Calibration and validation of physical behaviour cut-points using wrist-worn ActiGraphs for children and adolescents: A systematic review.

OBJECTIVES: To review cut-points calibrated and independently validated from wrist-worn ActiGraph accelerometers to measure moderate to vigorous physical activity (MVPA) and time spent sedentary (SED) in children and adolescents. DESIGN: Systematic literature review. METHODS: Five databases were searched for relevant cut-point calibration and independent validation studies relating to wrist worn ActiGraphs in children and adolescents from inception through 30 April 2022. Extracted data included: country of publication; study name; population; device model; wear location; sampling frequency; epoch length; activity protocol; criterion method and definitions used to classify PA intensity; statistical methods for calibration; statistical methods for validation/cross-validation; and MVPA and SED outcome. RESULTS: Fourteen calibration studies and seven independent validation studies were identified. Calibrated cut-points for MVPA vector magnitude counts ranged from 7065 to 9204 counts per minute (cpm) and 63.5 to 201 milli-gravitational units (mg). For SED, calibrated cut-points ranged from <2556 cpm to 4350 cpm and 30.8 to 48.1 mg. Classification accuracy values determined by independent validation studies varied, with kappa values ranging from 0.31 to 0.60 and area under the curve statistics ranging from 0.51 to 0.84 for MVPA and kappa values ranging from 0.31 to 0.44 and area under the curve statistics ranging from 0.70 to 0.85 for SED. CONCLUSIONS: The results of this systematic literature review support the use of the Crouter and colleagues cut-points for the measurement of MVPA and SED for children and adolescents aged 6-12 years. Further work is required to independently validate cut-points developed in younger children and older adolescents.

Objectively and subjectively measured physical activity levels in individuals with whiplash associated disorder and aged-matched healthy controls.

BACKGROUND: Whiplash associated disorders (WAD) are the most common non-hospitalised injuries resulting from a motor vehicle crash. Half of individuals with WAD experience ongoing pain and disability. Furthermore, individuals with persistent WAD have lower levels of aerobic capacity and isometric strength compared with age-matched controls. It is not known whether these differences are associated with increased levels of pain and disability, or with reduced physical activity (PA) participation. OBJECTIVE: Our primary aim was to compare PA levels in individuals with persistent WAD with healthy controls. Secondary aims were to: compare objective and subjective measurements of PA; explore factors that may influence PA; and describe proportions of these populations meeting World Health Organisation PA guidelines. METHODS: Objective (ActiGraph accelerometer; seven days) and subjective (International Physical Activity Questionnaire (IPAQ)) PA data were collected for n = 53 age-matched participants (WAD n = 28; controls n = 25). RESULTS: Independent sample t-tests showed no significant difference in objectively measured PA (p>0.05) between WAD and controls. For the subjective measure (IPAQ), controls reported more overall weekly PA (t = 0.219, p<0.05), while WAD participants reported more weekly walking minutes (t = -0.712, p<0.05). Linear regression showed mental health quality-of-life predicted objectively measured moderate intensity PA (R2 = 0.225, F (2, 44) = 6.379, p<0.004) and subjectively reported overall PA (R2 = 0.132, F (1, 41) = 6.226, p<0.017). Bland-Altman analyses indicated that subjects over-reported MVPA and under-reported sedentary time using the IPAQ. CONCLUSIONS: Individuals with WAD had levels of physical and mental health quality-of-life significantly lower than controls and below population norms yet participated in similar levels of PA. Given that increased perceptions of mental health quality-of-life were positively associated with objectively measured MVPA and subjectively reported overall PA, strategies to help people with WAD achieve adequate doses of MVPA may be beneficial. ActiGraph-measured and IPAQ-reported PA were discordant. Hence, IPAQ may not be a reliable measure of habitual PA in WAD.

Implementation of a risk-stratified, guideline-based clinical pathway of care to improve health outcomes following whiplash injury (Whiplash ImPaCT): a multicentre, randomized, controlled trial.

ABSTRACT: Current pathways of care for whiplash follow a "stepped care model," result in modest treatment outcomes and fail to offer efficient management solutions. This study aimed to evaluate the effectiveness of a risk-stratified clinical pathway of care (CPC) compared with usual care (UC) in people with acute whiplash. We conducted a multicentre, 2-arm, parallel, randomised, controlled trial in primary care in Australia. Participants with acute whiplash (n = 216) were stratified for risk of a poor outcome (low vs medium/high risk) and randomised using concealed allocation to either the CPC or UC. In the CPC group, low-risk participants received guideline-based advice and exercise supported by an online resource, and medium-risk/high-risk participants were referred to a whiplash specialist who assessed modifiable risk factors and then determined further care. The UC group received care from their primary healthcare provider who had no knowledge of risk status. Primary outcomes were neck disability index (NDI) and Global Rating of Change (GRC) at 3 months. Analysis blinded to group used intention-to-treat and linear mixed models. There was no difference between the groups for the NDI (mean difference [MD] [95% confidence interval (CI)] -2.34 [-7.44 to 2.76]) or GRC (MD 95% CI 0.08 [-0.55 to 0.70]) at 3 months. Baseline risk category did not modify the effect of treatment. No adverse events were reported. Risk-stratified care for acute whiplash did not improve patient outcomes, and implementation of this CPC in its current form is not recommended.

Selective acceptance of acute whiplash guidelines: a qualitative analysis of perceptions of health professionals in Australia.

PURPOSE: To explore health professionals' acceptance of the guidelines for acute whiplash associated disorders (WAD), and to identify barriers and facilitators to adherence. MATERIALS AND METHODS: Qualitative descriptive study involving focus group discussions among health professionals who treat people with WAD in primary and secondary care settings in New South Wales and Queensland, Australia. Twenty-eight health professionals (physiotherapists = 19; chiropractors = 6; osteopaths = 3) participated in six semi-structured focus group discussions that were held in independent offices in Sydney and Brisbane, Australia between September and December 2015. Discussions were audio recorded and verbatim, de-identified transcripts produced. Thematic analysis was conducted using an inductive approach to identify commonly held beliefs. RESULTS: Acceptance of guideline recommendations appeared to be influenced by factors related to the guideline itself, practitioner and practice characteristics, and patient-related factors. Specifically, acceptance was hindered by conflicting belief systems, ambiguity in guideline recommendations, and patient characteristics and expectations. CONCLUSIONS: Practitioners demonstrated a positive attitude towards the use of the guidelines in general; however, in some cases, acceptance of key recommendations appeared selective. Future guideline revision and implementation might focus on explaining the underlying principles of the guidelines, providing more detailed recommendations, and involving strategies that challenge inconsistent beliefs and promote informed decision-making. IMPLICATIONS FOR REHABILITATIONSelective acceptance of guideline recommendations in favour of those not requiring practice change may present a challenge for the implementation of evidence-based practice in the management of whiplash.Participants demonstrated variable, sometimes polar attitudes to guideline key messages and recommendations.Guideline developers need to focus more strongly on changing practitioner beliefs and attitudes, as well as better explaining the underlying principles of the guidelines, and providing more detailed recommendations.

A systematic review shows minimal evidence for measurement properties of psychological functioning outcomes in whiplash.

OBJECTIVES: The aim of this study was to systematically identify, synthesize, and appraise studies on the measurement properties of patient-reported outcome measures (PROMs) for anxiety, depression, fear of movement, pain catastrophizing, post-traumatic stress, self-efficacy, and stress in people with whiplash-associated disorders (WAD). STUDY DESIGN AND SETTING: PsycINFO, MEDLINE, EMBASE, CINAHL, PILOTS, Web of Science, and Scopus were searched (November 9, 2021). Studies evaluating any measurement property of relevant PROMs in WAD were included. Two reviewers independently screened the studies and assessed the measurement properties in accordance with the COSMIN guidelines. RESULTS: Measurement properties of 10 PROMs were evaluated in WAD: Pictorial Fear of Activity Scale-Cervical (PFActS-C), Tampa Scale of Kinesiophobia-11, Pain Catastrophizing Scale (PCS), Pain Self-Efficacy Questionnaire (PSEQ), PSEQ-4 item, PSEQ-2a, PSEQ-2b, Self-Efficacy Scale, Harvard Trauma Questionnaire, and Post-Traumatic Stress Diagnostic Scale. Content validity was not examined in any of these PROMs in whiplash. Moderate- or high-quality evidence showed adequate internal structure for the PSEQ, PCS, and PFActS-C, whereas the original structures of the remaining seven PROMs were not confirmed in whiplash. CONCLUSION: Until further research on the measurement properties of these PROMs is available, researchers may opt to use the PSEQ, PCS, or PFActS-C if the construct is aligned with research aims.

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.

Evaluation of a physical activity promotion intervention for adults with whiplash associated disorders: a single-case experimental design study.

PURPOSE: There is considerable variation in the physical and psychological presentations of people with whiplash-associated disorder (WAD). Optimal treatment continues to be a challenge. This research evaluated the efficacy of a community-located, theory-based intervention designed to promote physically active behaviour in people with persistent WAD, and thereby improve perceptions of pain interference and confidence completing activities in the presence of neck pain. MATERIALS AND METHODS: A multiple-baseline, single-case experimental design was used to evaluate the 16-week intervention across six participants. RESULTS: Weighted Tau-U showed significantly increased accelerometer-measured physical activity in three participants with large effect sizes (>0.5), with increased confidence in one participant (ES > 0.5), and reduced pain interference in another participant (ES > 0.7). Changes in other behaviours included clinically important improvements in quality of life for five participants and, in those participants with baseline symptom levels outside threshold levels, improvements in pain catastrophizing and pain self-efficacy. CONCLUSIONS: Participation in a theory-based intervention resulted in significant improvements in physical and psychological health for five of six participants. Providing this type of community-located physical activity promotion strategy, to individuals with persistent WAD, may help address physical impairments and psychological distress commonly experienced in WAD. Trial registration: The trial was registered with the Australia and New Zealand Clinical Trials Registry (ACTRN: ACTRN12617001261303p) and ClinicalTrials.gov (Protocol Number: 2018000349/2017/743).Implications for rehabilitationRehabilitation professionals should consider recommending theory-based physical activity promotion strategies to reduce physical impairments and psychological distress in individuals with persistent WAD.Individually tailored physical activity promotion strategies may help individuals with persistent WAD become more physically active thereby reducing their risk of diseases associated with inactivity which may compound the effects of WADImprovements in physical and psychological health may occur independently of increasing habitual physical activity.Rehabilitation professionals may find that other community-located strategies which aim to promote physically active behaviour confer similar benefits for individuals with persistent WAD.

Development and use of mobile messaging for individuals with musculoskeletal pain conditions: a scoping review protocol.

INTRODUCTION: Previous reviews of mobile messaging for individuals with musculoskeletal pain have shown positive effects on pain and disability. However, the configuration of digital content, method of presentation and interaction, dose and frequency needed for optimal results remain unclear. Patient preferences concerning such systems are also unclear. Addressing these knowledge gaps, incorporating evidence from both experimental and observational studies, may be useful to understand the extent of the relevant literature, and to influence the design and outcomes of future messaging systems. We aim to map information that could be influential in the design of future mobile messaging systems for individuals with musculoskeletal pain conditions, and to summarise the findings of efficacy, effectiveness, and economics derived from both experimental and observational studies. METHODS AND ANALYSIS: We will include studies describing the development and/or use of mobile messaging to support adults (≥18 years) with acute or chronic musculoskeletal pain. We will exclude digital health studies that lack a mobile messaging component, or those targeted at other health conditions unrelated to the bones, muscles and connective tissues, or involving surgical or patients with cancer, or studies involving solely healthy individuals. Our sources of information will be online databases and reference lists of relevant papers. We will include papers published in English in the last 10 years. Two pairs of independent reviewers will screen, select and extract the data, with any disagreements mediated by a third reviewer. We will report the results according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews checklist. We will synthesise the findings in a tabular format and provide a descriptive summary. ETHICS AND DISSEMINATION: Formal ethical approval is not required. We will disseminate the findings through publication in a peer-reviewed journal, relevant conferences, and relevant consumer forums. TRIAL REGISTRATION: Open Science Framework https://osf.io/8mzya; DOI: 10.17605/OSF.IO/8MZYA.

A randomised controlled trial of implementation of a guideline-based clinical pathway of care to improve health outcomes following whiplash injury (Whiplash ImPaCT): Statistical analysis plan.

BACKGROUND: Statistical analysis plans describe the processes of data handling and analysis in clinical trials; by doing so they increase the transparency of the analysis and reporting of studies. This paper reports the planned statistical analysis plan for the Whiplash ImPaCT study. For individuals with whiplash injury, Whiplash ImPaCT aims to assess the effectiveness of a guidelines-based clinical pathway of care compared with usual care. METHODS: We report the planned procedures, methods, and reporting for the primary and secondary analyses of the Whiplash ImPaCT study. The primary outcomes are Global Recovery and Neck Disability Index at 3 months post-randomisation. Outcomes will be analysed according to the intention to treat principle using linear mixed models. A cost-utility analysis will be conducted to compute the incremental cost-effectiveness of the intervention to usual care. We describe data handling, our analytical approach, assumptions about missing data, and our planned methods of reporting. DISCUSSION: This paper will provide a detailed description of the planned analyses for the Whiplash ImPaCT trial.

Comparison of the Accuracy of WhipPredict to That of a Modified Version of the Short-Form Örebro Musculoskeletal Pain Screening Questionnaire to Predict Poor Recovery After Whiplash Injury.

OBJECTIVE: To compare the accuracy of a whiplash-specific risk screening tool (WhipPredict) with that of the modified generic short-form Örebro Musculoskeletal Pain Screening Questionnaire (SF-ÖMPSQ) for predicting poor recovery in patients following whiplash injury. STUDY DESIGN: Inception cohort study. METHODS: Two hundred two participants with acute whiplash completed the WhipPredict and modified SF-ÖMPSQ at baseline. Poor recovery was measured at 6 and 12 months using the Neck Disability Index (greater than 10%), numeric pain-rating scale (greater than 3/10), global perceived recovery (less than +4), and inability to return to preinjury work level. Accuracy statistics were calculated to predict poor recovery. RESULTS: Seventy-one percent (n = 143) of participants completed the 6-month assessment and 56% (n = 113) completed the 12-month assessment. At baseline, agreement between the WhipPredict and modified SF-ÖMPSQ was fair (prevalence-adjusted and bias-adjusted κ = 0.26; 95% confidence interval: 0.12, 0.39). Depending on the outcome, 20% to 72% of people had not recovered at 6 months and 12% to 71% had not recovered at 12 months. At 6 and 12 months, the WhipPredict tool showed high sensitivity (88%-96%) and low specificity (all outcomes less than 31%) on all 4 separate outcomes. The modified SF-ÖMPSQ showed moderate sensitivity (67%-75%) for the Neck Disability Index, numeric pain-rating scale, and global perceived recovery, high sensitivity for return to work (81%-90%), and moderate specificity (54%-77%) for all 4 outcomes. CONCLUSION: Both tools showed acceptable accuracy in predicting poor recovery. The WhipPredict tool is recommended to correctly identify patients who will not recover but may falsely classify those who recover well. Using the modified SF-ÖMPSQ will result in fewer patients falsely categorized as being at risk of poor recovery and may result in some people being undertreated. J Orthop Sports Phys Ther 2021;51(5):207-215. Epub 19 Feb 2021. doi:10.2519/jospt.2021.9987.

Implementation of a novel stratified PAthway of CarE for common musculoskeletal (MSK) conditions in primary care: protocol for a multicentre pragmatic randomised controlled trial (the PACE MSK trial).

INTRODUCTION: Musculoskeletal (MSK) conditions constitute the highest burden of disease globally, with healthcare services often utilised inappropriately and overburdened. The aim of this trial is to evaluate the effectiveness of a novel clinical PAthway of CarE programme (PACE programme), where care is provided based on people's risk of poor outcome. METHODS AND ANALYSIS: Multicentre randomised controlled trial. 716 people with MSK conditions (low back pain, neck pain or knee osteoarthritis) will be recruited in primary care. They will be stratified for risk of a poor outcome (low risk/high risk) using the Short Form Örebro Musculoskeletal Pain Screening Questionnaire (SF-ÖMSPQ) then randomised to usual care (n=358) or the PACE programme (n=358). Participants at low risk in the PACE programme will receive up to 3 sessions of guideline based care from their primary healthcare professional (HCP) supported by a custom designed website (mypainhub.com). Those at high risk will be referred to an allied health MSK specialist who will conduct a comprehensive patient-centred assessment then liaise with the primary HCP to determine further care. Primary outcome (SF 12-item PCS) and secondary outcomes (eg, pain self-efficacy, psychological health) will be collected at baseline, 3, 6 and 12 months. Cost-effectiveness will be measured as cost per quality-adjusted life-year gained. Health economic analysis will include direct and indirect costs. Analyses will be conducted on an intention-to-treat basis. Primary and secondary outcomes will be analysed independently, using generalised linear models. Qualitative and mixed-methods studies embedded within the trial will evaluate patient experience, health professional practice and interprofessional collaboration. ETHICS AND DISSEMINATION: Ethics approval has been received from the following Human Research Ethics Committees: The University of Sydney (2018/926), The University of Queensland (2019000700/2018/926), University of Melbourne (1954239), Curtin University (HRE2019-0263) and Northern Sydney Local Health District (2019/ETH03632). Dissemination of findings will occur via peer-reviewed publications, conference presentations and social media. TRIAL REGISTRATION NUMBER: ACTRN12619000871145.

Exercise-induced Hypoalgesia Is Impaired in Chronic Whiplash-associated Disorders (WAD) With Both Aerobic and Isometric Exercise.

OBJECTIVES: Exercise-induced hypoalgesia (EIH) can be impaired in patients with chronic pain and may be dependent on exercise type. Factors predictive of EIH are not known. This study aimed to: (1) compare EIH in participants with chronic whiplash-associated disorders (WAD) to asymptomatic controls, (2) determine if EIH differs between aerobic and isometric exercise, (3) determine predictors of EIH. MATERIALS AND METHODS: A pre-post study investigated the effect of single sessions of submaximal aerobic treadmill walking and isometric knee extension on EIH in 40 participants with chronic WAD and 30 controls. Pressure pain thresholds were measured at the hand, cervical spine, and tibialis anterior. Pain intensity, reported previous week physical activity, temporal summation, and conditioned pain modulation (CPM) were measured at baseline. RESULTS: Participants with WAD demonstrated impaired EIH. Although, the WAD participants demonstrated a partial EIH response (EIH induced at the hand during exercise), no EIH response was found immediately after exercise. There was no difference in EIH between exercise types. In the WAD group, moderate physical activity levels predicted EIH at the hand and high physical activity levels predicted impaired EIH at the neck. More efficient CPM predicted EIH at the hand and less efficient CPM predicted impaired EIH at the neck. These associations were found for isometric exercise only. DISCUSSION: Individuals with chronic WAD have impaired EIH with both aerobic and isometric exercise. Higher levels of physical activity and less efficient CPM may be associated with impaired EIH. This may have implications for exercise prescription in this patient group.

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.

Evaluation of a novel intervention to improve physical activity for adults with whiplash associated disorders: Protocol for a multiple-baseline, single case experimental study.

Half of individuals with a whiplash injury experience ongoing pain and disability. Many are insufficiently active for good health, increasing their risk of preventable morbidity and mortality, and compounding the effects of the whiplash injury. This paper describes a protocol for evaluating the efficacy of a physical activity promotion intervention in adults with whiplash associated disorders. A multiple-baseline, single case experimental design will be used to evaluate the effects of a physical activity (PA) intervention that includes evidence-based behaviour change activities and relapse prevention strategies for six adults with chronic whiplash. A structured visual analysis supplemented with statistical analysis will be used to analyse: accelerometer-measured PA, confidence completing PA in the presence of neck pain, and pain interference.

An Interactive Website for Whiplash Management (My Whiplash Navigator): Process Evaluation of Design and Implementation.

BACKGROUND: Whiplash is a health and economic burden worldwide. Contributing to this burden is poor guideline adherence and variable management by health care professionals (HCPs). Web-based tools that facilitate clinical pathways of care are an innovative solution to improve management. OBJECTIVE: The study aimed to develop, implement, and evaluate a Web-based tool to support whiplash management following a robust process. METHODS: This study followed the first 3 processes of a research translation framework (idea generation, feasibility, and efficacy) to inform the development, implementation, and evaluation of a website that supports HCPs in whiplash management. Development followed the idea generation and feasibility processes to inform the content, design, features, and functionality of the website. This involved stakeholder (eg, industry partners, website developers, and HCPs) consultations through face-to-face meetings, surveys, and focus group discussions. Implementation followed the feasibility process to determine the practicality of the website for clinical use and the most effective strategy to promote wider uptake. Implementation strategies included classroom education, educational meetings, educational outreach, reminders, and direct phone contact. The analysis of website use and practicality of implementation involved collection of website metrics. Evaluation followed the feasibility and efficacy processes to investigate the acceptability and extent to which the website assisted HCPs in gaining knowledge about whiplash management. Surveys were conducted among student, primary, and specialist HCPs to explore ease of access, use, and satisfaction with the website, as well as self-rated improvements in knowledge of risk assessment, management, and communication between HCPs. Website logs of specialist management decisions (eg, shared care, specialist care, and referred care) were also obtained to determine actual practice. RESULTS: The development process delivered an interactive, user-friendly, and acceptable website, My Whiplash Navigator, tailored to the needs of HCPs. A total of 260 registrations were recorded from June 2016 to March 2018, including 175 student, 65 primary, and 20 specialist HCPs. The most effective implementation strategies were classroom education for students (81% uptake, 175/215) and educational meetings for primary HCPs (43% uptake, 47/110). Popular pages visited included advice and exercises and risk assessment. Most HCPs agreed that their knowledge about risk management (79/97, 81%) and exercises (85/97, 88%) improved. The specialists' most common management decision was shared care, an improvement from a previous cohort. Areas to improve were navigation and access to outcome measures. CONCLUSIONS: A robust process resulted in an innovative, interactive, user-friendly, and acceptable website, the My Whiplash Navigator. Implementation with HCPs was best achieved through classroom education and educational meetings. Evaluation of the website showed improved knowledge and practice to be more consistent with a risk-based clinical care pathway for whiplash. The positive results provide sufficient evidence to scale implementation nationally and involve other target markets such as people with whiplash, insurers, and insurance regulators.

Agreement is very low between a clinical prediction rule and physiotherapist assessment for classifying the risk of poor recovery of individuals with acute whiplash injury.

BACKGROUND: A prognostic clinical prediction rule (whiplash CPR) has been validated for use in individuals with acute whiplash associated disorders (WAD). The clinical utility of this tool is unknown. OBJECTIVES: To investigate: 1) the level of agreement between physiotherapist- and whiplash CPR-determined prognostic risk classification of people with acute WAD; 2) which clinical findings are used by physiotherapists to classify prognostic risk; and 3) whether physiotherapists plan to differ the number of treatment sessions provided based on prognostic risk classification. DESIGN: Pragmatic, observational. METHOD: 38 adults with acute WAD were classified as low, medium, or high risk of poor recovery by their treating physiotherapist (n = 24) at the conclusion of the initial consultation. A weighted Cohen's kappa examined the agreement between physiotherapist estimated risk classification and the whiplash CPR. Physiotherapists' reasons for classification were provided and summarised descriptively. Kruskal-Wallis and post-hoc Dunn's tests compared projected number of treatment sessions between risk subgroups. RESULTS: Physiotherapist agreement with the whiplash CPR occurred in 29% of cases (n = 11/38), which was less than what is expected by chance (K = -0.03; 95%CI -0.17 to 0.12). Physiotherapists most frequently considered range of movement (n = 23/38, 61%), a premorbid pain condition (n = 14/38, 37%), response to initial physiotherapy treatment (n = 12/38, 32%), and pain intensity (n = 12/38, 32%) when classifying prognostic risk. The projected number of treatment sessions was not different between risk groups using classifications provided by the physiotherapists (χ2(2) = 2.69, p = 0.26). CONCLUSIONS: Physiotherapists should consider incorporating the whiplash CPR into current assessment processes to enhance accuracy in prognostic decision-making.

Medicine use during acute and chronic postinjury periods in whiplash-injured individuals.

Medicine use as part of multimodal management for whiplash-associated disorders (WAD) is common: neck pain is the cardinal symptom, mental health conditions are common, and some individuals may have neurological signs and symptoms. Almost half of the individuals with WAD have ongoing pain and disability. However, medicine use during acute and chronic recovery periods for WAD management is unknown. We analysed medicine use during acute (<12 weeks) and chronic (12 weeks to 2 years) postinjury periods in adults claiming compensation for WAD in the no-fault jurisdiction of Victoria, Australia (n = 2871). Compared with males, females were more likely to have only nonopioid analgesic and/or NSAID claims during the acute postinjury period (odds ratio = 1.35 [95% confidence interval: 1.08-1.68]). However, high medicine use was more likely in males (1.39 [1.16-1.67]), middle-aged claimants (35-44 years) (1.74 [1.12-2.56]), and claimants with a common law claim (2.96 [2.38-3.68]). During both acute and chronic postinjury periods, over half of the pharmaceutical claimants were prescribed NSAIDs and weak opioid medicines, and over one quarter were prescribed benzodiazepines. Antidepressant use was high during the chronic period. The proportion of strong opioid claimants quadrupled between 2000/2001 (5.5%) and 2012/2013 (23.4%). Opioid consumption, expressed as oral morphine equivalent, was double in males than in females (z = -5.4, P < 0.001), and higher in middle-aged than in younger or older claimants (χ = 13.9, P < 0.001). The high opioid, benzodiazepine, and antidepressant medicine use in this study is concerning and highlights the need for pharmaceutical approaches that balance pain management while minimising risk.

Physiotherapist-delivered Stress Inoculation Training for acute whiplash-associated disorders: A qualitative study of perceptions and experiences.

BACKGROUND: Formally trained and accredited physiotherapists delivered Stress Inoculation Training (SIT) integrated with guideline-based physiotherapy management to individuals with acute whiplash associated disorders (WAD) as part of a randomised controlled trial. The delivery of SIT by physiotherapists is new. OBJECTIVES: To investigate physiotherapists' perspectives on delivering SIT as part of the trial and in routine practice. DESIGN: Qualitative descriptive. METHOD: Physiotherapists (n = 11) participated in semi-structured interviews. Interviews were audio-recorded, transcribed verbatim, and analysed thematically. Findings were triangulated against an audit of physiotherapists' adherence to the SIT protocol. RESULTS: Three themes were identified: perceived value; capacity to deliver; and adaptation and implementation. Physiotherapists' saw value in SIT in that they perceived the program to have improved patient outcomes, enhanced their therapeutic alliance, and provided new skills to manage psychological contributors to WAD. Physiotherapists' capacity to deliver the program was facilitated through the development of confidence in their ability to deliver sessions, viewing SIT as falling within their current professional identity, and having confidence in their ability to manage mismatches in patients' expectations of care. All physiotherapists reported having used SIT to some extent in routine practice, by selectively delivering sessions and/or integrating the content with other management. Physiotherapists were able to deliver SIT as was intended (94.6% adherence). CONCLUSIONS: Physiotherapists' supported adding SIT to usual management of individuals with acute WAD. Education on SIT principles is recommended during pre-professional training to facilitate future implementation.

Referral to specialist physiotherapists in the management of whiplash associated disorders: Perspectives of healthcare practitioners.

BACKGROUND: Guidelines for whiplash associated disorders (WAD) recommend early referral to specialists (e.g. specialist physiotherapists) of people who are not recovering. This recommendation is a key component of a proposed clinical pathway of care for WAD. OBJECTIVE: To explore healthcare practitioners' opinions about referral to specialist physiotherapists of people with WAD at high risk of non-recovery. DESIGN: Qualitative descriptive study. METHODS: Six focus groups were conducted among primary care allied-health practitioners (n = 16) and specialist physiotherapists (n = 12) in New South Wales and Queensland, Australia. Discussions were audio recorded and transcribed for thematic analysis. RESULTS: Ten themes were generated from analysis. Practitioners appeared to have good knowledge of indicators for referral; however, referrals were often made to the medical practitioner, less commonly to specialist physiotherapists. There was general support for referral to specialist physiotherapists, which was deemed as a viable alternative for people who are not recovering. Practitioners, however, had differing views about the attributes of a specialist physiotherapist and referral timeframe. A number of factors have been identified to influence the referral process and practitioners expressed specific expectations of the desired outcomes of referral as well as considerations for specialist management approaches. There was strong support for a collaborative approach in management that involved the referring practitioner. CONCLUSION: Results support the feasibility of referral to specialist physiotherapists despite limited uptake in practice and recognised barriers to referral. These findings have implications for further study and adopting strategies to facilitate effective implementation and translation of the proposed pathway into primary care practice.

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.