Usefulness of the DN4, S-LANSS, and painDETECT screening questionnaires to detect the neuropathic pain components in people with acute whiplash-associated disorders: a cross-sectional study.

OBJECTIVE: Although the presence of neuropathic pain (NP) components has been reported in whiplash-associated disorders (WAD), no studies have analyzed the usefulness of NP screening questionnaires to detect NP components in WAD. This study aimed to assess the usefulness of 3 NP screening tools (Douleur Neuropathique 4 [DN4], self-administered Leeds Assessment of Neuropathic Symptoms and Signs [S-LANSS], and painDETECT questionnaire [PDQ]) to detect the presence of NP components in acute WAD. DESIGN: A cross-sectional study. SETTING: Hospital. SUBJECTS: Of 188 eligible individuals, 50 people (68% women, mean age = 40.3 ± 12.5 years) with acute WAD (52% Grade III) were included. METHODS: Specialized physicians initially screened participants for the presence of NP components according to clinical practice and international recommendations. After physician assessment, blinded investigators used NP screening questionnaires (DN4, S-LANSS, and PDQ) to assess participants within 2 weeks of their accident. The diagnostic accuracy of these tools was analyzed and compared with the reference standard (physicians' assessments). RESULTS: The 3 screening questionnaires showed excellent discriminant validity (area under the curve: ≥0.8), especially S-LANSS (area under the curve: 0.9; P < .001). DN4 demonstrated the highest sensitivity (87%), followed by S-LANSS (75%), while S-LANSS and PDQ showed the highest specificity (85% and 82%, respectively). These tools demonstrated a strong correlation with the reference standard (S-LANSS: rho = 0.7; PDQ: rho = 0.62; DN4: rho = 0.7; all, P < .001). CONCLUSIONS: The DN4, S-LANSS, and PDQ show excellent discriminant validity to detect the presence of NP components in acute WAD, especially S-LANSS. Initial screening with these tools might improve management of WAD.

SEVERE MACULAR EDEMA AFTER TRAUMATIC HEAD INJURY: A CASE OF WHIPLASH MACULOPATHY.

PURPOSE: Whiplash or "traumatic" maculopathy is associated with retinal concussion, typically after the rapid acceleration/deceleration experienced in motor vehicle collisions. It has rarely been discussed in the literature, likely given the spontaneous and relatively rapid nature with which the acute macular edema resolves. A focused clinical history around the trauma and characteristic signs and structural features on retinal imaging help to distinguish this condition from other sequelae of concussive retinal injury. We report a case of whiplash maculopathy after a blunt injury to the head, which presented with unilateral and substantial macular edema in the left eye. METHODS: Case report. RESULTS: A 38-year-old man presented with complaint of a central scotoma in his left eye after a blunt trauma to his head. Comprehensive ophthalmological evaluation and retinal imaging with optical coherence tomography confirmed whiplash maculopathy, with acute macular edema in his left eye. Management with observation and close follow-up showed rapid improvement in his visual symptoms over the course of days and improvement in the severity of macular edema. One month after his injury, macular edema had resolved with only mild structural irregularities, the patient's vision had improved, and he was asymptomatic. CONCLUSION: When observing patients with significant macular edema after concussive head injury, whiplash maculopathy should be considered, regardless of a history of motor vehicle collision. The condition can present with significant asymmetry of disease. The diagnosis generally carries a good prognosis for vision; however, there are cases of persistent central visual disturbances.

Systematic diagnostics and documentation for whiplash.

Whiplash injuries are common in Denmark affecting around 16,000 new patients annually. Approximately 50% of the casualties develop chronic symptoms and 10% become disabled. Many of these patients will have contact to the healthcare system, and there is a need for structured and knowledge-based examination, diagnosis and recording of findings in all clinical settings. This review discusses which variables should be recorded in clinical practice, in order to establish the best possible foundation for a structured individualized treatment protocol of the whiplash patient.

Headache production during physical examination in patients with and without headache attributed to a whiplash injury: A case-control study.

BACKGROUND: Provocation of headache on physical examination of the neck may reflect a role of cervical structures in the presence of acute whiplash-associated headache (WAH). OBJECTIVE: To determine differences in headache provocation during physical tests in people with and without WAH after a whiplash injury. DESIGN: Case-control study. METHODS: Forty-seven people with acute whiplash-associated disorders participated, 28 with WAH. Passive accessory intervertebral movement over the tubercle of C1, the spinous processes of C2-C3 and facet joints of C0-C4, the flexion-rotation test (FRT), manual palpation of cranio-cervical muscles and the upper limb neurodynamic test + cranio-cervical flexion were assessed bilaterally twice by a blinded examiner; headache provocation was determined. Cohen's kappa and Chi-squared were determined to evaluate the intra-rater reliability of test results and differences between groups, respectively. A logistic regression model was also performed. RESULTS: Intra-rater reliability of headache provocation was good or excellent for most tests. Significant differences between groups were found with higher positive tests in WAH for the assessment of C2 (68%), the most painful side of C0-C1 (57%), C1-C2 (75%) and C2-C3 (53%), most (79%) and least (25%) restricted sides of the FRT, and manual palpation of the most painful side for the trapezius (53%), masseter (50%) and temporalis (46%) muscles. Provocation of headache during the assessment of C2 and C1-C2 on the most painful side demonstrated the highest association with WAH. CONCLUSION: Mechanical provocation of headache is more frequent in people with WAH than in those without headache soon after a whiplash injury.

Headache features in people with whiplash associated disorders: A scoping review.

BACKGROUND: Whiplash-associated headache (WAH) is one of the most common symptoms after a whiplash injury, leading to high disability. Nevertheless, the clinical characteristics of WAH have not been well described. OBJECTIVE: To synthesise the existing literature on the clinical characteristics of WAH. DESIGN: Scoping review. METHODS: The protocol for this scoping review was registered in Open Science Framework and the PRISMA extension for Scoping Reviews tool was used to ensure methodological and reporting quality. A systematic search was conducted in PubMed, EMBASE, CINAHL, Web of Science and Scopus. The search was performed by one author and the screening of articles was conducted by two authors independently. RESULTS: A total of 11363 articles were initially identified and finally 26 studies were included in the review. Headache intensity was the most commonly reported feature. Headache duration, frequency and location were also reported in at least four studies. Few studies reported physical impairments that may be related to the presence of WAH. A differentiation with concussion characteristics was only performed in eight studies. CONCLUSION: WAH appears to be of mild to moderate intensity, typically with episodes of short duration which is commonly experienced in the occipital region amongst other regions, and with a tendency to reduce in intensity over time.

Evaluation of surface electromyography of selected neck muscles during the whiplash mechanism in aware and unaware conditions due to safe punching in kickboxing.

BACKGROUND: Kickboxing is considered as a combat sport in progress, in which injuries are frequent and significant, and close injury monitoring is highly recommended. Sports injuries to the head and neck are estimated to cause 70% deaths and 20% permanent disabilities although they are much less common than those to the limbs. Whiplash mechanism involves the rapid extension (opening) and flexion (bending) of neck. The purpose of the current study was to investigate the electromyographic activity of selected muscles in the whiplash mechanism in aware and unaware conditions of the safe punching in kickboxing so that we can design special exercises. METHOD: In the present study, 24 male kickboxing athletes aged 18-40 years were selected based on a purposive sampling method. The surface electromyography (EMG) signals of muscles were recorded with and without awareness of safe punching by using a nine-channel wireless EMG device. Additionally, a nine-channel 3D inertial measurement unit (IMU, wireless,) was utilized to determine the acceleration, kinematics, and angular velocity of the subjects' head. The statistical dependent t-test was applied to compare the EMG activity of each muscle, as well as its participation ratio. RESULTS: The results of statistical analysis represented a significant increase in the EMG activity of sternocleidomastoid (p = 0.001), upper trapezius (p = 0.001) and cervical erector spinae muscles (p = 0.001), as well as the neck extension and flexion angles between the athletes aware (open eyes) and unaware (closed eyes) of the safe punching. CONCLUSION: In this study, the EMG activity of the sternocleidomastoid, upper trapezius, and cervical erector spine muscles in the aware condition was significantly different from the activity under unaware condition. In fact, the intended muscles exhibited significantly different behaviors in preventing extension and flexion in the two conditions.

Exploring sex as a moderator of other prognostic variables in whiplash associated disorder: An observational study.

BACKGROUND: Prognostic variables for assessing people with whiplash associated disorder (WAD) following a motor vehicle collision (MVC) have been evaluated in numerous studies. However, there is minimal evidence assessing how these variables may differ between males and females. QUESTION/PURPOSE: 1) To assess if the sex of a person interacts with known prognostic variables within the development of chronic WAD. 2) To determine if commonly used outcome measures used in the assessment of chronic WAD differ between sexes. METHODS: The study was a secondary analysis of an observational study with an inception cohort immediately following an MVC in an emergency department in Chicago, IL, USA. Ninety-seven adults aged 18 to 60 (mean 34.7 years old; 74% female) participated in the study. The primary outcome was long-term disability as determined by Neck Disability Index (NDI) scores at 52-weeks post-MVC. Data was collected at baseline (less than 1-week), 2, 12, 52-weeks post MVC. Hierarchal linear regression was used to determine significance (ΔF-score, p < 0.05) and R2 for each of the variables. The primary variables of interest were sex of the participant, age, baseline scores on the numeric pain rating scale (NPRS) and NDI and created interaction terms for sex x z-baseline NPRS and sex x z-NDI. RESULTS: From analysis 1, both NDI (R2 = 8.7%, p < 0.01) and NPRS (R2 = 5.7%, p = 0.02) collected at baseline predicted significant variance in NDI score at 52-weeks. The interaction term of sex x z-NPRS was also significant (R2 = 3.8%, p = 0.04). In analysis 2 the regression models when disaggregated by sex showed that baseline NDI was the significant predictor of 52-week outcome in males (R2 = 22.4%, p = 0.02) while it was the NPRS as the significant predictor in females (R2 = 10.5%, p < 0.01).

Physical testing in patients with acute whiplash-associated disorders: A within session test-retest reliability study.

BACKGROUND: People with whiplash-associated disorders (WAD) commonly present with a variety of physical impairments. However, the reliability of physical tests has not been established for patients with acute WAD. OBJECTIVE: To assess test-retest reliability of different physical tests in acute WAD. DESIGN: Intra-rater test-retest reliability. METHODS: Patients with acute WAD were recruited. Physical tests were used to evaluate articular, muscular and neural systems in two blocks of measurements separated by 10 min. Bland-Altman plots were performed to assess intrarater agreement, which included calculation of the mean difference (d) between rates, the 95% CI for d, the standard deviation of the differences and the 95% limits of agreement. Reliability was calculated via the standard error of measurement, the minimal detectable change, percent of agreement, the intraclass-correlation coefficient, and kappa coefficient. RESULTS: 47 patients participated. Test-retest reliability was excellent or good for almost all measures, except for extension ROM, ULTT for the radial nerve, and active cervical extension and upper cervical rotation performed in 4-point kneeling, which presented moderate reliability. Systematic bias was found in cervical ROM in flexion, left and right lateral-flexion, left and right rotation; left ULTT for radial nerve; right trapezius, suboccipitalis and temporalis muscles, left temporalis; C3, both sides of C1-C2, left C3-C4. CONCLUSION: The majority of physical tests achieved good or excellent test-retest intra-rater reliability when tested in patients with acute WAD. Findings must be considered with caution for those tests which demonstrated systematic bias. Additional research is warranted to evaluate inter-rater reliability.

Whiplash-associated temporomandibular disorders: a review article.

Data from the literature on temporomandibular disorder (TMD) amplification or exacerbation in whiplash injuries is quite discordant. Substantial controversy exists regarding the incidence, prevalence, proposed mechanism of injury, clinical characteristics, and prognosis of TMDs due to whiplash.This article describes this controversy and presents findings from contemporary literature.

How well can we detect cervical driven sensorimotor dysfunction in concussion patients? An observational study comparing patients with idiopathic neck pain, whiplash associated disorders and concussion.

BACKGROUND: Patients with mild traumatic brain injury (mTBI) suffer from sensorimotor impairments. Evidence is emerging that cervical spine plays an important role in mTBI, but it is not known how cervicocephalic kinaesthetic sensibility measured during dynamic unpredictable head movements and measures of position sense, cervical induced postural balance and eye movement control differ between mTBI, whiplash associated disorders (WAD) patients, idiopathic neck pain patients and healthy controls. RESEARCH QUESTION: Are cervical sensorimotor deficits present in mTBI patients and do they differ from sensorimotor deficits found in traumatic and nontraumatic neck pain patients and whether they differ from healthy controls. METHODS: Twenty idiopathic neck pain patients, 18 WAD, 17 mTBI and 20 healthy controls were enroled in the study. Frequency and velocity of centre of pressure movements were measured during parallel stance in the neutral and neck torsion positions, gain and smooth pursuit neck torsion difference of eye movements during smooth pursuit neck torsion test (SPNTT) and cervicocephalic kinaesthesia using Butterfly and head-to-neutral relocation test. RESULTS: Statistically significant differences in postural balance, both tests of cervicocephalic kinaesthesia and SPNTT were observed between healthy controls and all patient groups. No differences were observed between patient groups for SPNTT, Butterfly and head-to-neutral relocation test, but differences were present in postural balance between mTBI and both groups of patients with neck pain disorders. Differences were found in the ML direction for mTBI, but not differences were found for AP direction. SIGNIFICANCE: Results of our study show that mTBI present with similar impairment in cervical driven sensorimotor deficits as patients with neck pain disorders, but they differ from healthy individuals. Clinical practice would benefit from identifying cervical spine related sensorimotor impairments in patients with mTBI. This could enable to design more targeted prevention and rehabilitation programs to minimise cervical spine related disorders in concussion patients.

Does peripheral neuroinflammation predict chronicity following whiplash injury? Protocol for a prospective cohort study.

INTRODUCTION: Whiplash-associated disorder grade 2 (WAD2) is characterised by musculoskeletal pain/tenderness but no apparent nerve injury. However, studies have found clinical features indicative of neuropathy and neuropathic pain. These studies may indicate peripheral nerve inflammation, since preclinical neuritis models found mechanical sensitivity in inflamed, intact nociceptors. The primary aim of this study is to establish the contribution of peripheral neuroinflammation to WAD2 and its role in prognosis. Participants will be invited to participate in a sub-study investigating the contribution of cutaneous small fibre pathology to WAD2. METHODS AND ANALYSIS: 115 participants within 1 month following whiplash injury and 34 healthy control participants will be recruited and complete validated questionnaires for pain, function and psychological factors. Data collection will take place at the Universities of Sussex and Oxford, UK. Clinical examination, quantitative sensory testing and blood samples will be undertaken. MRI scans using T2-weighted and diffusion tensor images of the brachial plexus and wrist will determine nerve inflammation and nerve structural changes. Skin biopsies from a substudy will determine structural integrity of dermal and intraepidermal nerve fibres. At 6 months, we will evaluate recovery using Neck Disability Index and a self-rated global recovery question and repeat the outcome measures. Regression analysis will identify differences in MRI parameters, clinical tests and skin biopsies between participants with WAD2 and age/gender-matched controls. Linear and logistic regression analyses will assess if nerve inflammation (MRI parameters) predicts poor outcome. Mixed effects modelling will compare MRI and clinical measures between recovered and non-recovered participants over time. ETHICS AND DISSEMINATION: Ethical approval was received from London-Brighton and Sussex Research Ethics Committee (20/PR/0625) and South Central-Oxford C Ethics Committee (18/SC/0263). Written informed consent will be obtained from participants prior to participation in the study. Results will be disseminated through publications in peer-reviewed journals, presentations at national/international conferences and social media. TRIAL REGISTRATION NUMBER: NCT04940923.

[Distortion of the cervical spine : Pathophysiology, diagnostics, treatment and assessment]. / Distorsion der Halswirbelsäule : Pathophysiologie, Diagnostik, Therapie und Begutachtung.

Distortion or whiplash trauma of the cervical spine is an injury pattern associated with motor vehicle collisions and typically occurs after rear impact collisions, but is not limited to this type of collision and accident. The vast majority of these injuries are low-grade injuries according to the Quebec Task Force (QTF) classification, whereby no objective morphological correlates can be determined in clinical and radiological examinations. The prognosis is predominantly favorable and the condition is self-limiting; however, care must be taken with respect to complex courses with chronic pain and the manifestation of neuropsychiatric complaints. Due to the mechanism of the accident this injury pattern is particularly frequent in accidents associated with third party liability insurance claims. The discrepancy between subjective complaints and the presence of objective findings is a particular challenge for the assessment by the medical expert.

Exercise-induced hypoalgesia after aerobic versus neck-specific exercise in people with acute/subacute whiplash-associated disorders: protocol for a randomised controlled trial.

INTRODUCTION: A disturbance in exercise-induced hypoalgesia (EIH) has been observed in patients with chronic whiplash-associated disorders (WAD). Yet, no studies have examined whether EIH occurs in people with acute/subacute WAD. This study will determine whether EIH occurs immediately after and 24 hours after aerobic exercise (AE) and neck-specific exercise (NSE) in people with acute/subacute WAD. METHODS AND ANALYSIS: A randomised controlled trial has been designed and is reported in line with the Standard Protocol Items: Recommendations for Interventional Trials. EIH will be assessed immediately after and 24 hours after AE, NSE and a control intervention (randomly allocated). As dependent variables of the study, we will measure pressure pain thresholds measured over the region of the spinous process of C2 and C5, the muscle belly of the tibialis anterior and over the three main peripheral nerve trunks, Neck Pain Intensity, Neck-Disability Index, Pain Catastrophizing Scale, Tampa Scale Kinesiophobia-11, self-reported Leeds Assessment of Neuropathic Symptoms and Signs Scale. ETHICS APPROVAL AND DISSEMINATION: Ethical approval has been granted by the Ethics Committee from University Rey Juan Carlos (Madrid, Spain; reference number 0707202116721). The results of this study will be disseminated through presentations at scientific conferences and publication in scientific journals. TRIAL REGISTRATION NUMBER: RBR-9tqr2jt, https://ensaiosclinicos.gov.br/observador/submissao/sumario/11551.

A clinical test to assess isometric cervical strength in chronic whiplash associated disorder (WAD): a reliability study.

BACKGROUND: Cervical spine muscle weakness is well demonstrated in individuals with chronic neck pain. There is a lack of literature evaluating clinically applicable means of assessing isometric cervical strength in chronic whiplash associated disorder (WAD). This study assessed the reliability of self-resisted isometric cervical strength testing using a handheld dynamometer. The relationship between strength and neck pain-related disability and kinesiophobia was also investigated. METHODS: Twenty subjects with chronic WAD performed maximum-effort isometric cervical flexion, extension, side flexion, and rotation against a hand held dynamometer. The dynamometer was held by the subject, who provided self-resistance. Subjects completed two sessions of testing on one day with two different examiners, and one session on a subsequent day with one of the original examiners. Subjects completed the Neck Disability Index (NDI) and Tampa Scale for Kinesiophobia (TSK) prior to the first testing session. RESULTS: Intraclass correlation coefficients (ICC) for directional strength measures were fair to high (0.71-0.88 for intra-rater and 0.79-0.91 for inter-rater). Total strength (sum of all directional strengths) ICCs were high for both intra-rater (ICC = 0.91) and inter-rater (ICC = 0.94) measures. All statistical tests for ICCs demonstrated significance (α < 0.05). Agreement was assessed using Bland Altman (BA) analysis with 95% limits of agreement. BA analysis demonstrated difference scores between the two testing sessions that ranged from 3.0-17.3% and 4.5-28.5% of the mean score for intra and inter-rater measures, respectively. Most measures did not meet the a priori standard for agreement. A moderate to good inverse relationship was demonstrated between kinesiophobia (TSK score) and six out of seven strength measures (α < .05). No significant correlation was found between neck disability (NDI) and cervical strength in any direction. CONCLUSION: This study demonstrated fair to high reliability of self resisted isometric cervical strength testing in the chronic WAD population. All directional strength measures except flexion demonstrated a significant inverse relationship with kinesiophobia. No cervical strength measures were correlated with neck disability. These results support testing cervical strength in this manner to reliably assess change over time within individual patients. The value of such measurement requires further consideration given the lack of correlation between cervical strength and disability. Further research is required to establish normative values and enhance clinical utility.

Values-based cognitive behavioural therapy for the prevention of chronic whiplash associated disorders: A randomized controlled trial.

BACKGROUND: Whiplash is a common traffic-related injury with up to 50% of those affected continuing to experience symptoms one-year post-injury. Unfortunately, treatments have not proven highly effective in preventing and treating chronic symptomatology. The overall aim of this study was to test the effectiveness of an early values-based cognitive-behavioural therapeutic intervention (V-CBT) delivered within 6 months post-injury in preventing chronic symptomatology compared to wait list controls. METHODS: The study was a two-armed randomized controlled trial. Participants (n = 91) experienced pain, disability and at least one psychological risk factor (e.g. enhanced pain-catastrophizing) after a whiplash trauma no later than 6 months prior. Participants were randomized to 10 sessions of V-CBT starting 1 week (group A) or 3 months (group B) post-randomization. The primary outcome was pain-related disability, while secondary outcomes were pain intensity, neck-pain related disability, depression, anxiety, PTSD symptoms, pain-catastrophizing and kinesiophobia. These were evaluated at baseline and at 3, 6, 9 and 12 months post-randomization. RESULTS: At 3 months, group A demonstrated clinically important effects on all outcomes that were significantly better than group B (waitlist). When group B received the intervention at 6 months, they also demonstrated clinically important effects on all outcomes. However, there was a significant difference at 12 months for the primary outcome, in which group B increased their disability levels, while group A remained stable. CONCLUSIONS: While this indicates that an intervention window for early prevention of disability after whiplash injury may exist, this needs to be tested in a truly early intervention. SIGNIFICANCE: An early Values-based Cognitive Behavioural Therapeutic intervention delivered within 6 months post-injury (mean days 117) was effective in reducing pain-related disability and psychological distress compared to the control group that received the intervention later after a three months wait-list period. The effects were sustained at 12 months follow-up. The early intervention was significantly more effective in reducing pain-related disability compared to the control group, indicating that an intervention window for early prevention of disability after whiplash injury may exist.

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.

Temporal changes in pain processing after whiplash injury, based on Quantitative Sensory Testing: A systematic review.

BACKGROUND AND OBJECTIVE: After whiplash injury, some patients develop chronic whiplash-associated disorders. The exact pathophysiology of this chronification is still unclear and more knowledge is needed regarding the different post-injury phases. Therefore, studies were searched that examined temporal changes in pain processing, measured by Quantitative Sensory Testing (QST). DATABASES AND DATA TREATMENT: This systematic review searched three electronic databases (Medline, Web of Science and Embase) for articles meeting the eligibility requirements. Risk of bias was assessed according to a modified Newcastle-Ottawa Scale. RESULTS: The 12 included studies presented moderate to good methodological quality. These studies showed altered pain processing within the first month after injury and normalization within 3 months in 59%-78% of the patients. After 3 months, recovery stagnates during the following years. Thermal and widespread mechanical hyperalgesia occur already in the acute phase, but only in eventually non-recovered patients. CONCLUSIONS: Differences in pain processing between recovering and non-recovering patients can be observed already in the acute phase. Early screening for signs of altered pain processing can identify patients with high risk for chronification. These insights in temporal changes show the importance of rehabilitation in the acute phase. Future research should target to develop a standardized (bed-site) QST protocol and collect normative data which could, in relation with self-reported pain parameters, allow clinicians to identify the risk for chronification. SIGNIFICANCE: Altered pain processing is present soon after whiplash injury, but usually recovers within 3 months. Non-recovering patients show little to no improvements in the following years. Differences between recovering and non-recovering patients can be observed by Quantitative Sensory Testing already in the acute phase. Therefore, it is considered a feasible and effective tool that can contribute to the identification of high-risk patients and the prevention of chronification.

An irritability-based approach to whiplash-associated concussion rehabilitation: a case series.

BACKGROUND: An estimated 45% of concussions are reported to be related to motor vehicle collisions (MVC). However, limited research exists involving the treatment of MVC-related concussion, especially when combined with whiplash-associated disorders (WAD). Purpose: The purpose of this case series is to examine the patient response to an irritability-based approach to the physiological, cervical, and vestibulo-ocular trajectories in patients with diagnosed concussion and WAD disorder following an MVC. Case Description: Three patients clinically diagnosed by a neurologist with WAD and concussion following a rear-end MVC were evaluated and treated in an outpatient physical therapy setting. Each individual was progressed through an irritability-based treatment approach based on individual symptom presentation. Outcomes: Following therapy, 2 of 3 patients reported full resolution of subjective symptoms with a negative Vestibular Oculo-motor Screening All patients exceeded their predicted goals based on Focus on Therapeutic Outcomes score. CONCLUSION: This case series demonstrated successful treatment of all three individuals with concussion and concurrent WAD. Two of three individuals demonstrated full resolution of subjective symptoms and objective impairments at the end of treatment. Further research is warranted into the effectiveness of a multi-factorial approach to address the highly variable symptom profile of individuals with concussion and WAD.

Are Reports of Pain, Disability, Quality of Life, Psychological Factors, and Central Sensitization Related to Outcomes of Quantitative Sensory Testing in Patients Suffering From Chronic Whiplash Associated Disorders?

BACKGROUND: Chronic whiplash associated disorders (CWAD) are characterized by long-lasting symptoms of neck pain occurring after an acceleration-deceleration injury. Central sensitization (CS) has been suggested as the possible underlying mechanism for these symptoms, and is characterized by changes in the central nervous system. Besides CS, psychological factors are believed to play an important role in the experience of (chronic) pain. OBJECTIVE: Investigating the relationships between self-reported pain, disability, quality of life, psychological factors, and symptoms of CS; and electrical-based quantitative sensory testing (QST) outcomes in CWAD patients. Secondly, to investigate the differences in QST between CWAD patients and pain-free controls. METHODS: Seventy-two individuals with CWAD and 55 pain-free controls underwent electrical stimuli-based QST. Detection and pain thresholds (EPT), temporal summation (TS), and conditioned pain modulation were examined. Spearman correlation and linear mixed models analyses were performed to assess, respectively, the hypothesized associations and group differences in QST. RESULTS: The Pain Catastrophizing magnification subscale correlated with the left wrist EPT (r=-0.332; P=0.004), and the Pain Anxiety Symptom Scale-20 with the left wrist (r=-0.325; P=0.005) and ankle (r=-0.330; P=0.005) EPT. TS at the ankle correlated with the CS inventory (r=0.303; P=0.010), Short Form 36 pain subscale (r=-0.325; P=0.005), and Illness Perception Questionnaire revised consequences subscale (r=0.325; P=0.005). EPTs left (P=0.011) and right wrist (P=0.023) were lower in the CWAD group, but conditioned pain modulation and TS did not differ between groups. CONCLUSION: QST outcomes relate to psychological constructs, rather than to self-reported pain intensity and distribution. Local hyperalgesia was found in individuals with CWAD, but no differences in endogenous pain facilitation nor inhibition.

Clinimetric Properties of Self-reported Disability Scales for Whiplash: A Systematic Review for the Whiplash Core Outcome Set (CATWAD).

OBJECTIVES: A core outcomes set (COS) for whiplash-associated disorders (WADs) has been proposed to improve consistency of outcome reporting in clinical trials. Patient-reported disability was one outcome of interest within this COS. The aim of this review was to identify the most suitable tools for measuring self-reported disability in WAD based on clinimetric performance. METHODS: Database searches took place in 2 stages. The first identified outcome measures used to assess self-reported disability in WAD, and the second identified studies assessing the clinimetric properties of these outcome measures in WAD. Data on the study, population and outcome measure characteristics were extracted, along with clinimetric data. Quality and clinimetric performance were assessed in accordance with the Consensus-based Standards for the Selection of Health Status Measurement Instruments (COSMIN). RESULTS: Of 19,663 records identified in stage 1 searches, 32 were retained following stage 2 searches and screening. Both the Whiplash Disability Questionnaire and Neck Disability Index performed well in reliability (intraclass correlation coefficient=0.84 to 0.98), construct validity (74% to 82% of hypotheses accepted), and responsiveness (majority of correlations in accordance with hypotheses). Both received Category B recommendations due to a lack of evidence for content validity. DISCUSSION: This review identified the Neck Disability Index and Whiplash Disability Questionnaire as the most appropriate patient-reported outcome measures (PROMs) for assessing self-reported disability in WAD based on moderate to high-quality evidence for sufficient reliability, construct validity and responsiveness. However, the content validity of these PROMs has yet to be established in WAD, and until this is undertaken, it is not possible to recommend 1 PROM over the other for inclusion in the WAD COS.