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.

Effect of intensive inpatient physical therapy on whole-body indefinite symptoms in patients with whiplash-associated disorders.

BACKGROUND: A considerable number of patients with whiplash-associated disorders (WAD) report variable and indefinite symptoms involving the whole body, despite there being no evidence of direct injuries to organs other than the neck. However, little is known about their management or underlying mechanism. This study examined the effect of intensive physical therapy at the cervical muscles in patients with WAD reporting whole-body indefinite symptoms. METHODS: A total of 194 hospitalized patients with WAD who were resistant to outpatient care by reporting whole-body indefinite symptoms between May 2006 and May 2017 were enrolled in this observational study. All patients underwent daily physical therapies by low-frequency electric stimulation therapy and far-infrared irradiation to the cervical muscles during hospitalization. Self-rated records in the medical interview sheets on 22 representative whole-body symptoms at admission and discharge were compared. RESULTS: The number of symptoms was markedly decreased by the physical therapies during hospitalization. Almost all symptoms showed recovery rates of more than 80% at discharge as compared to those at admission. Although the percentage of patients reporting at least four of the 22 representative indefinite symptoms was 99.0% at admission, it decreased to 7.7% at discharge. Sixteen percent of patients recovered completely without any residual symptoms. The mean number of symptoms significantly decreased from 13.1 at admission to 2.0 at discharge. Notably, symptoms other than those in the neck or shoulder recovered to a greater extent than those in the neck or shoulder. CONCLUSIONS: This study, for the first time, examined the management of whole-body indefinite symptoms in patients with WAD. The intensive physical therapy markedly improved the symptoms, suggesting the involvement of cervical muscles in the pathogenesis. TRIAL REGISTRATION: UMIN000035435 (Retrospectively registered on Jan 3, 2019).

Pathophysiology behind prolonged whiplash associated disorders: study protocol for an experimental study.

BACKGROUND: There is insufficient knowledge of pathophysiological parameters to understand the mechanism behind prolonged whiplash associated disorders (WAD), and it is not known whether or not changes can be restored by rehabilitation. The aims of the projects are to investigate imaging and molecular biomarkers, cervical kinaesthesia, postural sway and the association with pain, disability and other outcomes in individuals with longstanding WAD, before and after a neck-specific exercise intervention. Another aim is to compare individuals with WAD with healthy controls. METHODS: Participants are a sub-group (n = 30) of individuals recruited from an ongoing randomized controlled study (RCT). Measurements in this experimental prospective study will be carried out at baseline (before intervention) and at a three month follow-up (end of physiotherapy intervention), and will include muscle structure and inflammation using magnetic resonance imaging (MRI), brain structure and function related to pain using functional MRI (fMRI), muscle function using ultrasonography, biomarkers using samples of blood and saliva, cervical kinaesthesia using the "butterfly test" and static balance test using an iPhone app. Association with other measures (self-reported and clinical measures) obtained in the RCT (e.g. background data, pain, disability, satisfaction with care, work ability, quality of life) may be investigated. Healthy volunteers matched for age and gender will be recruited as controls (n = 30). DISCUSSION: The study results may contribute to the development of improved diagnostics and improved rehabilitation methods for WAD. TRIAL REGISTRATION: Clinicaltrial.gov Protocol ID: NCT03664934, initial release 09/11/2018.

Reliability and Responsiveness of Patient-Reported Outcome Measures of Neck Disability to Physical Therapy: Comparison of the Copenhagen, Northwick Park, and Neck Bournemouth Questionnaires and the Neck Disability Index.

OBJECTIVE: The purpose of this study was to identify the external and internal reliability and responsiveness of the validated patient-reported outcome measures (PROMs) of neck pain to a standardized regimen of physiotherapy administered acutely after mild whiplash injury using the clinically significant improvement components of the Patient Global Impression of Change (PGIC) as the outcome measure. METHODS: Eighty-six patients with neck pain alone were referred for physiotherapy within 2 weeks of whiplash injury. They completed the Copenhagen, Northwick Park (NP), and Neck Bournemouth (NBQ) questionnaires and the Neck Disability Index (NDI) before starting and after treatment when they also completed the PGIC. Treatment comprised deep soft tissue massage, myofascial releases, muscle energy techniques, joint articulation and manipulation techniques, and a home exercise program. The duration of treatment was between 3 and 6 weeks. A PGIC of 6 or 7 was considered to be clinically significant improvement. RESULTS: The external reliability of the PROMs was >0.7 and internal >0.87. All components of the PROMs contributed to the final score except headache in the Copenhagen and upper-limb dysesthesia in the NP. The most reliable questionnaire was the NBQ, which was significantly more responsive than the Copenhagen (P = .008). The NBQ was slightly more responsive than the NDI and NP. The NBQ and NDI were successfully completed more frequently than the NP and Copenhagen. CONCLUSION: The NP, NDI, and NBQ are all reliable and responsive measures of change after physiotherapy for neck pain after acute whiplash injury.

Neck-specific exercises with internet-based support compared to neck-specific exercises at a physiotherapy clinic for chronic whiplash-associated disorders: study protocol of a randomized controlled multicentre trial.

BACKGROUND: Globally, neck pain is the fourth most common condition associated with longer periods of living with disability. Annually, approximately 0.3% of the population of Western countries undergo whiplash trauma, and half of those individuals will develop chronic problems with high costs for the individual and society. Evidence for chronic whiplash-associated disorders (WAD) treatment is scarce, though neck-specific training at a physiotherapy clinic twice a week for 12 weeks has demonstrated good results. More efficient, flexible rehabilitation with reduced waiting times and lower costs is needed, ideally replacing lengthy on-site treatment series by healthcare providers. Internet-based care has been shown to be a viable alternative for a variety of diseases and interventions, but studies are lacking on Internet-based interventions for individuals with chronic neck problems. The aim of the trial described here is to compare the effects of an Internet-based neck-specific exercise programme to the same exercises performed at a physiotherapy clinic in regards to self-reported and clinical measures, as well as cost-effectiveness. METHODS: This prospective, randomized controlled trial will involve 140 participants. Measurements will be made at baseline, 3 months (end of treatment), and 15 months (12 months after end of intervention) and will include ratings of pain, disability, satisfaction with care, work ability, quality of life, and cost-effectiveness. DISCUSSION: The study results may contribute to the development of a more effective rehabilitation, flexible and equal care, shorter waiting times, increased availability, and lower costs for healthcare and society. TRIAL REGISTRATION: ClinicalTrials.gov Protocol ID: NCT03022812 , initial release 12/20/2016.

Effects of Neck-Specific Exercises Compared to Waiting List for Individuals With Chronic Whiplash-Associated Disorders: A Prospective, Randomized Controlled Study.

OBJECTIVE: To determine whether 3 months of neck-specific exercises (NSEs) could benefit individuals with chronic whiplash-associated disorder (WAD) who were on a waiting list (WL) for treatment. DESIGN: A prospective, randomized controlled study. SETTING: Primary health care. PARTICIPANTS: Individuals (N=41; 31 women, 10 men; mean age ± SD, 38±11.2y) with chronic (6-36mo) WAD, grades 2 and 3, were analyzed. INTERVENTIONS: Patients were randomly assigned to NSEs or no treatment for 3 months. MAIN OUTCOME MEASURES: Neck-specific disability (Neck Disability Index [NDI]), neck pain (visual analog scale), general pain-related disability (Pain Disability Index [PDI]), self-perceived performance ability (Self-Efficacy Scale [SES]), and health-related quality of life (EuroQol 5 dimensions [EQ-5D]) were measured. RESULTS: NSEs significantly improved the NDI, SES, and EQ-5D compared with WL (P<.01). There was significant improvement (P<.0001) over time in all outcomes for NSEs, and apart from the PDI, significant worsening (P=.002-.0002) over time for the untreated group. CONCLUSIONS: NSEs were more beneficial than no intervention while on a WL for individuals with chronic WAD.

What is the comparative effectiveness of current standard treatment, against an individually tailored behavioural programme delivered either on the Internet or face-to-face for people with acute whiplash associated disorder? A randomized controlled trial.

OBJECTIVE: To investigate the comparative effectiveness of current standard treatment, against an individually tailored behavioural programme delivered via the Internet or face-to-face for people with acute whiplash associated disorders. DESIGN: A multicentre, randomized, three-group design, with concealed allocation. SUBJECTS AND SETTINGS: A total of 55 participants (37 female), age 18-65, with acute Whiplash Associated Disorder (Grade I-II), recruited at two emergency clinics in Sweden. INTERVENTIONS: Before randomization all participants received standard self-care instructions. The Internet and face-to-face groups followed a seven-week behavioural programme involving individual tailoring, via email (Internet group), or in sessions at a physical therapy unit (face-to-face group). The control group only received the self-care instructions. MAIN MEASURES: Pain-related disability, pain intensity, self-efficacy in daily activities, catastrophizing and fear of movement/(re)injury. Assessments were performed at baseline (2-4 weeks postinjury) and at three, six and 12 months postintervention. RESULTS: Both the Internet (n = 16) and face-to-face (n = 14) group showed a larger decrease in pain-related disability than the control group (n = 16); -12 and -11, respectively, compared with -5 in the control group at 12-months follow-up. Significant differences between the groups in overall treatment effect were shown in all outcomes except pain intensity. All groups improved significantly over time in all outcomes, except for fear of movement/(re)injury and catastrophizing in the control group. CONCLUSION: An individually tailored behavioural programme improved biopsychosocial factors in patients with whiplash associated disorders up to 12 months after treatment. Internet-delivered intervention was as effective as clinic-based face-to-face therapy sessions.

The effect of 3 different exercise approaches on neck muscle endurance, kinesiophobia, exercise compliance, and patient satisfaction in chronic whiplash.

OBJECTIVE: The purpose of this study was to compare the effects of 3 different exercise approaches on neck muscle endurance (NME), kinesiophobia, exercise compliance, and patient satisfaction in patients with chronic whiplash. METHODS: This prospective randomized clinical trial included 216 individuals with chronic whiplash. Participants were randomized to 1 of 3 exercise interventions: neck-specific exercise (NSE), NSE combined with a behavioral approach (NSEB), or prescribed physical activity (PPA). Measures of ventral and dorsal NME (endurance time in seconds), perceived pain after NME testing, kinesiophobia, exercise compliance, and patient satisfaction were recorded at baseline and at the 3- and 6-month follow-ups. RESULTS: Compared with individuals in the prescribed physical activity group, participants in the NSE and NSEB groups exhibited greater gains in dorsal NME (P = .003), greater reductions in pain after NME testing (P = .03), and more satisfaction with treatment (P < .001). Kinesiophobia and exercise compliance did not significantly differ between groups (P > .07). CONCLUSION: Among patients with chronic whiplash, a neck-specific exercise intervention (with or without a behavioral approach) appears to improve NME. Participants were more satisfied with intervention including neck-specific exercises than with the prescription of general exercise.

The return-to-work process of individuals sick-listed because of whiplash-associated disorder: a three-year follow-up study in a Danish cohort of long-term sickness absentees.

BACKGROUND: The chronic course of whiplash-associated disorder (WAD) has implications for both the individual and society. It has been shown that up to 50% of patients have not yet returned to work six months after a whiplash injury. We wanted to study the return-to-work (RTW) process in individuals sick-listed for more than eight weeks in six Danish municipalities. RTW in individuals sick-listed due to WAD was compared to that in those sick-listed for other musculoskeletal disorders (MSD). METHODS: Information about long-term sick-listed individuals in six Danish municipalities was retrieved from an existing database. Data on public transfer income were collected and the RTW process was followed on a weekly basis. Multivariate logistic regression analysis of RTW was done four times during the first three years after the start of sick-listing. RESULTS: One hundred and four individuals were sick-listed due to WAD and 3,204 individuals were sick-listed due to other MSDs. After 6 months, the RTW was significantly lower in the WAD group. OR for RTW in the WAD group was 0.29 (0.18-0.49) compared to the MSD group. The RTW process for both groups stabilised after two years of follow-up; 44% returned to work in the WAD group as compared to 58% in the MSD group. CONCLUSION: Sick-listed individuals with whiplash-associated disorder are less likely to return to work than individuals who are sick-listed because of other musculoskeletal disorders. In both groups, RTW stabilised after two years of follow-up.

Factors related to non-recovery from whiplash. The Nord-Trøndelag Health Study (HUNT).

BACKGROUND: Whiplash injuries show a variable prognosis which is difficult to predict. Most individuals experiencing whiplash injuries rapidly recover but a significant proportion develop chronic symptoms and ongoing disability. PURPOSE: By employing longitudinal data, we investigated how psychological and physical symptoms, self-rated health, use of health services and medications, health behavior and demographic factors predict recovery from whiplash. METHOD: Data from two waves of a large, Norwegian, population-based study (The Nord-Trøndelag Health Study: HUNT2 and HUNT3) were used. Individuals reporting whiplash in HUNT2 (baseline) were identified in HUNT3 11 years later. The characteristics of individuals still suffering from whiplash in HUNT3 were compared with the characteristics of individuals who had recovered using Pearson's chi-squared test, independent sample t-tests and logistic regression. RESULTS: At follow-up, 31.6 % of those reporting whiplash at baseline had not recovered. These individuals (n = 199) reported worse health at baseline than recovered individuals (n = 431); they reported poorer self-rated health (odds ratio [OR] = 3.12; 95 % confidence interval [CI], 2.20-4.43), more symptoms of anxiety (OR = 1.70; 95 % CI, 1.15-2.50), more diffuse somatic symptoms (OR = 2.38; 95 % CI, 1.61-3.51) and more musculoskeletal symptoms (OR = 1.21; 95 % CI, 1.13-1.29). Individuals still suffering from whiplash also visited more health practitioners at baseline (OR = 1.18; 95 % CI, 1.06-1.32) and used more medications (OR = 1.24; 95 % CI, 1.09-1.40). CONCLUSION: Poor self-rated health seems to be a strong risk factor for whiplash injuries becoming chronic. Diffuse somatic symptoms, musculoskeletal symptoms and symptoms of anxiety at baseline are important prognostic risk factors. Knowledge of these maintaining risk factors enables identification of individuals at risk of non-recovery, facilitating adequate treatment for this vulnerable group.

Are work disability prevention interventions effective for the management of neck pain or upper extremity disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.

PURPOSE: We conducted a systematic review to critically appraise and synthesize literature on the effectiveness of work disability prevention (WDP) interventions in workers with neck pain, whiplash-associated disorders (WAD), or upper extremity disorders. METHODS: We searched electronic databases from 1990 to 2012. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Scientifically admissible studies were summarized and synthesized following best-evidence synthesis methodology. RESULTS: Of the 6,359 articles retrieved, 16 randomized controlled trials were eligible for critical appraisal and five were admissible. We found that a return-to-work coordination program (including workplace-based work hardening) was superior to clinic-based work hardening for persistent rotator cuff tendinitis. Workplace high-intensity strength training and workplace advice had similar outcomes for neck and shoulder pain. Mensendieck/Cesar postural exercises and strength and fitness exercises had similar outcomes for non-specific work-related upper limb complaints. Adding a brief job stress education program to a workplace ergonomic intervention was not beneficial for persistent upper extremity symptoms. Adding computer-prompted work breaks to ergonomic adjustments and workplace education benefited workers' recovery from recent work-related neck and upper extremity complaints. CONCLUSIONS: At present, no firm conclusions can be drawn regarding the effectiveness of WDP interventions for managing neck pain, WAD, and upper extremity disorders. Our review suggests a return-to-work coordination program is more effective than clinic-based work hardening. Also, adding computer-prompted breaks to ergonomic and workplace interventions benefits workers' recovery. The current quality of evidence does not allow for a definitive evaluation of the effectiveness of ergonomic interventions.

Use of cervical collar after whiplash injuries.

Whiplash injuries, also known as neck sprains and strains, are currently some of the most common injuries of the cervical spine. Mechanism of injury is still controversial and current treatment methods do not provide satisfactory results. In this article we present QTF classification of related disorders, epidemiological data and treatment methods. We described basic principles of using a soft collar, goals and effects of collar use and potential complications ensuing from immobilization. Authors reviewed publications comparing the effects of collar use with other methods of treatment and physiotherapy following whiplash injury.

Results of neck-specific exercise for altered postural sway in individuals with chronic whiplash-associated disorders: a longitudinal case-control study.

Postural sway has not been investigated before or after a neck exercise intervention in individuals with chronic whiplash-associated disorders (WAD). The aim of the study was to investigate postural sway in individuals with chronic WAD grades 2 and 3: (a) compared with healthy matched controls at baseline; (b) after three months of neck-specific exercise and (c) to investigate the correlation between postural sway with self-reported dizziness during motion and balance problems/unsteadiness. This is a longitudinal prospective experimental case-control intervention study. Individuals with WAD (n = 30) and age- and gender-matched healthy volunteers (n = 30) participated. Postural sway was assessed using an iPhone application. Measurements were carried out at baseline, and for those with WAD a second measurement was performed at the three-month follow-up when neck-specific exercise intervention ended. The WAD group performed significantly worse than the healthy group in both pathway and ellipse area double stance eyes closed at baseline (main outcome), but not at the three-month follow-up. The WAD group significantly improved after rehabilitation in both pathway double stance eyes closed and pathway single stance eyes open. The correlation between postural sway and self-rated dizziness during motion and balance problems was low to moderate. One may conclude that postural sway was improved after a neck-specific exercise programme. The study results strengthen earlier findings that individuals with WAD have worse balance outcome when they have to rely on neck proprioception (eyes closed). The study results may be important for the development of improved rehabilitation methods for WAD.

Effect of neck-specific exercises with and without internet support on cervical range of motion and neck muscle endurance in chronic whiplash-associated disorders: analysis of functional outcomes of a randomized controlled trial.

OBJECTIVE: To compare the effects of a neck-specific exercise programme with internet support and 4 physiotherapist sessions (NSEIT) and the same neck-specific exercises supervised by a physiotherapist (NSE) on neck muscle endurance and cervical range of motion. DESIGN: Randomized controlled trial. PATIENTS: A total of 140 participants with chronic whiplash-associated disorders grade II or grade III were randomly assigned to the NSEIT or NSE groups. METHODS: Outcomes were changes in active cervical range of motion, cranio-cervical flexion test, neck muscle endurance, and neck pain, at 3- and 15-month follow-ups. RESULTS: There were no significant differences between the NSEIT and NSE groups. There was a significant group-by-time inter-action effect in active cervical range of motion flexion/extension where the NSEIT group improved to 3-month follow-up, but the NSE group did not. Both groups were significantly improved over time in all other outcomes (p < 0.001) at 3- and 15-month follow-ups, with effect size between 0.64 and 1.35 in active cervical range of motion, cranio-cervical flexion test, dorsal neck muscle endurance, and neck pain, and effect size between 0.22 and 0.42 in ventral neck muscle endurance. CONCLUSION: Both NSE and NSEIT led to improved neck function. Depending on the patients' needs, either NSE or NSEIT could be used as treatment for patients with chronic whiplash-associated disorders.

German version of the whiplash disability questionnaire: reproducibility and responsiveness.

BACKGROUND: The Whiplash Disability Questionnaire (WDQ) poses a validated tool for the assessment of patients who experience whiplash-associated disorders. A German translation and cross-cultural adaptation was recently produced and presented high validity and internal consistency. As a follow-up, the presented study tests the translated Whiplash Disability Questionnaire's (WDQ-G) retest reliability and responsiveness to change. METHODS: The WDQ-G was assessed on three different measurement events: first upon entry (ME1), second four days after entry (ME2), and third at discharge (ME3). Test-retest reliability data from ME1 and ME2 was analysed in a group of stable patients to obtain the intraclass correlation coefficient (ICC) and the standard error of measurement (SEM). To test the instrument's responsiveness, WDQ-G change data were compared to concurrent instruments. The probability of each instrument, to correctly distinguish patients of the stable phase (ME1 to ME2) from patients who deemed to have improved between from ME1 to ME3, was analysed. RESULTS: In total, 53 patients (35 females, age=45 ± 12.2) were recruited. WDQ-G scores changed from ME1 to ME2 by 5.41 ± 11.6 points in a stable group. This corresponds to a test-retest reliability of ICC=0.91 (95% CI=0.80-0.95) with a SEM of 6.14 points. Minimal Detectable Change, at 95% confidence, was calculated to be 17 points change in scores. Area under Receiver Operator Characteristics of the WDQ-G's responsiveness revealed a probability of 84.6% (95% CI=76.2%-93%) to correctly distinguish between improved and stable patients. Optimal sensitivity (73.2%) and specificity (76.2%) was established at 11-point change. CONCLUSIONS: High retest reliability and good responsiveness of the WDQ-G support clinical implementation of the translated version. The data suggest, that change in total score greater than eleven points can be interpreted as clinical relevant from a patient's perspective. Minimal Important Change is suggested at 15 points where there is still high specificity and a 90% confidence MDC.

German translation, cross-cultural adaptation and validation of the whiplash disability questionnaire.

BACKGROUND: The Australian Whiplash Disability Questionnaire (WDQ) was cross-culturally translated, adapted, and tested for validity to be used in German-speaking patients. The self-administered questionnaire evaluates actual pain intensity, problems in personal care, role performance, sleep disturbances, tiredness, social and leisure activities, emotional and concentration impairments with 13 questions rated on an 11-point rating scale from zero to ten. METHODS: In a first part, the Australian-based WDQ was forward and backward translated. In a consensus conference with all translators and health care professionals, who were experts in the treatment of patients with a whiplash associated disorder (WAD), formulations were refined. Original authors were contacted for clarification and approval of the forward-backward translated version. The German version (WDQ-G) was evaluated for comprehensiveness and clarity in a pre-study patient survey by a random sample of German-speaking patients after WAD and four healthy twelve to thirteen year old teenagers. In a second part, the WDQ-G was evaluated in a patient validation study including patients affected by a WAD. Inpatients had to complete the WDQ-G, the North American Spine Society questionnaire (NASS cervical pain), and the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) at entry in the rehabilitation centre. RESULTS: In the pre-study patient survey (response rate 31%) patients rated clarity for title 9.6 ± 0.9, instruction 9.3 ± 1.4 and questions 9.6 ± 0.7, and comprehensiveness for title 9.6 ± 0.7, instruction 9.3 ± 1.4 and questions 9.8 ± 0.4. Time needed to fill in was 13.7 ± 9.0 minutes. In total, 70 patients (47 females, age = 43.4 ± 12.5 years, time since injury: 1.5 ± 2.6 years) were included in the validation study. WDQ-G total score was 74.0 ± 21.3 points (range between 15 and 117 points). Time needed to fill in was 6.7 ± 3.4 minutes with data from 22 patients. Internal consistency was confirmed with Cronbachs's α = 0.89. Concurrent validity showed a highly significant correlation with subscale pain and disability (NASS) at r = 0.74 and subscale pain (SF-36) at r = 0.71. CONCLUSIONS: The officially translated and adapted WDQ-G can be used in German-speaking patients affected by a WAD to evaluate patients' impairments in different domains. The WDQ-G is a self-administered outcome measure showing a high internal consistency and good concurrent validity.

Effects of neck-specific exercise with or without a behavioural approach in addition to prescribed physical activity for individuals with chronic whiplash-associated disorders: a prospective randomised study.

BACKGROUND: Up to 50% of chronic whiplash associated disorders (WAD) patients experience considerable pain and disability and remain on sick-leave. No evidence supports the use of physiotherapy treatment of chronic WAD, although exercise is recommended. Previous randomised controlled studies did not evaluate the value of adding a behavioural therapy intervention to neck-specific exercises, nor did they compare these treatments to prescription of general physical activity. Few exercise studies focus on patients with chronic WAD, and few have looked at patients' ability to return to work and the cost-effectiveness of treatments. Thus, there is a great need to develop successful evidence-based rehabilitation models. The study aim is to investigate whether neck-specific exercise with or without a behavioural approach (facilitated by a single caregiver per patient) improves functioning compared to prescription of general physical activity for individuals with chronic WAD. METHODS/DESIGN: The study is a prospective, randomised, controlled, multi-centre study with a 2-year follow-up that includes 216 patients with chronic WAD (> 6 months and < 3 years). The patients (aged 18 to 63) must be classified as WAD grade 2 or 3. Eligibility will be determined with a questionnaire, telephone interview and clinical examination. The participants will be randomised into one of three treatments: (A) neck-specific exercise followed by prescription of physical activity; (B) neck-specific exercise with a behavioural approach followed by prescription of physical activity; or (C) prescription of physical activity alone without neck-specific exercises. Treatments will be performed for 3 months. We will examine physical and psychological function, pain intensity, health care consumption, the ability to resume work and economic health benefits. An independent, blinded investigator will perform the measurements at baseline and 3, 6, 12 and 24 months after inclusion. The main study outcome will be improvement in neck-specific disability as measured with the Neck Disability Index. All treatments will be recorded in treatment diaries and medical records. DISCUSSION: The study findings will help improve the treatment of patients with chronic WAD. TRIALS REGISTRATION: ClinicalTrials.gov identifier: NCT01528579.

Reliability and safety of functional capacity evaluation in patients with whiplash associated disorders.

INTRODUCTION: Whiplash-associated disorders (WAD) are a burden for both individuals and society. It is recommended to evaluate patients with WAD at risk of chronification to enhance rehabilitation and promote an early return to work. In patients with low back pain (LBP), functional capacity evaluation (FCE) contributes to clinical decisions regarding fitness-for-work. FCE should have demonstrated sufficient clinimetric properties. Reliability and safety of FCE for patients with WAD is unknown. METHODS: Thirty-two participants (11 females and 21 males; mean age 39.6 years) with WAD (Grade I or II) were included. The FCE consisted of 12 tests, including material handling, hand grip strength, repetitive arm movements, static arm activities, walking speed, and a 3 min step test. Overall the FCE duration was 60 min. The test-retest interval was 7 days. Interclass correlations (model 1) (ICCs) and limits of agreement (LoA) were calculated. Safety was assessed by a Pain Response Questionnaire, observation criteria and heart rate monitoring. RESULTS: ICCs ranged between 0.57 (3 min step test) and 0.96 (short two-handed carry). LoA relative to mean performance ranged between 15 % (50 m walking test) and 57 % (lifting waist to overhead). Pain reactions after WAD FCE decreased within days. Observations and heart rate measurements fell within the safety criteria. CONCLUSIONS: The reliability of the WAD FCE was moderate in two tests, good in five tests and excellent in five tests. Safety-criteria were fulfilled. Interpretation at the patient level should be performed with care because LoA were substantial.

Further validation of a measure of injury-related injustice perceptions to identify risk for occupational disability: a prospective study of individuals with whiplash injury.

PURPOSE: Emerging evidence suggests that perceptions of injustice negatively impact return to work following whiplash injury. The Injustice Experiences Questionnaire (IEQ) is a recently developed measurement tool that may be used to assess injury-related perceptions of injustice following injury. To date, although research has supported the predictive validity of the IEQ, a clinical cut off for interpreting this measure has not been established. Increased support for the validity and clinical interpretation of the IEQ represents a first step towards identifying patients that might benefit from targeted intervention to mitigate the impact of perceived injustice. METHODS: The IEQ was completed by 103 whiplash-injured patients upon commencement and completion of a standardized multidisciplinary rehabilitation program. One year later, individuals reported on their employment activity, pain severity, and use of narcotics. A receiver operating characteristic (ROC) curve analysis was conducted to identify the post-treatment IEQ score that was optimally associated with unemployment status at the follow-up. Secondary ROC curve analyses examined IEQ scores best associated with high pain severity and narcotic use 1 year following treatment. RESULTS: Results indicated that IEQ scores significantly discriminated individuals who returned and did not return to work at the follow-up. An IEQ score of 19 optimally identified participants in terms of follow-up employment status. IEQ scores at the end of treatment also discriminated individuals with high and low pain severity ratings and narcotic use status at the follow-up. Post-treatment IEQ scores of 18 and 20 optimally identified participants who had high pain severity ratings and who were using narcotics at the follow-up, respectively. CONCLUSIONS: These results further support the validity of the IEQ and provide a guideline for its clinical interpretation in patients with persistent pain and disability following musculoskeletal injury. IEQ scores above the identified cut off may represent a barrier to work return and may warrant targeted intervention.

Validity and reliability of the perceived deficit questionnaire to assess cognitive symptoms in people with chronic whiplash-associated disorders.

OBJECTIVE: To investigate the validity and reliability of the Perceived Deficit Questionnaire (PDQ) for use in people with chronic whiplash-associated disorders. DESIGN: Cross-sectional. SETTING: Tertiary institution. PARTICIPANTS: Patients (N=105) with chronic whiplash-associated disorders and asymptomatic controls (n=50). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The 20-item PDQ inclusive of 4 sections (attention/concentration, retrospective memory, prospective memory, and organization/planning) rated on a 5-point scale. RESULTS: Internal construct validity of the PDQ was examined by Rasch analysis, confirming the appropriateness of its 5-point scale and the unidimensionality of each section after modification by eliminating 1 item each from the attention/concentration and retrospective memory sections. Preliminary evidence was also gained for external construct validity (convergent validity) of the modified PDQ by demonstrating significant (P<.05) correlations of all sections with a global measure of disability due to neck pain (the Neck Disability Index). The whiplash group demonstrated significantly (P<.05) higher scores in each section of the modified PDQ than did the control group, indicating evidence for discriminant validity. In addition, the modified PDQ demonstrated good internal consistency (Rasch-generated reliability >.8) and acceptable test-retest reliability with 1-month interval (intraclass correlation coefficients >.8). CONCLUSIONS: The modified PDQ appears to be a valid and reliable questionnaire and could be used quickly in clinical practice to gain a basic understanding of perceived cognitive symptoms in people with chronic whiplash-associated disorders.