Annika Bring

A three-group study, internet-based, face-to-face based and standard- management after acute whiplash associated disorders (WAD) – choosing the most efficient and cost-effective treatment : study protocol of a randomized controlled trial

BackgroundThe management of Whiplash Associated Disorders is one of the most complicated challenges with high expenses for the health care system and society. There are still no general guidelines or scientific documentation to unequivocally support any single treatment for acute care following whiplash injury.The main purpose of this study is to try a new behavioural medicine intervention strategy at acute phase aimed to reduce the number of patients who have persistent problems after the whiplash injury. The goal is also to identify which of three different interventions that is most cost-effective for patients with Whiplash Associated Disorders. In this study we are controlling for two factors. First, the effect of behavioural medicine approach is compared with standard care. Second, the manner in which the behavioural medicine treatment is administered, Internet or face-to-face, is evaluated in its effectiveness and cost-effectiveness.Methods/DesignThe study is a randomized, prospective, experimental three-group study with analyses of cost-effectiveness up to two-years follow-up. Internet – based programme and face-to-face group treatment programme are compared to standard-treatment only. Patient follow-ups take place three, six, twelve and 24 months, that is, short-term as well as long-term effects are evaluated. Patients will be enrolled via the emergency ward during the first week after the accident.DiscussionThis new self-help management will concentrate to those psychosocial factors that are shown to be predictive in long-term problems in Whiplash Associated Disorders, i.e. the importance of self-efficacy, fear of movement, and the significance of catastrophizing as a coping strategy for restoring and sustaining activities of daily life. Within the framework of this project, we will develop, broaden and evaluate current physical therapy treatment methods for acute Whiplash Associated Disorders. The project will contribute to the creation of a cost-effective behavioural medicine approach to management of acute Whiplash Associated Disorders. The results of this study will answer an important question; on what extent and how should these patients be treated at acute stage and how much does the best management cost.Trial registration numberCurrent Controlled Trials ISRCTN61531337

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.

Daily stressors in patients with acute whiplash associated disorders

Purpose: Stressors in acute whiplash associated disorders (WAD), as reported on a daily basis, have hitherto been neglected in research. The primary aim of this study was to describe the most stressful daily situation or event reported by individuals with acute WAD within a month of a whiplash trauma. Another aim was to describe the meaning and significance of these daily stressors, i.e. primary appraisal. Method: A descriptive design with a content analysis approach was used. 260 WAD-daily coping assessments (WAD-DCA) generated during 1 week by 51 participants with acute WAD were included in the study. Stressors were analysed using qualitative content analysis. Results: The reported stressors generated 13 categories covering a wide range of stressful situations in daily life related to (i) work, (ii) physical symptoms, (iii) feelings and cognitions, (iv) family and home responsibilities and (v) recreation. The majority of the stressors were appraised as “expected” as well as “disabling”. Most threatening stressors were related to work, driving and feelings/cognitions. Conclusions: The wide variety of stressors indicates that it is not only pain itself that influences daily life in acute WAD. Early identification of individual and situation-specific stressors gives new data regarding what bothers individuals suffering from WAD after a collision and may be helpful in understanding the coping process in relation to specific stressors and stressor appraisals. Implications for Rehabilitation Little is known about the coping process in acute WAD. In particular, what constitutes the most frequent stressors as reported on a daily basis. This study shows that individuals with acute WAD experience stressors from a wide variety of areas in everyday life, not only pain. Early identification of individual and situation-specific stressors may be helpful in understanding the coping process in relation to specific stressors and stressor appraisals in acute WAD.

Systematic review of rehabilitation in focal dystonias: classification and recommendations

Rehabilitation interventions are rarely utilized as an alternative or adjunct therapy for focal dystonias. Reasons for limited utilization are unknown, but lack of conclusive evidence of effectiveness is likely a crucial factor.

Stressful events and coping related to acute and sub-acute whiplash-associated disorders.

Abstract Purpose To describe daily stressors affecting and coping strategies employed by individuals with whiplash-associated disorders (WAD) immediately to one month (acute) and three to four months (sub-acute) after injury events using a daily coping assessment. Levels of pain, anxiety, depressed mood and activity are also compared between phases. Method A descriptive prospective design with a content analysis approach was used. Participants completed daily coping assessments for one week during both acute and sub-acute phases. Main measure was whiplash-associated disorders-daily coping assessment (WAD-DCA). Results Nine participants used words describing recovery in the sub-acute phase; 31 described stressful events during both phases. Most frequently reported stressors were related to “symptoms”, “emotions” and “occupations/studies”. These were equally reported during both phases. Cognitive coping strategies were employed more often during the sub-acute phase (p = 0.008). The only behavioral strategy that increased in prevalence over time was the “relaxed” strategy (p = 0.001). Anxiety levels declined over time (p = 0.022). Conclusion The reported stressors were largely uniform across both acute and sub-acute phases; however, the use of cognitive coping strategies increased over time. The WAD-DCA captures individual stressors and coping strategies employed during a vulnerable phase of rehabilitation and can thus provide information that is useful to clinical practice. Implications for rehabilitation The WAD-DCA provides valuable information for clinical practice when employed during early phases of whiplash-associated disorder development. Reported stressors during the acute and sub-acute phases are essentially the same, whereas cognitive coping strategies grow in prevalence over time. Tailored treatments in early phases of whip-lash associated disorders may benefit from strategies aimed at matching patient-specific stressors with contextually adapted coping strategies.

Level of physical activity in men and women with chronic stroke.

ABSTRACT Introduction: Community-dwelling stroke survivors generally show low levels of physical activity (PA). An improved understanding of the factors influencing participation in PA after stroke is imperative to improve levels of PA. Furthermore, gender differences in PA have received little attention in stroke research. The objective of this study was to examine gender differences in PA, physical functioning and psychological factors and the association between these factors and PA in men and women 1–3-year post-stroke. Materials and methods: A total of 187 community-dwelling individuals with stroke (65–85 years old, 29% women) were included in a secondary analysis based on data from a cross-sectional study. The exclusion criteria were severe cognitive or language dysfunction or dementia. The level of PA was measured by the Physical Activity Scale for the Elderly. Physical function included balance, walking speed and mobility. Psychological factors included depression, health-related quality of life and fall-related self-efficacy. Falls and fear of falling were each measured with a single question. Results: There were no significant differences in PA levels between men and women. In multiple regression analyses, walking speed (p < 0.001) was associated with PA in men, and balance (p = 0.038) was associated with PA in women. Conclusions: The results indicate that strategies to increase PA levels 1–3-year post-stroke could be improved by considering gender-specific factors.

Measuring gait – how the choice of measure can affect the statistical results and the clinical interpretation

Abstract Aims: The aim of this study was to illustrate how the choice of gait measure could affect the statistical analysis of data and the resulting clinical conclusions. Methodology: A descriptive design in which the results from different tests from 10 patients with normal pressure hydrocephalus illustrates the potential to generate different clinical conclusions. Major findings and principal conclusion: The results illustrate how the choice of measure can affect the statistical results and the clinical interpretation of a study. It is possible to have the paradoxical situation in which one group has a better walking ability if the variable speed is used but the other group has a better walking ability if the variable time is used. An important message is that the choice of measurement and the transformation of data are not primarily statistical issues. If the statistical results are to be useful for clinical decisions, the variables used must be directly related to the utility for the subjects. An understanding of the clinical relevance of different outcomes is required. The distinction between when numbers are purely descriptive and when numbers represent a valuation is subtle and difficult to comprehend.

936 COMPARISON OF DIFFERENT TREATMENT APPROACHES AFTER ACUTE WAD — STANDARD‐TREATMENT COMPARED TO BEHAVIOURAL MEDICINE INTERVENTIONS: A RANDOMIZED GROUP STUDY

Comparison of different treatment approaches after acute WAD – Standard-treatment compared to behavioural medicine interventions : A randomized group study