sixteen participants (8 WAD, 8 pain-free [CON]) were randomised to either aerobic or strengthening exercise. MRI for brain morphometry, functional MRI for brain connectivity, and magnetic resonance spectroscopy for brain biochemistry, were used at baseline and after the 8-week intervention. RESULTS: There were no differences in brain changes between exercise groups in either the WAD or CON group, therefore aerobic and strengthening data were combined to optimise sample size. After the exercise intervention, the CON group demonstrated increased cortical thickness (left parahippocampus: mean difference = 0.04, 95% CI = 0.07-0.00, p = 0.032; and left lateral orbital frontal cortex: mean difference = 0.03, 95% CI = 0.00-0.06, p = 0.048). The WAD group demonstrated an increase in prefrontal cortex (right medial orbital frontal) volume (mean difference = 95.57, 95% CI = 2.30-192.84, p = 0.046). Functional changes from baseline to follow-up between the default mode network and the insula, cingulate cortex, temporal lobe, and somatosensory and motor cortices, were found in the CON group, but not in the WAD group. There were no changes post-exercise in brain biochemistry. CONCLUSION: Aerobic and strengthening exercises did not exert differential effects on brain characteristics, however differences in structural and functional changes were found between WAD and CON groups. This suggests that an altered central pain modulatory response may be responsible for differential effects of exercise in individuals with chronic WAD.

Genetic basis to structural grey matter associations with chronic pain.

Structural neuroimaging studies of individuals with chronic pain conditions have often observed decreased regional grey matter at a phenotypic level. However, it is not known if this association can be attributed to genetic factors. Here we employed a novel integrative data-driven and hypothesis-testing approach to determine whether there is a genetic basis to grey matter morphology differences in chronic pain. Using publicly available genome-wide association study summary statistics for regional chronic pain conditions (n = 196 963) and structural neuroimaging measures (n = 19 629-34 000), we applied bivariate linkage disequilibrium-score regression and latent causal variable analyses to determine the genetic correlations (rG) and genetic causal proportion (GCP) between these complex traits, respectively. Five a priori brain regions (i.e. prefrontal cortex, cingulate cortex, insula, thalamus and superior temporal gyrus) were selected based on systematic reviews of grey matter morphology studies in chronic pain. Across this evidence-based selection of five brain regions, 10 significant negative genetic correlations (out of 369) were found (false discovery rate < 5%), suggesting a shared genetic basis to both reduced regional grey matter morphology and the presence of chronic pain. Specifically, negative genetic correlations were observed between reduced insula grey matter morphology and chronic pain in the abdomen (mean insula cortical thickness), hips (left insula volume) and neck/shoulders (left and right insula volume). Similarly, a shared genetic basis was found for reduced posterior cingulate cortex volume in chronic pain of the hip (left and right posterior cingulate), neck/shoulder (left posterior cingulate) and chronic pain at any site (left posterior cingulate); and for reduced pars triangularis volume in chronic neck/shoulder (left pars triangularis) and widespread pain (right pars triangularis). Across these negative genetic correlations, a significant genetic causal proportion was only found between mean insula thickness and chronic abdominal pain [rG (standard error, SE) = -0.25 (0.08), P = 1.06 × 10-3; GCP (SE) = -0.69 (0.20), P = 4.96 × 10-4]. This finding suggests that the genes underlying reduced cortical thickness of the insula causally contribute to an increased risk of chronic abdominal pain. Altogether, these results provide independent corroborating evidence for observational reports of decreased grey matter of particular brain regions in chronic pain. Further, we show for the first time that this association is mediated (in part) by genetic factors. These novel findings warrant further investigation into the neurogenetic pathways that underlie the development and prolongation of chronic pain conditions.

Do expectations of recovery improve risk assessment for people with whiplash-associated disorders? Secondary analysis of a prospective cohort study.

BACKGROUND: WhipPredict, which includes prognostic factors of pain-related disability, age and hyperarousal symptoms, was developed and validated for prediction of outcome in people with whiplash associated disorders (WAD). Patient expectations of recovery was not an included factor, though is known to mediate outcomes. The aim of this study was to determine whether the addition of expectations of recovery could improve the accuracy of WhipPredict. METHODS: Two hundred twenty-eight participants with acute WAD completed questionnaires (WhipPredict and expectations of recovery) at baseline. Health outcomes (neck disability index (NDI) and Global Perceived Recovery (GPR)) were assessed at 6- and 12-months post injury. Cut-off points for expectations of recovery predictive of both full recovery (NDI ≤10 % , GPR ≥ 4) and poor outcome (NDI ≥30 % , GPR ≤ - 3) were determined, and multivariate logistic regression analyses were used to compare models with and without this variable. RESULTS: Expectations of recovery improved or maintained the accuracy of predictions of poor outcome (6-months: sensitivity 78 to 83%, specificity maintained at 79.5%; 12-months: sensitivity maintained at 80%, specificity 69 to 73%). The sensitivity of predictions of full recovery improved (6-months: 68 to 76%; 12-months: 57 to 81%), though specificity did not change appreciably at 6 months (80 to 81%) and declined at 12 (83 to 76%). ROC curves indicated a larger and more consistent improvement in model performance when expectations of recovery were added to the pathway predictive of full recovery. CONCLUSIONS: The addition of expectations of recovery may improve the accuracy of WhipPredict, though further validation is required.

A Comparison of Perceptions of Reassurance in Patients with Nontraumatic Neck Pain and Whiplash-Associated Disorders in Consultations with Primary Care Practitioners-An Online Survey.

OBJECTIVES: Neck pain remains highly prevalent and costly worldwide. Although reassurance has been recommended as a first line of treatment, specific advice on the best ways to provide reassurance has not been provided due to lack of evidence. Pain symptoms and experiences differ between patients with whiplash-associated disorder (WAD) and those with nontraumatic neck pain (NTNP). The aims of this study were to 1) identify and compare the concerns, fears, and worries of patients with WAD and NTNP; and 2) determine if patients believe their concerns are addressed by primary care providers. METHODS: These questions were investigated through an online survey, with a convenience sample of 30 participants with NTNP and 20 with WAD. RESULTS: A thematic analysis of survey responses resulted in the following seven themes related to common concerns, and two regarding how well concerns were addressed. Common concerns expressed by both groups shared four themes: 1) further structural damage, 2) psychological distress, 3) concerns about the future, and 4) hardships that eventuate. Theme 5), pain/disability is long term, was specific to WAD. Themes 6), pain is current or reoccurring, and 7), interference with daily life, were specific to NTNP. Regarding how well patient concerns were addressed, two overarching themes were common to both conditions: 1) concerns were addressed, with both groups sharing the subthemes "successful treatment," "reassurance," and "trust"; and 2) concerns were not addressed, where all subthemes were shared with the exception of two unique to NTNP. CONCLUSIONS: This detailed comparison provides information about neck pain patients' concerns and fears, while providing health practitioners support for selecting strategies to promote reassurance appropriately for individual patient needs. Our findings from patients' perspectives enhance the understanding for providing reassurance for neck pain as proposed by our analysis.

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

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

Spinal cord injury is not a feature of chronic whiplash-associated disorder: a magnetic resonance spectroscopy study.

PURPOSE: Injury to the cervical spinal cord has been suggested as a mechanism that may underpin chronic whiplash-associated disorder (WAD). This study aimed to assess metabolite concentrations indicative of neuronal injury or pathology in the cervical cord in people with chronic WAD. METHODS: Forty-one people with chronic WAD (mean [SD] age 39.6 [11.0] years, 25 females) and 14 healthy controls (39.2 [12.6] years, 9 females) underwent cervical spinal cord magnetic resonance spectroscopy to measure the metabolites N-acetylaspartate (NAA), creatine (Cr) and choline (Cho). Participants with WAD completed clinical questionnaires on pain intensity (Visual Analogue Scale), disability (Neck Disability Index) and psychological factors (Pain Catastrophising Scale, Post-traumatic Diagnostic Scale), and underwent cervical range of motion assessment and pain threshold testing to cold and pressure stimuli. Data were analysed using hypothesis testing and Spearman correlations (p < 0.05). RESULTS: There were no differences between the WAD and control groups for NAA/Cr (median [IQR] WAD 1.73 [1.38, 1.97], controls 2.09 [1.28, 2.89], p = 0.37), NAA/Cho (WAD 1.50 [1.18, 2.01], controls 1.57 [1.26, 1.93], p = 0.91) or Cr/Cho (WAD 0.84 [0.64, 1.17], controls 0.76 [0.60, 0.91], p = 0.33). There were no significant correlations between NAA/Cr, NAA/Cho or Cr/Cho and any clinical variable (p ≥ 0.06). CONCLUSIONS: Findings are consistent with major metabolic changes not being present in chronic WAD.

Medical and allied health service use during acute and chronic post-injury periods in whiplash injured individuals.

BACKGROUND: Individuals with whiplash associated disorder (WAD) frequently experience neck pain in addition to other physical, psychological and social symptoms. Consequently, treatment is sought from a variety of health professionals. The limited data available about health services use in this population are conflicting. This study aimed to characterise health service use in individuals with WAD from a motor vehicle crash. METHODS: Medical (general practitioner (GP), medical specialist, emergency services (ED), radiology - x-ray, computed tomography, magnetic resonance imaging, ultrasound) and allied health service (physiotherapy, chiropractor, psychologist, osteopath, occupational therapy) use during acute (< 12 weeks) and chronic (12 weeks to 2 years) post-injury periods were analysed in adults claiming compensation for WAD in the no-fault jurisdiction of Victoria, Australia (n = 37,315). RESULTS: Most WAD claimants had an acute post-injury health service payment (95%, n = 35,348), and approximately one-third (29%, n = 10,871) had a chronic post-injury health service payment. During an acute post-injury period, the most frequently compensated services were for: ED (82% of acute claimants), radiology (56%), and medical specialist (38%). Whereas, physiotherapy (64.4% of chronic claimants), GP (48.1%), and radiology (34.6%) were the most frequently paid services during the chronic period. Females received significantly more payments from physiotherapists (F = 23.4%, M = 18%, z = - 11.3, p < .001, r = 0.13), chiropractors (F = 7.4%, M = 5.6%, z = - 6.3, p < .001, r = 0.13), and psychologists (F = 4.2%, M = 2.8%, z = - 6.7, p < .001, r = 0.18); whereas, males received significantly more medical services payments from medical specialists (F = 41.8%, M = 43.8%, z = - 3.7, p < .001, r = 0.03), ED (F = 74.0%, M = 76.3%, z = - 4.9, p < .001, r = 0.03) and radiology (F = 58.3%, M = 60.1%, z = - 3.4, p < .001, r = 0.02). CONCLUSIONS: Individuals with WAD claimed for a range of health services. Radiology imaging use during the acute post-injury period, and physiotherapy and chiropractor service use during the chronic post-injury period appeared concordant with current WAD management guidelines. Conversely, low physiotherapy and chiropractic use during an acute post-injury period, and high radiology and medical specialists use during the chronic post-injury period appeared discordant with current guidelines. Strategies are needed to help inform medical health professionals of the current guidelines to promote early access to health professionals likely to provide an active approach to treatment, and to address unnecessary referral to radiology and medical specialists in individuals with on-going WAD.

Comparative effectiveness of physical exercise interventions for chronic non-specific neck pain: a systematic review with network meta-analysis of 40 randomised controlled trials.

OBJECTIVE: To compare the effectiveness of different physical exercise interventions for chronic non-specific neck pain. DESIGN: Systematic review and network meta-analysis. DATA SOURCES: Electronic databases: AMED, CINAHL, Cochrane Central Register of Controlled Trials, Embase, MEDLINE, Physiotherapy Evidence Database, PsycINFO, Scopus and SPORTDiscus. ELIGIBILITY CRITERIA: Randomised controlled trials (RCTs) describing the effects of any physical exercise intervention in adults with chronic non-specific neck pain. RESULTS: The search returned 6549 records, 40 studies were included. Two networks of pairwise comparisons were constructed, one for pain intensity (n=38 RCTs, n=3151 participants) and one for disability (n=29 RCTs, n=2336 participants), and direct and indirect evidence was obtained. Compared with no treatment, three exercise interventions were found to be effective for pain and disability: motor control (Hedges' g, pain -1.32, 95% CI: -1.99 to -0.65; disability -0.87, 95% CI: -1.45 o -0.29), yoga/Pilates/Tai Chi/Qigong (pain -1.25, 95% CI: -1.85 to -0.65; disability -1.16, 95% CI: -1.75 to -0.57) and strengthening (pain -1.21, 95% CI: -1.63 to -0.78; disability -0.75, 95% CI: -1.28 to -0.22). Other interventions, including range of motion (pain -0.98 CI: -2.51 to 0.56), balance (pain -0.38, 95% CI: -2.10 to 1.33) and multimodal (three or more exercises types combined) (pain -0.08, 95% CI: -1.70 to 1.53) exercises showed uncertain or negligible effects. The quality of evidence was very low according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. CONCLUSION: There is not one superior type of physical exercise for people with chronic non-specific neck pain. Rather, there is very low quality evidence that motor control, yoga/Pilates/Tai Chi/Qigong and strengthening exercises are equally effective. These findings may assist clinicians to select exercises for people with chronic non-specific neck pain. PROSPERO REGISTRATION NUMBER: CRD42019126523.

Cervical spine findings on MRI in people with neck pain compared with pain-free controls: A systematic review and meta-analysis.

BACKGROUND: There is uncertainty regarding the clinical significance of findings on MRI in patients with whiplash associated disorder (WAD) or nonspecific neck pain (NSNP). PURPOSE: To compare the presence of cervical spine MRI findings in people with WAD or NSNP with pain-free controls. STUDY TYPE: Systematic review and meta-analysis. POPULATION: Adults with WAD (n = 994), NSNP (n = 715), or pain-free controls (n = 2323). FIELD STRENGTH: 0.5T, 1.5T, and 3.0T. ASSESSMENT: Medline, EMBASE, CINAHL, Web of Science, SCOPUS, and Cochrane CENTRAL databases were searched. Two independent reviewers identified studies for inclusion and extracted data. Risk of bias was assessed using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Overall quality of the evidence from meta-analysis was assessed using the Grades of Recommendation, Assessment, Development, and Evaluation approach. STATISTICAL TESTS: Meta-analysis was performed using a random-effects model to calculate odds ratios or standard mean differences (SMDs) for binary and continuous data. RESULTS: In total, 31 studies were included (eight comparing acute WAD to controls, 14 comparing chronic WAD to controls, 12 comparing chronic NSNP to controls) comprising 4032 participants. Rectus capitis posterior major cross-sectional area was smaller in people with chronic NSNP than controls (two studies: SMD -1.18 [95% confidence interval [CI] -1.65, -0.71]). The remaining meta-analysis comparisons showed no group differences in MRI findings. The quality of evidence was mostly low due to small sample sizes and high heterogeneity. DATA CONCLUSION: Given the typically low-quality evidence, definitive conclusions cannot be drawn on the presence of MRI findings in individuals with WAD or NSNP compared with pain-free controls. LEVEL OF EVIDENCE: 3 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2018.

Evidence-based care in high- and low-risk groups following whiplash injury: a multi-centre inception cohort study.

BACKGROUND: Studies aimed at improving the provision of evidence-based care (EBC) for the management of acute whiplash injuries have been largely successful. However, whether EBC is broadly provided and whether delivery of EBC varies based on risk of non-recovery, is uncertain. Receiving EBC should improve recovery, though this relationship has yet to be established. Further, mitigating the effect of EBC is the relationship with the practitioner, a phenomenon poorly understood in WAD. This study aimed to determine the proportion of individuals with whiplash, at differing baseline risk levels, receiving EBC. This study also aimed to determine whether receiving EBC and the therapeutic relationship were associated with recovery at 3 months post injury. METHODS: Participants with acute whiplash were recruited from public hospital emergency departments, private physiotherapy practices, and State Insurance Regulatory Authority (SIRA) databases. Participants completed questionnaires at baseline (demographics, risk of non-recovery) and 3-months (treatment received, risk identification, therapeutic relationship) post injury. Primary health care providers (HCPs) treating these participants also completed questionnaires at 3-months. Recovery was defined as neck disability index ≤4/50 and global perceived effect of ≥4/5. RESULTS: Two-hundred and twenty-eight people with acute whiplash, and 53 primary care practitioners were recruited. The majority of the cohort reported receiving EBC, with correct application of the Canadian C-spine rule (74%), and provision of active treatments (e.g. 89% receiving advice) high. Non-recommended (passive) treatments were also received by a large proportion of the cohort (e.g. 50% receiving massage). The therapeutic relationship was associated with higher odds of recovery, which was potentially clinically significant (OR 1.34, 95% CI 1.18-1.62). EBC was not significantly associated with recovery. CONCLUSIONS: Guideline-based knowledge and practice has largely been retained from previous implementation strategies. However, recommendations for routine risk identification and tailored management, and reduction in the provision of passive treatment have not. The therapeutic relationship was identified as one of several important predictors of recovery, suggesting that clinicians must develop rapport and understanding with their patients to improve the likelihood of recovery.

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.

OBJECTIVE: There are few effective treatments for acute whiplash-associated disorders (WAD). Early symptoms of postinjury stress predict poor recovery. This randomised 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 randomly 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 postrandomisation. 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 resulted in clinically 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.

Living with ongoing whiplash associated disorders: a qualitative study of individual perceptions and experiences.

BACKGROUND: Whiplash associated disorders (WAD) are the most common non-hospitalised injury resulting from a motor vehicle crash. Approximately 50% of individuals with WAD experience on-going pain and disability. Results from intervention trials for individuals with chronic WAD are equivocal and optimal treatment continues to be a challenge. It may be that traditional quantitative measures included in treatment trials have not captured the full benefits patients experience through participation in an intervention. The aim of the present study was to explore participant subjective experiences and perceptions of living with on-going WAD. METHODS: Twenty-seven individuals with chronic WAD participated in a one-on-one, semi-structured individual telephone interview. All interviews were audio-taped, transcribed verbatim and data were analysed using an inductive thematic analysis process. RESULTS: Two themes emerged that described the experience of living with chronic WAD. First, all participants described navigating the healthcare system after their whiplash injury to help understand their injury and interpret therapeutic recommendations. Participants highlighted the need to 'find the right healthcare practitioner (HCP)' to help with this process. Many participants also described additional complexities in navigating and understanding healthcare incurred by interactions with compensation and funding systems. Second, participants described a journey of realisation, and the trial and error used to establish self-management strategies to both prevent and relieve pain. Participants described trying to understand the impact of their initial injury in relation to the gradual realisation that there may be on-going residual deficit. Seeking information from multiple sources, including personal experience gained through trial and error, was important in the search for acceptable management strategies. CONCLUSION: Recovery from a whiplash injury is an adaptive process and more than elimination of pain or disability, therefore may be different from common clinical patient reported outcomes. Early identification of patient understandings of pain, expectations of recovery, symptoms and therapy may help merge patient and HCP understandings. Additionally, helping individuals to recognise symptom triggers and develop appropriate strategies to minimise triggers may actively engage patients in their recovery. Finally, acknowledgement and validation of the whiplash injury by HCPs is seen by many as a necessary step in the recovery process.

Management of Whiplash Associated Disorders in Australian general practice.

BACKGROUND: Whiplash Associated Disorders (WAD) are common and costly, and are usually managed initially by general practitioners (GPs). How GPs manage WAD is largely unstudied, though there are clinical guidelines. Our aim was to ascertain the rate of management (percentage of encounters) of WAD among patients attending Australian general practice, and to review management of these problems, including imaging, medications and other treatments. METHODS: We analysed data from 2013 to 2016 collected by different random samples of approximately 1000 general practitioners (GPs) per year. Each GP collected data about 100 consecutive consultations for BEACH (Bettering the Evaluation and Care of Health), an Australian national study of general practice encounters. Main outcome measures were: the proportion of encounters involving management of WAD; management including imaging, medications and other treatments given; appropriateness of treatment assessed against published clinical guidelines. RESULTS: Of 291,100 encounters from 2919 GP participants (a nationally representative sample), WAD were managed at 137 encounters by 124 GPs (0.047%). Management rates were 0.050% (females) and 0.043% (males). For 63 new cases (46%), 19 imaging tests were ordered, most commonly neck/cervical spine x-ray (52.6% of tests for new cases), and neck/cervical spine CT scan (31.6%). One or more medications were prescribed/supplied for 53.3% of WAD. NSAIDs (11.7 per 100 WAD problems) and compound analgesics containing paracetamol and opioids (10.2 per 100 WAD problems) were the commonest medications used by GPs overall. Paracetamol alone was used in 8 per 100 WAD problems. The most frequent clinical/procedural treatments for WAD were physical medicine/rehabilitation (16.1 per 100 WAD problems), counselling (6.6), and general advice/education (5.8). CONCLUSIONS: GPs refer about 30% of new cases for imaging (possibly overutilising imaging), and prescribe a range of drugs, approximately 22% of which are outside clinical guidelines. These findings suggest a need for further education of GPs, including indications for imaging after whiplash injury, identification of those more likely to develop chronic WAD, and medication management guidelines. WAD carry a large personal and economic burden, so the impact of improvements in GP management is potentially significant.

General practitioners knowledge and management of whiplash associated disorders and post-traumatic stress disorder: implications for patient care.

BACKGROUND: In Australia, general practitioners (GPs) see around two-thirds of people injured in road traffic crashes. Road traffic crash injuries are commonly associated with diverse physical and psychological symptoms that may be difficult to diagnose and manage. Clinical guidelines have been developed to assist in delivering quality, consistent care, however the extent to which GPs knowledge and practice in diagnosing and managing road traffic crash injuries concords with the guidelines is unknown. This study aimed to explore Australian GPs knowledge, attitudes and practices regarding the diagnosis and management of road traffic crash injuries, specifically whiplash associated disorders (WAD) and post-traumatic stress disorder (PTSD). METHOD: A cross-sectional survey of 423 GPs across Australia conducted between July and December 2014. We developed a questionnaire to assess their knowledge of WAD and PTSD, confidence in diagnosing and managing WAD and PTSD, frequency of referral to health providers, barriers to referral, and attitudes towards further education and training. Factor analysis, Spearman's correlation, and multiple ordered logistic regressions were performed. RESULTS: Overall, GPs have good level knowledge of WAD and PTSD; only 9.6 % (95 % CI: 7.1 %, 12.8 %) and 23.9 % (95 % CI: 20.8 %, 28.2 %) of them were deemed to have lower level knowledge of WAD and PTSD respectively. Key knowledge gaps included imaging indicators for WAD and indicators for psychological referral for PTSD. GPs who were male, with more years of experience, working in the urban area and with higher knowledge level of WAD were more confident in diagnosing and managing WAD. Only GPs PTSD knowledge level predicted confidence in diagnosing and managing PTSD. GPs most commonly referred to physiotherapists and least commonly to vocational rehabilitation providers. Barriers to referral included out-of-pocket costs incurred by patients and long waiting times. Most GPs felt positive towards further education on road traffic crash injury management. CONCLUSION: This study has enhanced understanding of the knowledge skills and attitudes of GPs towards road traffic crash injury care in Australia, and has identified areas for further education and training. If delivered, this training has the potential to reduce unnecessary imaging for WAD and optimise the early referral of patients at risk of delayed recovery following a road traffic crash.

Low Pain Catastrophization and Disability Predict Successful Outcome to Radiofrequency Neurotomy in Individuals with Chronic Whiplash.

OBJECTIVES: Physical and psychological symptoms of individuals with chronic whiplash-associated disorders (WAD) are modulated by successful treatment with cervical radiofrequency neurotomy (cRFN). However, not all individuals respond to cRFN, and it is unknown which clinical features predict successful response to cRFN. METHODS: This prospective cohort study investigated 53 individuals with chronic WAD (36 female, 17 male; mean age = 44.7 ± 10.9 (SD) years) who underwent cRFN. Predictor variables measured at baseline (prior to RFN) included self-reported pain (VAS), disability (NDI), post-traumatic stress symptoms (PDS), pain catastrophizing (PCS), and measures of sensory hypersensitivity (pressure and cold pain thresholds). The outcome measure was perceived Global Rating of Change (where scores ≥ 4 were classified as a successful response) 3 months post-cRFN. RESULTS: Univariate logistic regression demonstrated that lower levels of disability and pain catastrophizing were associated with successful response of cRFN (both P < 0.05). Multivariable logistic regression demonstrated that low levels of pain catastrophizing and disability remained significant predictors of a successful response to cRFN (both P < 0.05). CONCLUSIONS: Low levels of pain catastrophizing and disability independently predicted a successful response to cRFN in patients with chronic WAD.

Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial.

BACKGROUND: Evidence suggests that brief physiotherapy programmes are as effective for acute whiplash-associated disorders as more comprehensive programmes; however, whether this also holds true for chronic whiplash-associated disorders is unknown. We aimed to estimate the effectiveness of a comprehensive exercise programme delivered by physiotherapists compared with advice in people with a chronic whiplash-associated disorder. METHODS: PROMISE is a two group, pragmatic randomised controlled trial in patients with chronic (>3 months and <5 years) grade 1 or 2 whiplash-associated disorder. Participants were randomly assigned by a computer-generated randomisation schedule to receive either the comprehensive exercise programme (20 sessions) or advice (one session and telephone support). Sealed opaque envelopes were used to conceal allocation. The primary outcome was pain intensity measured on a 0-10 scale. Outcomes were measured at baseline, 14 weeks, 6 months, and 12 months by a masked assessor. Analysis was by intention to treat, and treatment effects were calculated with linear mixed models. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12609000825257. FINDINGS: 172 participants were allocated to either the comprehensive exercise programme (n=86) or advice group (n=86); 157 (91%) were followed up at 14 weeks, 145 (84%) at 6 months, and 150 (87%) at 12 months. A comprehensive exercise programme was not more effective than advice alone for pain reduction in the participants. At 14 weeks the treatment effect on a 0-10 pain scale was 0·0 (95% CI -0·7 to 0·7), at 6 months 0·2 (-0·5 to 1·0), and at 12 months -0·1 (-0·8 to 0·6). CNS hyperexcitability and symptoms of post-traumatic stress did not modify the effect of treatment. We recorded no serious adverse events. INTERPRETATION: We have shown that simple advice is equally as effective as a more intense and comprehensive physiotherapy exercise programme. The need to identify effective and affordable strategies to prevent and treat acute through to chronic whiplash associated disorders is an important health priority. Future avenues of research might include improving understanding of the mechanisms responsible for persistent pain and disability, investigating the effectiveness and timing of drugs, and study of content and delivery of education and advice. FUNDING: The National Health and Medical Research Council of Australia, Motor Accidents Authority of New South Wales, and Motor Accident Insurance Commission of Queensland.

Measuring pain intensity in patients with neck pain: does it matter how you do it?

The aim of this study was to investigate whether variations in the way that pain intensity is measured in patients with neck pain influences the magnitude of pain ratings. The study uses data from 3 longitudinal studies (n = 361 at baseline) on people with neck pain due to whiplash injuries. Pain measures included verbal rating scales, numerical rating scales and a visual analog scale. Different measures asked patient to rate current pain, average pain over 24 hours, over 1 week, or over 4 weeks. Scores were converted to a 0-100 scale and tracked over time, correlations between measures were calculated. Mixed models regression was used to explore the factors which influenced the differences between scores on the measures. Scores on the different measures were significantly different from each other in each dataset (P < 0.02). The effect of recall period was significant in all datasets and the effect of number of response options was significant in 2 of 3 datasets. Pain intensity ratings appear to be sensitive to method of measurement. It is likely the length of recall time (eg, pain today vs. average pain over 4 weeks) has a significant influence on pain ratings. The influence of number of response options is less certain. Systematic reviewers should not uncritically rescale and pool absolute pain scores from instruments with varying scale descriptors or recall periods.

Cervical radiofrequency neurotomy reduces central hyperexcitability and improves neck movement in individuals with chronic whiplash.

OBJECTIVE: This study aims to determine if cervical medial branch radiofrequency neurotomy reduces psychophysical indicators of augmented central pain processing and improves motor function in individuals with chronic whiplash symptoms. DESIGN: Prospective observational study of consecutive patients with healthy control comparison. SETTING: Tertiary spinal intervention centre in Calgary, Alberta, Canada. SUBJECTS: Fifty-three individuals with chronic whiplash associated disorder symptoms (Grade 2); 30 healthy controls. METHODS: Measures were made at four time points: two prior to radiofrequency neurotomy, and 1- and 3-months post-radiofrequency neurotomy. Measures included: comprehensive quantitative sensory testing (including brachial plexus provocation test), nociceptive flexion reflex, and motor function (cervical range of movement, superficial neck flexor activity during the craniocervical flexion test). Self-report pain and disability measures were also collected. One-way repeated measures analysis of variance and Friedman's tests were performed to investigate the effect of time on the earlier measures. Differences between the whiplash and healthy control groups were investigated with two-tailed independent samples t-test or Mann-Whitney tests. RESULTS: Following cervical radiofrequency neurotomy, there were significant early (within 1 month) and sustained (3 months) improvements in pain, disability, local and widespread hyperalgesia to pressure and thermal stimuli, nociceptive flexor reflex threshold, and brachial plexus provocation test responses as well as increased neck range of motion (all P < 0.0001). A nonsignificant trend for reduced muscle activity with the craniocervical flexion test (P > 0.13) was measured. CONCLUSIONS: Attenuation of psychophysical measures of augmented central pain processing and improved cervical movement imply that these processes are maintained by peripheral nociceptive input.