Background
Whiplash injuries are among the leading injuries related to car crashes and it is important to determine the prognostic factors that predict the outcome of patients with these injuries. ...This meta-review aims to identify factors that are associated with outcome after acute whiplash injury.
Materials and methods
A systematic search for all systematic reviews on outcome prediction of acute whiplash injury was conducted across several electronic databases. The search was limited to publications in English, and there were no geographical or time of publication restrictions. Quality appraisal was conducted with A Measurement Tool to Assess Systematic Reviews.
Results
The initial search yielded 207 abstracts; of these, 195 were subsequently excluded by topic or method. Twelve systematic reviews with moderate quality were subsequently included in the analysis. Post-injury pain and disability, whiplash grades, cold hyperalgesia, post-injury anxiety, catastrophizing, compensation and legal factors, and early healthcare use were associated with continuation of pain and disability in patients with whiplash injury. Post-injury magnetic resonance imaging or radiographic findings, motor dysfunctions, or factors related to the collision were not associated with continuation of pain and disability in patients with whiplash injury. Evidence on demographic and three psychological factors and prior pain was conflicting, and there is a shortage of evidence related to the significance of genetic factors.
Conclusions
This meta-review suggests an association between initial pain and anxiety and the outcome of acute whiplash injury, and less evidence for an association with physical factors.
Level of evidence
Level 1.
Cross-sectional investigation of muscle changes in patients suffering from persistent whiplash-associated disorders (WAD).
To quantitatively compare the presence of fatty infiltrate in the cervical ...extensor musculature in a cohort of chronic whiplash patients (WAD II) and healthy control subjects across muscle and cervical segmental level.
Magnetic resonance imaging (MRI) can be regarded as the gold standard for muscle imaging; however, there is little knowledge about in vivo features of neck extensor muscles in patients suffering from persistent WAD and how fat content alters across the factors of muscle, vertebral segments, age, self-reported pain and disability, compensation status, body mass index, and duration of symptoms.
A reliable MRI measure for fatty infiltrate was performed of the cervical extensor muscles bilaterally in 113 female subjects (79 WAD, 34 healthy control; 18-45 years, 3 months to 3 years post injury). The measure was performed on all subjects for the rectus capitis posterior minor and major, multifidus, semispinalis cervicis and capitis, splenius capitis, and upper trapezius.
The WAD subjects had significantly larger amounts of fatty infiltrate for all of the cervical extensor muscles compared with healthy control subjects (all P < 0.0001). In addition, the amount of fatty infiltrate varied by both cervical level and muscle, with the rectus capitis minor/major and multifidi at C3 having the largest amount of fatty infiltrate (P < 0.0001). Intramuscular fat was independent of age, self-reported pain/disability, compensation status, body mass index, and duration of symptoms.
There is significantly greater fatty infiltration in the neck extensor muscles, especially in the deeper muscles in the upper cervical spine, in subjects with persistent WAD when compared with healthy controls. Future studies are required to investigate the relationships between muscular alterations and symptoms in patients suffering from persistent WAD.
Abstract
Individuals classified as having whiplash-associated disorder (WAD) grade II, which reflects approximately 93% of people with WAD who are commonly managed by health care professionals, ...exhibit both physical (eg, pain and disability) and psychological (eg, fear of movement, anxiety, posttraumatic stress) problems that, in approximately 50% of cases, persist beyond 3 months. There is still much ongoing debate regarding factors predictive of poor recovery. The strongest associations have been found for high initial pain and disability following whiplash injury. In addition, a growing body of evidence supports the clinical importance of characteristic features, such as disturbed nociceptive processing (eg, local or general hyperalgesia to cold and mechanical stimuli), inefficient cognitions and beliefs about pain/movement/recovery, and posttraumatic stress symptoms, in the development and maintenance of physical and psychological manifestations in individuals with WAD. For this reason, the field shifted away from single interventions that mainly follow a biomedical approach, such as exercise therapy and activity programs, to gold standard multimodal care (at least 2 distinct therapeutic modalities given by 1 or more health care professionals) that acknowledges the biopsychological nature of WAD. To date, there exist several multimodal care approaches to managing WAD; however, for most, the efficacy has been found to be rather limited. One may argue that the limited success of some approaches can be attributed to the fact that they focused mainly on rehabilitating the physical symptoms (eg, pain, disability) rather than also the associated cognitive (eg, catastrophizing) and psychological (eg, posttraumatic stress symptoms) symptoms of the condition, leaving much room for improvement. In this article, current and previous evidence is used to explain why and how a comprehensive and multimodal treatment for people with WAD—consisting of a combination of pain neuroscience education, cognition-targeted exercise therapy, and stress management—can be applied in clinical practice.
Whiplash injury is a common diagnosis and causes substantial economic burden. Numerous papers have been published to provide new insights into whiplash injury. However, so far there has not been a ...comprehensive analysis of the most influential publications on whiplash injury. This study aimed to determine the 100 most cited publications on whiplash injury and analyze their characteristics. A keyword search was conducted using the Web of Science database. The top 100 cited publications relevant to whiplash injury were gathered. The main characteristics including title, year of publication, citation, authorship, journal, country, institution, and topic were generated. The number of citations of the top 100 cited publications ranged from 82 to 777. Fifteen countries contributed the top 100 publications. Australia had the largest number of publications (26), followed by the United States (21), and Canada (12). The majority of the publications were from Europe (40) and North America (33). A total of 19 institutions and 17 authors published more than one publication. The University of Queensland (16) and the author Sterling M (7) had the leading publication record. This is the first citation analysis to identify and characterize the highest impact researches on whiplash injury. The present analysis provides the most influential studies on whiplash injury, and reveals the leading journals, counties, institutions, and authors with special contributions in this filed. The list may serve as an archive of historical development of whiplash injury and a basis for further research.
A comparative study of cervical range of motion in asymptomatic persons and those with whiplash.
To compare the primary and conjunct ranges of motion of the cervical spine in asymptomatic persons and ...those with persistent whiplash-associated disorders, and to investigate the ability of these measures of range of motion to discriminate between the groups.
Evidence that range of motion is an effective indicator of physical impairment in the cervical spine is not conclusive. Few studies have evaluated the ability to discriminate between asymptomatic persons and those with whiplash on the basis of range of motion or compared three-dimensional in vivo measures of range of motion in asymptomatic persons and those with whiplash-associated disorders.
The study participants were 89 asymptomatic volunteers (41 men, 48 women; mean age 39.2 years) and 114 patients with persistent whiplash-associated disorders (22 men, 93 women; mean age 37.2 years) referred to a whiplash research unit for assessment of their cervical region. Range of cervical motion was measured in three dimensions with a computerized, electromagnetic, motion-tracking device. The movements assessed were flexion, extension, left and right lateral flexion, and left and right rotation.
Range of motion was reduced in all primary movements in patients with persistent whiplash-associated disorder. Sagittal plane movements were proportionally the most affected. On the basis of primary and conjunct range of motion, age, and gender, 90.3% of study participants could be correctly categorized as asymptomatic or as having whiplash (sensitivity 86.2%, specificity 95.3%).
Range of motion was capable of discriminating between asymptomatic persons and those with persistent whiplash-associated disorders.
Abstract A whiplash injury can alter neck muscle function, which remains years after the injury and may explain why symptoms such as persistent pain and disability occur. There is currently limited ...knowledge about dynamic neck muscle function in chronic whiplash-associated disorders (WAD), and about the extent to which altered muscle function can improve after rehabilitation. Ultrasound can detect mechanical neck muscle function by measuring real-time deformation and deformation rate in the muscles. This method was used for five dorsal neck muscles in participants with chronic WAD versus matched controls in resistant neck rotation. We obtained real-time, non-invasive ultrasound measurements using speckle tracking, multivariate analyses, and mixed-design ANOVA analyses. The results showed altered deformation in the three deepest neck muscle layers, with less deformation area in the WAD group compared to controls in rotation to the most painful side at baseline. Participants in the WAD group performed three months of neck-specific exercises, resulting in improved deformation in the deep neck muscles in WAD and with a similar deformation pattern to controls, and the significant group differences ceased. We reveal new and important insights into the capability of ultrasound to diagnose altered neck muscle function and evaluate an exercise intervention.
A prospective randomized trial in 97 patients with a whiplash injury caused by a motor vehicle collision.
The study evaluates early active mobilization versus a standard treatment protocol and the ...importance of early versus delayed onset of treatment.
There is no compelling evidence to date on the management of acute whiplash-associated disorders. The few studies describing treatment, however, provide evidence to support the recommendation that an active treatment in the acute stage is preferable to rest and a soft collar in most patients.
Patients were randomized to four groups. Active versus standard treatment and early (within 96 hours) versus delayed (after 2 weeks) treatment. Measures of range of motion and pain were registered initially and at 6 months.
Eighty-eight patients (91%) could be followed up at 6 months. Active treatment reduced pain more than standard treatment (P < 0.001). When type and onset of treatment were analyzed, a combined effect was seen. When active treatment was provided, it was better when administered early, and if standard treatment was provided, it was better when administered late for reduction of pain (P = 0.04) and increasing cervical flexion (P = 0.01).
In patients with whiplash-associated disorders caused by a motor vehicle collision treatment with frequently repeated active submaximal movements combined with mechanical diagnosis and therapy is more effective in reducing pain than a standard program of initial rest, recommended use of a soft collar, and gradual self-mobilization. This therapy could be performed as home exercises initiated and supported by a physiotherapist.
To explore patient perspectives of the integrated intervention (intervention arm) of a recent randomised clinical trial that found clinically relevant and sustained benefits of a physiotherapist ...delivered integrated stress inoculation training (SIT) and exercise for people with acute whiplash-associated disorders (WAD) and at risk of poor recovery.
Twelve patients from the 53 who participated in the SIT and exercise arm of a randomised controlled trial (StressModex RCT) participated in semi-structured interviews. Data were analysed using inductive thematic analysis.
Five main themes were identified: "balance between the physical and psychological components," "dealing with stress," "coping with the injury," "pain relief and return to function," and "elements enhancing therapeutic alliance."
The majority of patients found the SIT techniques to be helpful in managing stress and pain, coping with their injury, and returning to function. The patients also found the exercises useful and acknowledged the importance of both the physical and the psychological aspects of whiplash injury.
IMPLICATIONS FOR REHABILITATION
Patients with acute WAD at risk of poor recovery welcomed the inclusion of psychological strategies as part of physiotherapy treatment.
The patients nominated both the psychological (SIT) component and exercise as assisting them with their stress, pain, and recovery.
Physiotherapists could consider including strategies targeting early stress responses in their management of patients with acute WAD.
Abstract Background There is limited knowledge about the possible long‐term effects on jaw motor function after whiplash trauma. Objectives The primary aim was to evaluate integrated jaw and ...head–neck movement amplitudes during jaw function in individuals 2 years after whiplash trauma, compared to controls. The secondary aim was to evaluate changes between the acute stage and a 2‐year follow‐up in terms of jaw and head–neck movement amplitudes during jaw function. Methods This study included 28 cases exposed to a whiplash trauma 2 years earlier (13 women) and 28 controls (13 women) without previous neck trauma. Head and jaw movement amplitudes were recorded during maximal jaw opening–closing movements using an optoelectronic 3D recording system. For a subpopulation of 12 cases and 15 controls, recordings had also been performed in the acute stage after the whiplash trauma. Jaw and head movement amplitudes were analysed using linear regression with group and sex as independent variables. The subpopulation longitudinal analysis was adjusted for movement amplitudes at baseline. Results Jaw movement amplitudes were significantly associated with group (coefficient: −0.359: 95% CI: −10.70 to −1.93, p = .006) with smaller amplitudes of jaw movements for whiplash cases. Head movement amplitudes were not associated with group (coefficient: −0.051, 95% CI: −4.81 to 3.20, p = .687). In the longitudinal analysis, both jaw and head movement amplitudes showed significant associations between baseline and the 2‐year follow‐up. Conclusion The present findings indicate that the effects on jaw function in terms of jaw opening capacity in the acute stage after whiplash trauma do not spontaneously recover.
Finite Element Study.
To determine the risk of spinal cord injury with pre-existing cervical stenosis during whiplash injury.
Patients with cervical spinal stenosis are often cautioned on the ...potential increased risk of spinal cord injury (SCI) from minor trauma such as rear impact whiplash injuries. However, there is no consensus on the degree of canal stenosis or the rate of impact that predisposes to cervical SCI from minor trauma.
A previously validated three-dimensional finite element model of the human head-neck complex with the spinal cord and activated cervical musculature was used. Rear impact acceleration was applied at 1.8 m/s and 2.6 m/s. Progressive spinal stenosis was simulated at the C5-C6 segment, from 14 mm to 6 mm, at 2 mm intervals of ventral disk protrusion. Spinal cord von Mises stress and maximum principal strain were extracted and normalized with respect to the 14 mm spine at each cervical spine level from C2 to C7.
The mean segmental range of motion was 7.3 degrees at 1.8 m/s and 9.3 degrees at 2.6 m/s. Spinal cord stress above the threshold for SCI was noted at C5-C6 for 6 mm stenosis at 1.8 m/s and 2.6 m/s. The segment (C6-C7) inferior to the level of maximum stenosis also showed increasing stress and strain with higher rate of impact. For 8 mm stenosis, spinal cord stress exceeded SCI thresholds only at 2.6 m/s. Spinal cord strain above SCI thresholds were only noted in the 6 mm stenosis model at 2.6 m/s.
Increased spinal stenosis and rate of impact are associated with greater magnitude and spatial distribution of spinal cord stress and strain during whiplash injury. Spinal canal stenosis of 6 mm was associated with consistent elevation of spinal cord stress and strain above SCI thresholds at 2.6 m/s.
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