What Motivates Engagement in Work and Other Valued Social Roles Despite Persistent Back Pain?

Purpose The prognosis of persistent back pain is variable, with some individuals adjusting poorly and others continuing to actively engage in work and other valued social roles. The aim of this study was to better understand why some individuals, despite persistent back pain, continue to actively engage in work and other valued social roles. Methods Individuals with persistent back pain, who were participating in their regular duties as a full-time employee, homemaker, student or any combination of these, were recruited from a multidisciplinary pain centre and orthopedic physical therapy clinics in Alberta, Canada. A qualitative study was conducted using semi-structured interviews of 15 participants and a thematic analysis to analyze the data. Results There were two motivators identified for participating in the work role: (1) participation formed part of the participant's self-schema (a cognitive framework that includes one's beliefs about oneself) and (2) participation made it possible to achieve a valued outcome. Conclusions Further understanding of important motivators for maintaining engagement in work and other valued social roles despite persistent back pain can help inform the development of more successful disability and pain management programs.

The association between a lifetime history of low back injury in a motor vehicle collision and future low back pain: a population-based cohort study.

PURPOSE: This population-based cohort study investigated the association between a lifetime history of a low back injury in a motor vehicle collision (MVC) and future troublesome low back pain. Participants with a history of a low back injury in a motor vehicle collision who had recovered (no or mild low back pain) were compared to those without a history of injury. Current evidence from two cross-sectional and one prospective study suggests that individuals with a history of a low back injury in a MVC are more likely to experience future LBP. There is a need to test this association prospectively in population-based cohorts with adequate control of known confounders. METHODS: We formed a cohort of 789 randomly sampled Saskatchewan adults with no or mild LBP. At baseline, participants were asked if they had ever injured their low back in a MVC. Six and 12 months later, participants were asked about the presence of troublesome LBP (grade II-IV) on the Chronic Pain Grade Questionnaire. Multivariable Cox proportional hazards regression analysis was used to estimate the association while controlling for known confounders. RESULTS: The follow-up rate was 74.8% (590/789) at 6 months and 64.5% (509/789) at 12 months. There was a positive crude association between a history of low back injury in a MVC and the development of troublesome LBP over a 12-month period (HRR = 2.76; 95% CI 1.42-5.39). Controlling for arthritis reduced this association (HRR = 2.25; 95% CI 1.11-4.56). Adding confounders that may be on the casual pathway (baseline LBP, depression and HRQoL) to the multivariable model further reduced the association (HRR = 2.20; 95% CI 1.04-4.68). CONCLUSION: Our analysis suggests that a history of low back injury in a MVC is a risk factor for developing future troublesome LBP. The consequences of a low back injury in a MVC can predispose individuals to experience recurrent episodes of low back pain.

The association between a lifetime history of work-related low back injury and future low back pain: a population-based cohort study.

PURPOSE: This population-based cohort study investigated the association between a lifetime history of a work-related low back injury, in those who had recovered to have no or mild low back pain, and the development of troublesome low back pain (LBP). A secondary analysis explored the possible effects of misclassification of the exposure by examining the association between a lifetime history of having taken time off work or performed light duties at work because of a work-related low back injury. Current evidence from cross-sectional studies suggests that individuals with a history of a work-related low back injury are more likely to experience future LBP. However, there is a need to examine this association prospectively in a large population-based cohort with adequate control of known confounders. METHODS: We formed a cohort of 810 randomly sampled Saskatchewan adults with no or mild LBP in September 1995. At baseline, participants were asked if they had ever injured their low back at work. The secondary analysis asked if they had ever had to take time off work or perform light duties at work because of a work-related low back injury. Prospective follow-up 6 and 12 months later, asked about the presence of troublesome LBP (grade II-IV) on the Chronic Pain Grade Questionnaire. Multivariable Cox proportional hazards regression analysis was used to estimate these associations while controlling for known confounders. RESULTS: The proportion followed up at 6 and 12 months was 76 and 65%, respectively. We found an association between a history of work-related low back injury and the onset of troublesome LBP after controlling for gender (adjusted HRR = 2.24; 95% CI 1.41-3.56). When covariates that may also be mediators of the association were added to the model, the effect estimate was attenuated (adjusted HRR = 1.37; 95% CI 1.41-3.56). We found a similar association between a lifetime history of having taken time off work or had to work light duties at work because of a work-related low back injury, adjusted for gender (adjusted HRR = 2.31; 95% CI 1.39-3.85) which was also diluted by the further adjustment for covariates that may also be mediators of the association (adjusted HRR = 1.80; 95% CI 1.08-3.01). CONCLUSION: Our study suggests that a history of work-related low back injury or taking time off work or having to perform light duties at work due to a work-related low back injury may be a risk factor for the development of troublesome LBP. Residual confounding may account for some of the observed associations, but this was less in the group who took time off work or had to work light duties due to a work-related low back 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.

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 systematically searched six databases from 2000 to 2014. Random pairs of independent reviewers critically appraised eligible systematic reviews using the Scottish Intercollegiate Guidelines Network criteria. We included systematic reviews with a low risk of bias in our best evidence synthesis. RESULTS: We screened 706 citations and 14 systematic reviews were eligible for critical appraisal. Eight systematic reviews 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.

Are non-invasive interventions effective for the management of headaches associated with neck pain? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

PURPOSE: To update findings of the 2000-2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders and evaluate the effectiveness of non-invasive and non-pharmacological interventions for the management of patients with headaches associated with neck pain (i.e., tension-type, cervicogenic, or whiplash-related headaches). METHODS: We searched five databases from 1990 to 2015 for randomized controlled trials (RCTs), cohort studies, and case-control studies comparing non-invasive interventions with other interventions, placebo/sham, or no interventions. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria to determine scientific admissibility. Studies with a low risk of bias were synthesized following best evidence synthesis principles. RESULTS: We screened 17,236 citations, 15 studies were relevant, and 10 had a low risk of bias. The evidence suggests that episodic tension-type headaches should be managed with low load endurance craniocervical and cervicoscapular exercises. Patients with chronic tension-type headaches may also benefit from low load endurance craniocervical and cervicoscapular exercises; relaxation training with stress coping therapy; or multimodal care that includes spinal mobilization, craniocervical exercises, and postural correction. For cervicogenic headaches, low load endurance craniocervical and cervicoscapular exercises; or manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine may also be helpful. CONCLUSIONS: The management of headaches associated with neck pain should include exercise. Patients who suffer from chronic tension-type headaches may also benefit from relaxation training with stress coping therapy or multimodal care. Patients with cervicogenic headache may also benefit from a course of manual therapy.

Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

PURPOSE: To develop an evidence-based guideline for the management of grades I-III neck pain and associated disorders (NAD). METHODS: This guideline is based on recent systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences (obtained from qualitative research) when formulating recommendations. Target audience includes clinicians; target population is adults with grades I-III NAD <6 months duration. RECOMMENDATION 1: Clinicians should rule out major structural or other pathologies as the cause of NAD. Once major pathology has been ruled out, clinicians should classify NAD as grade I, II, or III. RECOMMENDATION 2: Clinicians should assess prognostic factors for delayed recovery from NAD. RECOMMENDATION 3: Clinicians should educate and reassure patients about the benign and self-limited nature of the typical course of NAD grades I-III and the importance of maintaining activity and movement. Patients with worsening symptoms and those who develop new physical or psychological symptoms should be referred to a physician for further evaluation at any time during their care. RECOMMENDATION 4: For NAD grades I-II ≤3 months duration, clinicians may consider structured patient education in combination with: range of motion exercise, multimodal care (range of motion exercise with manipulation or mobilization), or muscle relaxants. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, strain-counterstrain therapy, relaxation massage, cervical collar, electroacupuncture, electrotherapy, or clinic-based heat. RECOMMENDATION 5: For NAD grades I-II >3 months duration, clinicians may consider structured patient education in combination with: range of motion and strengthening exercises, qigong, yoga, multimodal care (exercise with manipulation or mobilization), clinical massage, low-level laser therapy, or non-steroidal anti-inflammatory drugs. In view of evidence of no effectiveness, clinicians should not offer strengthening exercises alone, strain-counterstrain therapy, relaxation massage, relaxation therapy for pain or disability, electrotherapy, shortwave diathermy, clinic-based heat, electroacupuncture, or botulinum toxin injections. RECOMMENDATION 6: For NAD grade III ≤3 months duration, clinicians may consider supervised strengthening exercises in addition to structured patient education. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, cervical collar, low-level laser therapy, or traction. RECOMMENDATION 7: For NAD grade III >3 months duration, clinicians should not offer a cervical collar. Patients who continue to experience neurological signs and disability more than 3 months after injury should be referred to a physician for investigation and management. RECOMMENDATION 8: Clinicians should reassess the patient at every visit to determine if additional care is necessary, the condition is worsening, or the patient has recovered. Patients reporting significant recovery should be discharged.

Patients' Experiences With Vehicle Collision to Inform the Development of Clinical Practice Guidelines: A Narrative Inquiry.

OBJECTIVE: The purpose of this narrative inquiry was to explore the experiences of persons who were injured in traffic collisions and seek their recommendations for the development of clinical practice guideline (CPG) for the management of minor traffic injuries. METHODS: Patients receiving care for traffic injuries were recruited from 4 clinics in Ontario, Canada resulting in 11 adult participants (5 men, 6 women). Eight were injured while driving cars, 1 was injured on a motorcycle, 2 were pedestrians, and none caused the collision. Using narrative inquiry methodology, initial interviews were audiotaped, and follow-up interviews were held within 2 weeks to extend the story of experience created from the first interview. Narrative plotlines across the 11 stories were identified, and a composite story inclusive of all recommendations was developed by the authors. The research findings and composite narrative were used to inform the CPG Expert Panel in the development of new CPGs. RESULTS: Four recommended directions were identified from the narrative inquiry process and applied. First, terminology that caused stigma was a concern. This resulted in modified language ("injured persons") being adopted by the Expert Panel, and a new nomenclature categorizing layers of injury was identified. Second, participants valued being engaged as partners with health care practitioners. This resulted in inclusion of shared decision-making as a foundational recommendation connecting CPGs and care planning. Third, emotional distress was recognized as a factor in recovery. Therefore, the importance of early detection and the ongoing evaluation of risk factors for delayed recovery were included in all CPGs. Fourth, participants shared that they were unfamiliar with the health care system and insurance industry before their accident. Thus, repeatedly orienting injured persons to the system was advised. CONCLUSION: A narrative inquiry of 11 patients' experiences with traffic collision and their recommendations for clinical guidelines informed the Ontario Protocol for Traffic Injury Management Collaboration in the development of new Minor Injury Guidelines. The values and findings of the qualitative inquiry were interwoven into each clinical pathway and embedded within the final guideline report submitted to government.

The Effectiveness of Multimodal Care for Soft Tissue Injuries of the Lower Extremity: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

OBJECTIVE: The purpose of this systematic review was to evaluate the effectiveness of multimodal care for the management of soft tissue injuries of the lower extremity. METHODS: We systematically searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Random pairs of independent reviewers screened studies for relevance and critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. We included studies with a low risk of bias in our best evidence synthesis. RESULTS: We screened 6794 articles. Six studies had a low risk of bias and addressed the following: plantar heel pain (n = 2), adductor-related groin pain (n = 1), and patellofemoral pain (n = 3). The evidence suggests that multimodal care for the management of persistent plantar heel pain may include mobilization and stretching exercise. An intensive, clinic-based, group exercise program (strengthening, stretching, balance, agility) is more effective than multimodal care for the management of adductor-related groin pain in male athletes. There is inconclusive evidence to support the use of multimodal care for the management of persistent patellofemoral pain. Our search did not identify any low risk of bias studies examining multimodal care for the management of other soft tissue injuries of the lower extremity. CONCLUSION: A multimodal program of care for the management of persistent plantar heel pain may include mobilization and stretching exercise. Multimodal care for adductor-related groin pain is not recommended based on the current evidence. There is inconclusive evidence to support the use of multimodal care for the management of persistent patellofemoral pain.

The Effectiveness of Exercise on Recovery and Clinical Outcomes in Patients With Soft Tissue Injuries of the Hip, Thigh, or Knee: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

OBJECTIVE: The purpose of this systematic review was to determine the effectiveness of exercise for the management of soft tissue injuries of the hip, thigh, and knee. METHODS: We conducted a systematic review and searched MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL Plus with Full Text from January 1, 1990, to April 8, 2015, for randomized controlled trials (RCTs), cohort studies, and case-control studies evaluating the effect of exercise on pain intensity, self-rated recovery, functional recovery, health-related quality of life, psychological outcomes, and adverse events. Random pairs of independent reviewers screened titles and abstracts and assessed risk of bias using the Scottish Intercollegiate Guidelines Network criteria. Best evidence synthesis methodology was used. RESULTS: We screened 9494 citations. Eight RCTs were critically appraised, and 3 had low risk of bias and were included in our synthesis. One RCT found statistically significant improvements in pain and function favoring clinic-based progressive combined exercises over a "wait and see" approach for patellofemoral pain syndrome. A second RCT suggests that supervised closed kinetic chain exercises may lead to greater symptom improvement than open chain exercises for patellofemoral pain syndrome. One RCT suggests that clinic-based group exercises may be more effective than multimodal physiotherapy in male athletes with persistent groin pain. CONCLUSION: We found limited high-quality evidence to support the use of exercise for the management of soft tissue injuries of the lower extremity. The evidence suggests that clinic-based exercise programs may benefit patients with patellofemoral pain syndrome and persistent groin pain. Further high-quality research is needed.

Is low back pain associated with worse health-related quality of life 6 months later?

PURPOSE: The purpose of this study was to investigate the impact of low back pain (LBP) on future health-related quality of life (HRQoL). Current evidence suggests that individuals with LBP have poorer HRQoL than those without LBP. However, most of the evidence comes from cross-sectional studies where LBP and HRQoL are determined at the same time. One prospective study examined the association between days with LBP and HRQoL but did not account for the intensity of LBP. Therefore, this association needs to be tested in a large prospective population-based sample with a valid measure of LBP and adequate control of known confounders. METHODS: We formed a cohort of 1,110 randomly sampled Saskatchewan adults in September 1995. LBP at baseline was measured with the chronic pain questionnaire. The SF-36 questionnaire was used to measure physical and mental HRQoL at 6 months follow-up. Multivariable linear regression was used to estimate the association between graded LBP at baseline and HRQoL at 6 months while controlling for the effects of confounding. RESULTS: The 6-month follow-up rate was 70.7 % (785/1,110). LBP had a dose-response relationship with worsening physical HRQoL at 6 months, after controlling for age, income, arthritis, neck pain, and kidney disorders: grade III-IV LBP (ß = -10.23; 95 % CI -12.46, -7.99), grade II LBP (ß = -6.72, 95 % CI -8.79, -4.65), and grade I LBP (ß = -1.77; 95 % CI -3.18, -0.36). There was no dose-response relationship between LBP and mental HRQoL at 6 months. CONCLUSIONS: Low back pain has an impact on future physical HRQoL. Strategies for reducing the effects of LBP on HRQoL should be an important focus for clinicians, researchers, and health policy makers.

The effectiveness of noninvasive interventions for musculoskeletal thoracic spine and chest wall pain: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.

OBJECTIVE: The purpose of this study was to critically appraise and synthesize evidence on the effectiveness of noninvasive interventions, excluding pharmacological treatments, for musculoskeletal thoracic pain. METHODS: Randomized controlled trials (RCTs), cohort studies, and case-control studies evaluating the effectiveness of noninvasive interventions were eligible. We searched MEDLINE, EMBASE, PsycINFO, and the Cochrane Central Register of Controlled Trials accessed through Ovid Technologies, Inc, and CINAHL Plus with Full Text accessed through EBSCOhost from 1990 to 2015. Our search strategies combined controlled vocabulary relevant to each database (eg, MeSH for MEDLINE) and text words relevant to our research question and the inclusion criteria. Random pairs of independent reviewers screened studies for relevance and critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with a low risk of bias were synthesized following best evidence synthesis principles. RESULTS: We screened 6988 articles and critically appraised 2 studies. Both studies had a low risk of bias and were included in our synthesis. One RCT compared thoracic spinal manipulation, needle acupuncture, and placebo electrotherapy for recent thoracic spine pain. There were statistically significant but clinically nonimportant short-term reductions in pain favoring manipulation. There were no differences between acupuncture and placebo electrotherapy. Another RCT compared a multimodal program of care and a session of education for recent musculoskeletal chest wall pain. The multimodal care resulted in statistically significant but clinically nonimportant short-term reductions in pain over education. However, participants receiving multimodal care were more likely to report important improvements in chest pain. CONCLUSIONS: Quality evidence on the management of musculoskeletal thoracic pain is sparse. The current evidence suggests that compared to placebo, spinal manipulation is associated with a small and clinically nonimportant reduction in pain intensity and that acupuncture leads to similar outcomes as placebo. Furthermore, a multimodal program of care (ie, manual therapy, soft tissue therapy, exercises, heat/ice, and advice) and a single education session lead to similar pain reduction for recent-onset musculoskeletal chest wall pain. However, patients who receive multimodal care are more likely to report pain improvements.

The effectiveness of passive physical modalities for the management of soft tissue injuries and neuropathies of the wrist and hand: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.

OBJECTIVE: The purpose of this systematic review was to determine the effectiveness of passive physical modalities compared to other interventions, placebo/sham interventions, or no intervention in improving self-rated recovery, functional recovery, clinical outcomes and/or administrative outcomes (eg, time of disability benefits) in adults and/or children with soft tissue injuries and neuropathies of the wrist and hand. METHODS: We systematically searched MEDLINE, EMBASE, PsycINFO, and the Cochrane Central Register of Controlled Trials, accessed through Ovid Technologies, Inc, and CINAHL Plus with Full Text, accessed through EBSCO host, from 1990 to 2015. Our search strategies combined controlled vocabulary relevant to each database (eg, MeSH for MEDLINE) and text words relevant to our research question and the inclusion criteria. Randomized controlled trials, cohort studies, and case-control studies were eligible. Random pairs of independent reviewers screened studies for relevance and critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with low risk of bias were synthesized following best evidence synthesis principles. RESULTS: We screened 6618 articles and critically appraised 11 studies. Of those, 7 had low risk of bias: 5 addressed carpal tunnel syndrome (CTS) and 2 addressed de Quervain disease. We found evidence that various types of night splints lead to similar outcomes for the management of CTS. The evidence suggests that a night wrist splint is less effective than surgery in the short term but not in the long term. Furthermore, a night wrist splint and needle electroacupuncture lead to similar outcomes immediately postintervention. Finally, low-level laser therapy and placebo low-level laser therapy lead to similar outcomes. The evidence suggests that kinesio tape or a thumb spica cast offers short-term benefit for the management of de Quervain disease. Our search did not identify any low risk of bias studies examining the effectiveness of passive physical modalities for the management of other soft tissue injuries or neuropathies of the wrist and hand. CONCLUSIONS: Different night orthoses provided similar outcomes for CTS. Night orthoses offer similar outcomes to electroacupuncture but are less effective than surgery in the short term. This review suggests that kinesio tape or a thumb spica cast may offer short-term benefit for the management of de Quervain disease.

Population-based, inception cohort study of the incidence, course, and prognosis of mild traumatic brain injury after motor vehicle collisions.

OBJECTIVE: To determine the incidence, course, and prognosis of adult mild traumatic brain injury (MTBI) caused by motor vehicle collisions. DESIGN: Prospective, population-based, inception cohort study. SETTING: The province of Saskatchewan, Canada, with a population of about 1,000,000 inhabitants. PARTICIPANTS: All adults (N=1716) incurring an MTBI in a motor vehicle collision between November 1997 and December 1999 in Saskatchewan. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Age- and sex-stratified incidence rates, time to self-reported recovery, and prognostic factors over a 1-year follow-up. RESULTS: Of 7170 adults injured in a motor vehicle collision over the 2-year inception period, 1716 (24%) met our cohort definition of MTBI. There were more women affected (53%), and MTBI was most common in the 18- to 23-year-old group. Most were not hospitalized (73%), but 28% reported loss of consciousness and 23% reported posttraumatic amnesia. The annual incidence of MTBI per 100,000 adults was 106.1 (95% confidence interval [CI], 98.9-113.6) in the first year and 118.3 (95% CI, 110.8-126.3) in the second year of the study. The 1-year follow-up rate was 84%. The median time to recovery was 100 days (95% CI, 97-103), and about 23% reported not having recovered by 1 year. Factors associated with delayed recovery included being older than 50 years, having less than a high school education, having poor expectations for recovery, having depressive symptoms, having arm numbness, having hearing problems, having headaches, having low back pain, and having thoracic back pain. Loss of consciousness and posttraumatic amnesia were not associated with recovery. CONCLUSIONS: MTBI affects almost a quarter of persons reporting an injury after a traffic collision. The median time to recovery is 100 days, but 23% have still not recovered by 1 year. A mix of biopsychosocial factors is associated with recovery, including a strong effect of poor expectations for recovery.

Mild traumatic brain injury after motor vehicle collisions: what are the symptoms and who treats them? A population-based 1-year inception cohort study.

OBJECTIVE: To describe the 1-year course of symptoms following mild traumatic brain injury (MTBI) sustained in a motor vehicle collision as well as patterns of care-seeking. DESIGN: One-year follow-up of a population-based inception cohort. SETTING: The province of Saskatchewan, Canada, with a population of about 1,000,000 inhabitants. PARTICIPANTS: Persons (N=1716) sustaining an MTBI during a car collision between November 1997 and December 1999. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We report the prevalence of sleep disturbances, tiredness, dizziness, forgetfulness, vision problems, hearing problems, headache, neck pain, mid back pain, and low back pain at 6 weeks and 3, 6, 9, and 12 months postcollision. At the same time points, we report self-reported care-seeking from registered health care professionals. RESULTS: A total of 1716 adults suffered MTBI after a motor vehicle collision over the 2-year inception period. Six weeks after the collision, 75% reported having more than 3 symptoms and 30% had clinically significant pain in more than 3 body sites. Over time, the prevalence of symptoms and pain decreased but they were still common after 1 year. Almost all participants sought care for their symptoms at all time points, most commonly from a physician. Care-seeking from physiotherapists, chiropractors, and massage therapists was also very common, and most participants sought care from 2 or 3 providers at all follow-up points. CONCLUSIONS: Up to 1 year after sustaining an MTBI during a motor vehicle collision, multiple symptoms and pain in several anatomical sites are common. Care-seeking from multiple providers continues throughout the first year postinjury.

Psychosocial consequences of mild traumatic brain injury in children: results of a systematic review by the International Collaboration on Mild Traumatic Brain Injury Prognosis.

OBJECTIVE: To synthesize the best available evidence regarding psychosocial consequences of mild traumatic brain injury (MTBI) in children. DATA SOURCES: MEDLINE, Embase, CINAHL, PsycINFO, and SPORTDiscus were searched (2001-2012). Inclusion criteria included published peer-reviewed reports in English, French, Norwegian, Spanish, Swedish, and Danish. References were also identified from relevant reviews and meta-analyses, and the bibliographies of eligible articles. STUDY SELECTION: This article presents an update of a previous review with a much larger scope, of which this topic is a small subset of the questions addressed by that review. Controlled trials and cohort and case-control studies were selected according to predefined criteria. Two independent reviewers used modified Scottish Intercollegiate Guidelines Network criteria to critically appraise eligible studies. A total of 77,914 records were screened; 101 of these articles were deemed scientifically admissible, of which 6 investigated the psychosocial consequences of MTBI in children. DATA EXTRACTION: Two reviewers independently extracted data from accepted studies into evidence tables. DATA SYNTHESIS: We conducted a best-evidence synthesis by linking our conclusions to the evidence tables. Most accepted studies were exploratory rather than confirmatory. Preliminary evidence suggests that most children recover within 3 months post-MTBI. After 1 year, the prevalence of postconcussion symptoms and syndrome is similar between children with MTBI and children with orthopedic injuries. The functional status of children with MTBI improves over a 30-month follow-up period, but further research is needed to investigate the possibility that children with MTBI experience greater rates of psychiatric illness during the 3 years after their injury. CONCLUSIONS: The prognosis of MTBI is favorable in children. Most appear to recover functionally from a physical and psychological perspective. However, future research should investigate the risk for psychiatric illness.

Systematic review of prognosis after mild traumatic brain injury in the military: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.

OBJECTIVE: The World Health Organization Collaborating Centre Task Force on Mild Traumatic Brain Injury (MTBI) published its findings on the prognosis of MTBI in 2004. This is an update of that review with a focus on deployed military personnel. DATA SOURCES: Relevant literature published between January 2001 and February 2012 listed in MEDLINE and 4 other databases. STUDY SELECTION: Controlled trials and cohort and case-control studies were selected according to predefined criteria. After 77,914 titles and abstracts were screened, 13 articles were rated eligible for this review and 3 (23%) with a low risk of bias were accepted. Two independent reviewers critically appraised eligible studies using a modification of the Scottish Intercollegiate Guidelines Network criteria. DATA EXTRACTION: The reviewers independently extracted data from eligible studies and produced evidence tables. DATA SYNTHESIS: The evidence was synthesized qualitatively and presented in evidence tables. Our findings are based on 3 studies of U.S. military personnel who were deployed in Iraq or Afghanistan. We found that military personnel with MTBI report posttraumatic stress disorder and postconcussive symptoms. In addition, reporting of postconcussive symptoms differed on the basis of levels of combat stress the individuals experienced. The evidence suggests a slight decline in neurocognitive function after MTBI, but this decline was in the normal range of brain functioning. CONCLUSIONS: We found limited evidence that combat stress, posttraumatic stress disorder, and postconcussive symptoms affect recovery and prognosis of MTBI in military personnel. Additional high-quality research is needed to fully assess the prognosis of MTBI in military personnel.

Systematic review of the clinical course, natural history, and prognosis for pediatric mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.

OBJECTIVE: To synthesize the best available evidence on prognosis after pediatric mild traumatic brain injury (MTBI). DATA SOURCES: We searched MEDLINE, Embase, PsycINFO, CINAHL, and SPORTDiscus (2001-2012), as well as reference lists of eligible articles, and relevant systematic reviews and meta-analyses. STUDY SELECTION: Controlled trials and cohort and case-control studies were selected according to predefined criteria. Studies had to have a minimum of 30 MTBI pediatric cases. After 77,914 records were screened for the entire review, 299 studies were eligible and assessed for scientific rigor. DATA EXTRACTION: Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers independently reviewed each study and extracted data from accepted articles into evidence tables. DATA SYNTHESIS: Evidence from 25 accepted articles was synthesized qualitatively according to SIGN criteria, and prognostic information was prioritized according to design as exploratory or confirmatory. Most studies show that postconcussion symptoms and cognitive deficits resolve over time. Limited evidence suggests that postconcussion symptoms may persist in those with lower cognitive ability and intracranial pathology on neuroimaging. Preliminary evidence suggests that the risk of epilepsy is increased for up to 10 years after MTBI; however, there is insufficient high-quality evidence at this time to support this link. CONCLUSIONS: Common post-MTBI symptoms and deficits in children are not specific to MTBI and appear to resolve with time; however, limited evidence suggests that children with intracranial pathology on imaging may experience persisting symptoms or deficits. Well-designed, long-term studies are needed to confirm these findings.

Are performance-based functional assessments superior to semistructured interviews for enhancing return-to-work outcomes?

OBJECTIVE: To examine whether use of functional capacity evaluation (FCE) leads to better outcomes for injured workers. DESIGN: Cluster randomized controlled trial conducted with analysis at level of claimant. SETTING: Rehabilitation facility. PARTICIPANTS: Participants included claimants (N=203); of these, 103 were tested with FCE. Data were collected on all claimants undergoing RTW assessment at the facility for musculoskeletal conditions. Participants were predominantly employed (59%) men (73%) with chronic musculoskeletal conditions (median duration, 496d). INTERVENTIONS: FCEs are commonly used to identify work abilities and inform return-to-work (RTW) decisions. Therefore, FCE results have important consequences. Clinicians who were trained and experienced in performing FCEs were randomized into 2 groups. One group included 14 clinicians who were trained to conduct a semistructured functional interview; the other group (control group) continued to use standard FCE procedures. MAIN OUTCOME MEASURES: Outcomes included RTW recommendations after assessment, functional work level at time of assessment and 1, 3, and 6 months after assessment, and compensation outcomes. Analysis included Mann-Whitney U, chi-square, and t tests. RESULTS: All outcomes were similar between groups, and no statistically or clinically significant differences were observed. Mean differences between groups on functional work levels at assessment and follow-up ranged from 0.1 to 0.3 out of 4 (3%-8% difference, P>.05). CONCLUSIONS: Performance-based FCEs did not appear to enhance RTW outcomes beyond information gained from semistructured functional interviewing. Use of functional interviewing has the potential to improve efficiency of RTW assessment without compromising clinical, RTW, or compensation outcomes.

Methodological issues and research recommendations for prognosis after mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.

The International Collaboration on Mild Traumatic Brain Injury (MTBI) Prognosis performed a comprehensive search and critical review of the literature from 2001 to 2012 to update the 2002 best-evidence synthesis conducted by the World Health Organization Collaborating Centre for Neurotrauma, Prevention, Management and Rehabilitation Task Force on the prognosis of MTBI. Of 299 relevant studies, 101 were accepted as scientifically admissible. The methodological quality of the research literature on MTBI prognosis has not improved since the 2002 Task Force report. There are still many methodological concerns and knowledge gaps in the literature. Here we report and make recommendations on how to avoid methodological flaws found in prognostic studies of MTBI. Additionally, we discuss issues of MTBI definition and identify topic areas in need of further research to advance the understanding of prognosis after MTBI. Priority research areas include but are not limited to the use of confirmatory designs, studies of measurement validity, focus on the elderly, attention to litigation/compensation issues, the development of validated clinical prediction rules, the use of MTBI populations other than hospital admissions, continued research on the effects of repeated concussions, longer follow-up times with more measurement periods in longitudinal studies, an assessment of the differences between adults and children, and an account for reverse causality and differential recall bias. Well-conducted studies in these areas will aid our understanding of MTBI prognosis and assist clinicians in educating and treating their patients with MTBI.

Systematic review of self-reported prognosis in adults after mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.

OBJECTIVE: To update the mild traumatic brain injury (MTBI) prognosis review published by the World Health Organization Task Force in 2004. DATA SOURCES: MEDLINE, PsycINFO, Embase, CINAHL, and SPORTDiscus were searched from 2001 to 2012. We included published, peer-reviewed studies with more than 30 adult cases. STUDY SELECTION: Controlled trials and cohort and case-control studies were selected according to predefined criteria. Studies had to assess subjective, self-reported outcomes. After 77,914 titles and abstracts were screened, 299 articles were eligible and reviewed for scientific quality. This includes 3 original International Collaboration on MTBI Prognosis (ICoMP) research studies. DATA EXTRACTION: Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network criteria. Two reviewers independently reviewed each study and tabled data from accepted articles. A third reviewer was consulted for disagreements. DATA SYNTHESIS: Evidence from accepted studies was synthesized qualitatively into key findings, and prognostic information was prioritized according to design as exploratory or confirmatory. Of 299 reviewed studies, 101 (34%) were accepted and form our evidence base of prognostic studies. Of these, 23 addressed self-reported outcomes in adults, including 2 of the 3 original ICoMP research studies. These studies show that common postconcussion symptoms are not specific to MTBI/concussion and occur after other injuries as well. Poor recovery after MTBI is associated with poorer premorbid mental and physical health status and with more injury-related stress. Most recover over 1 year, but persistent symptoms are more likely in those with more acute symptoms and more emotional stress. CONCLUSIONS: Common subjective symptoms after MTBI are not necessarily caused by brain injury per se, but they can be persistent in some patients. Those with more initial complaints and psychological distress recover slower. We need more high-quality research on these issues.