G.G.M. Scholten-Peeters

Prognostic factors of whiplash-associated disorders: a systematic review of prospective cohort studies

&NA; We present a systematic review of prospective cohort studies. Our aim was to assess prognostic factors associated with functional recovery of patients with whiplash injuries. The failure of some patients to recover following whiplash injury has been linked to a number of prognostic factors. However, there is some inconsistency in the literature and there have been no systematic attempts to analyze the level of evidence for prognostic factors in whiplash recovery. Studies were selected for inclusion following a comprehensive search of MEDLINE, EMBASE, CINAHL, the database of the Dutch Institute of Allied Health Professions up until April 2002 and hand searches of the reference lists of retrieved articles. Studies were selected if the objective was to assess prognostic factors associated with recovery; the design was a prospective cohort study; the study population included at least an identifiable subgroup of patients suffering from a whiplash injury; and the paper was a full report published in English, German, French or Dutch. The methodological quality was independently assessed by two reviewers. A study was considered to be of ‘high quality’ if it satisfied at least 50% of the maximum available quality score. Two independent reviewers extracted data and the association between prognostic factors and functional recovery was calculated in terms of risk estimates. Fifty papers reporting on twenty‐nine cohorts were included in the review. Twelve cohorts were considered to be of ‘high quality’. Because of the heterogeneity of patient selection, type of prognostic factors and outcome measures, no statistical pooling was able to be performed. Strong evidence was found for high initial pain intensity being an adverse prognostic factor. There was strong evidence that for older age, female gender, high acute psychological response, angular deformity of the neck, rear‐end collision, and compensation not being associated with an adverse prognosis. Several physical (e.g. restricted range of motion, high number of complaints), psychosocial (previous psychological problems), neuropsychosocial factors (nervousness), crash related (e.g. accident on highway) and treatment related factors (need to resume physiotherapy) showed limited prognostic value for functional recovery. High initial pain intensity is an important predictor for delayed functional recovery for patients with whiplash injury. Often mentioned factors like age, gender and compensation do not seem to be of prognostic value. Scientific information about prognostic factors can guide physicians or other care providers to direct treatment and to probably prevent chronicity.

Prognostic factors for poor recovery in acute whiplash patients

&NA; The objective of our prospective inception cohort study was to identify prognostic factors for poor recovery in patients with whiplash‐associated disorders grade 1 or 2 who still had neck pain and accompanying complaints 2 weeks after the accident. The study was carried out in a primary health care setting in The Netherlands and included 125 patients. The primary outcome measure was functional recovery defined in terms of neck pain intensity or work disability without medication use. The secondary outcome measures included neck pain intensity, work disability and sick leave. The outcomes were assessed at 4, 12 and 52 weeks after the accident. Prognostic factors were identified by logistic regression analyses. One year after the injury, 64% of the patients were recovered. Factors related to poor recovery were female gender, a low level of education, high initial neck pain, more severe disability, higher levels of somatisation and sleep difficulties. Neck pain intensity and work disability proved to be the most consistent predictors for poor recovery. The accuracy of the predictions of the prognostic models was high, meaning that the models adequately distinguished patients with poor recovery from those regarded as recovered. These findings add to the growing body of evidence, indicating that socio‐demographic, physical and psychological factors affect short‐ and long‐term outcome after whiplash injury. Our findings also indicate that care providers can easily identify patients at risk for poor recovery with a visual analogue scale for initial pain intensity and work‐related activities.

Clinical practice guideline for the physiotherapy of patients with whiplash-associated disorders.

Study Design. A clinical practice guideline. Objectives. To assist physiotherapists in decision making and to improve the efficacy and uniformity of care for patients with whiplash-associated disorders Grades I and II. Summary of Background Data. Whiplash constitutes a considerable problem in health care. Many interventions are used in physiotherapy practice, despite increasing evidence for the use of active interventions. There is still no clinical practice guideline for the management of patients with whiplash-associated disorders. Method of Development. A computerized literature search of Medline, Cinahl, Cochrane Controlled Trial Register, Cochrane Database of Systematic Reviews, and the Database of the Dutch National Institute of Allied Health Professions was performed to search for information about the diagnostic process and the therapeutic process in whiplash patients. When no evidence was available, consensus between experts was achieved to develop the guideline. Practicing physiotherapists reviewed the clinical applicability and feasibility of the guideline, and their comments were used to improve it. Recommendations. The diagnostic process consists of systematic history taking and a physical examination supported by reliable and valid assessment tools to document symptoms and functional disabilities. The primary goals of treatment are a quick return to normal activities and the prevention of chronicity. Active interventions such as education, exercise therapy, training of functions, and activities are recommended according to the length of time since the accident and the rate of recovery. The biopsychosocial model is used to address the consequences of whiplash trauma. Conclusions. Scientific evidence for the diagnosis and physiotherapeutic management of whiplash is sparse; therefore, consensus is used in different parts of the guideline. The guideline reflects the current state of knowledge of the effective and appropriate physiotherapy in whiplash patients. More and better research is necessary to validate this guideline in the future.

Education by general practitioners or education and exercises by physiotherapists for patients with whiplash-associated disorders? A randomized clinical trial.

Study Design. Randomized clinical trial. Objective. To compare the effectiveness of education and advice given by general practitioners (GPs) with education, advice, and active exercise therapy given by physiotherapists (PTs) for patients with whiplash-associated disorders. Summary of Background Data. Available evidence from systematic reviews has indicated beneficial effects for active interventions in patients with whiplash-associated disorders. However, it remained unclear which kind of active treatment was most effective. Methods. Whiplash patients with symptoms or disabilities at 2 weeks after accident were recruited in primary care. Eligible patients still having symptoms or disabilities at 4 weeks were randomly allocated to GP care or physiotherapy. GPs and PTs treated patients according to a dynamic multimodal treatment protocol primarily aimed to increase activities and influence unfavorable psychosocial factors for recovery. We trained all health care providers about the characteristics of the whiplash problem, available evidence regarding prognosis and treatment, and protocol of the interventions. The content of the information provided to patients during treatment depended on the treatment goals set by the GPs or PTs. Also, the type of exercises chosen by the PTs depended on the treatment goals, and it was not explicitly necessary that exercise therapy was provided in all patients. Primary outcome measures included neck pain intensity, headache intensity, and work activities. Furthermore, an independent blinded assessor measured functional recovery, cervical range of motion, disability, housekeeping and social activities, fear of movement, coping, and general health status. We assessed outcomes at 8, 12, 26, and 52 weeks after the accident. Results. A total of 80 patients were randomized to either GP care (n = 42) or physiotherapy (n = 38). At 12 and 52 weeks, no significant differences were found concerning the primary outcome measures. At 12 weeks, physiotherapy was significantly more effective than GP care for improving 1 of the measures of cervical range of motion (adjusted mean difference 12.3°; 95% confidence interval [CI] 2.7–21.9). Long-term differences between the groups favored GP care but were statistically significant only for some secondary outcome measures, including functional recovery (adjusted relative risk 2.3; 95% CI 1.0–5.0), coping (adjusted mean difference 1.7 points; 95% CI 0.2–3.3), and physical functioning (adjusted mean difference 8.9 points; 95% CI 0.6–17.2). Conclusions. We found no significant differences for the primary outcome measures. Treatment by GPs and PTs were of similar effectiveness. The long-term effects of GP care seem to be better compared to physiotherapy for functional recovery, coping, and physical functioning. Physiotherapy seems to be more effective than GP care on cervical range of motion at short-term follow-up.

Lack of uniform diagnostic criteria for cervical radiculopathy in conservative intervention studies: a systematic review

PurposeCervical radiculopathy (CR) is a common diagnosis. It is unclear if intervention studies use uniform definitions and criteria for patient selection. Our objective was to assess the uniformity of diagnostic criteria and definitions used in intervention studies to select patients with CR.MethodsWe electronically searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE and CINAHL. Studies were included when evaluating conservative interventions in randomised clinical trials (RCTs) in patients with CR. Selection criteria and definitions for patients with CR were extracted and evaluated on their uniformity.ResultsThirteen RCTs were included. Pain was used as an inclusion criterion in 11 studies. Inclusion based on the duration and location of pain varied between studies. Five studies used sensory symptoms in the arm as inclusion criterion. Four studies used cervical range of motion and motor disturbances as inclusion criteria, while reflex changes were used in two studies. Three studies included patients with a positive Spurling’s test and two studies used it within a cluster of provocation tests.ConclusionsCriteria used to select patients with CR vary widely between different intervention studies. Selection criteria and test methods used are poorly described. There is consensus on the presence of pain, but not on the exact location of pain.

Randomized clinical trial of conservative treatment for patients with whiplash-associated disorders: Considerations for the design and dynamic treatment protocol

BACKGROUND Whiplash concerns a considerable problem to health care. Available evidence from systematic reviews indicates beneficial effects of active interventions for patients with whiplash injury. In order to evaluate whether a general practitioner or a physiotherapist should provide these active interventions, we have designed a randomized clinical trial. OBJECTIVE The purpose of this article is to present the design of the trial and to provide transparency into the dynamic treatment protocol used. PATIENTS Patients with whiplash-associated disorders grade I and II who still have symptoms and disabilities 4 weeks after the accident. INTERVENTIONS A dynamic treatment protocol consisting of 4 different subprotocols. The primary aim is to increase their activities and to improve their quality of life. Content and intensity of treatment are described. Outcome measures The primary outcome measures are pain and disability. The short-term effects are measured at 12 weeks and long-term effects at 1 year after the trauma. CONCLUSION To date, generally the effect of one intervention compared to another intervention has been examined. In our opinion, this cannot be considered as usual care for physiotherapy or general practice. Therefore, a dynamic treatment protocol has been developed to structure the black box of usual physiotherapy and general practice treatment. The results of this trial will be available in 0.5 year.

Validity of the Thessaly Test in Evaluating Meniscal Tears Compared With Arthroscopy: A Diagnostic Accuracy Study

STUDY DESIGN Diagnostic accuracy study. OBJECTIVE To evaluate the diagnostic accuracy of the Thessaly test compared with an arthroscopic examination in patients with suspected meniscal tears. BACKGROUND The Thessaly test was introduced to improve the diagnostic accuracy of the clinical examination in detecting meniscal tears. This test appears to be a valuable alternative to other meniscal clinical tests usually performed, but additional diagnostic accuracy data are required. METHODS Patients with suspected meniscal tears, referred to a hospital for arthroscopic surgery, were eligible. The Thessaly test alone and the combination of the Thessaly and McMurray tests were considered as index tests, and arthroscopy was used as the reference test. Experienced physical therapists performed the Thessaly test at 20° of flexion and the McMurray test for both knees. The physical therapist was blinded to patient information, the affected knee, and the results from possible earlier diagnostic imaging. An orthopaedic surgeon blinded to the clinical test results from the physical therapist performed the arthroscopic examination. RESULTS A total of 593 patients were included, of whom 493 (83%) had a meniscal tear, as determined by the arthroscopic examination. The Thessaly test had a sensitivity of 64% (95% confidence interval [CI]: 60%, 68%), specificity of 53% (95% CI: 43%, 63%), positive predictive value of 87% (95% CI: 83%, 90%), negative predictive value of 23% (95% CI: 18%, 29%), and positive and negative likelihood ratios of 1.37 (95% CI: 1.10, 1.70) and 0.68 (95% CI: 0.59, 0.78), respectively. The combination of positive Thessaly and McMurray tests showed a sensitivity of 53% and specificity of 62%. CONCLUSION The results of the Thessaly test alone or combined with the McMurray test do not seem useful to determine the presence or absence of meniscal tears. LEVEL OF EVIDENCE Diagnosis, level 2b.

Diagnostic accuracy of premanipulative vertebrobasilar insufficiency tests: A systematic review

STUDY DESIGN A systematic review of diagnostic accuracy studies. OBJECTIVE To evaluate the diagnostic accuracy of the premanipulative vertebrobasilar insufficiency (VBI) tests. SUMMARY OF BACKGROUND DATA The aim of premanipulative vertebrobasilar testing is to evaluate the adequacy of blood supply to the brain, by compressing the vertebral artery and examining for the onset of signs and symptoms of cerebrovascular ischemia. Although clinicians consider pre-manipulative testing important before applying spinal manipulations, the diagnostic accuracy has not been systematically reviewed. METHODS A search was made in PUBMED, CINAHL and EMBASE databases from their date of inception until 2nd May 2012. Studies were included if they compared a VBI test with a reference test, and sensitivity and specificity were reported or could be calculated. The methodological quality of the studies was evaluated using QUADAS. Agreement between reviewers was calculated and expressed as a percentage and quantified by kappa statistics. RESULTS Of the 1677 potential citations only 4 studies were included, all of questionable quality. Sensitivity was low and ranged from 0 to 57%, specificity from 67 to 100%, positive predictive value from 0% to 100%, and negative predictive value from 26 to 96%. The positive likelihood ratio ranged from 0.22 to 83.25 and the negative likelihood ratio from 0.44 to 1.40. CONCLUSION Based on this systematic review of only 4 studies it was not possible to draw firm conclusions about the diagnostic accuracy of premanipulative tests. However, data on diagnostic accuracy indicate that the premanipulative tests do not seem valid in the premanipulative screening procedure. A surplus value for premanipulative tests seems unlikely.

Prevalence, incidence and course of lower extremity injuries in runners during a 12-month follow-up period.

To describe the incidence, 12‐month prevalence, and course of lower extremity injuries that occurred during and after the Amgen Singelloop Breda in 2009. The design was based on a prospective cohort study with a population‐based setting. In total, 3605 registered runners received a web‐based baseline questionnaire of which 713 participants completed and returned it. Information about previous injuries, training programs, and demographic data were gathered at baseline. Site and intensity of running injuries and occurrence of new injuries were obtained from five post‐race questionnaires. The main outcome measurement was lower extremity injury. The incidence of running injuries during the Amgen Singelloop Breda itself was 7.8%; most of these injuries occurred in the calf muscle, thigh, and knee joint. Three‐month incidence of injuries during follow‐up varied between 13.5% and 16.3%. During the 12‐month follow‐up period, 277 new running injuries were reported. Runners who ran more than 10 km are more susceptible to injury in comparison with runners who ran short distances (10 km or less). In total, 69.1% of running injuries resolves within 10 days. Running injuries are very common among recreational runners. Injuries mostly occur in the knee, thigh, and calf muscle.

Diagnostic Accuracy of Upper Cervical Spine Instability Tests: A Systematic Review

Background Patients with neck pain, headache, torticollis, or neurological signs should be screened carefully for upper cervical spine instability, as these conditions are “red flags” for applying physical therapy interventions. However, little is known about the diagnostic accuracy of upper cervical spine instability tests. Purpose The purpose of this study was to evaluate the diagnostic accuracy of upper cervical spine instability screening tests in patients or people who are healthy. Data Sources PubMed, CINAHL, EMBASE, and RECAL Legacy databases were searched from their inception through October 2012. Study Selection Studies were included that assessed the diagnostic accuracy of upper cervical instability screening tests in patients or people who are healthy and in which sensitivity and specificity were reported or could be calculated using a 2 × 2 table. Data Extraction and Quality Assessment Two reviewers independently performed data extraction and the methodological quality assessment using the QUADAS-2. Data Synthesis Depending on heterogeneity, statistical pooling was performed. All diagnostic parameters (sensitivity, specificity, predictive values, and likelihood ratios) were recalculated, if possible. Results Five studies were included in this systematic review. Statistical pooling was not possible due to clinical and statistical heterogeneity. Specificity of 7 tests was sufficient, but sensitivity varied. Predictive values were variable. Likelihood ratios also were variable, and, in most cases, the confidence intervals were large. Limitations The included studies suffered from several biases. None of the studies evaluated upper cervical spine instability tests in patients receiving primary care. Conclusions The membranes tests had the best diagnostic accuracy, but their applicability as a test for diagnosing upper cervical spine instability in primary care has yet to be confirmed.