Les Barnsley

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.

Long term outcomes of inversion ankle injuries

Background: Ankle sprains are common sporting injuries generally believed to be benign and self limiting. However, some studies report a significant proportion of patients with ankle sprains having persistent symptoms for months or even years. Aims: To determine the proportion of patients presenting to an Australian sports medicine clinic who had long term symptoms after a sports related inversion ankle sprain. Methods: Consecutive patients referred to the NSW Institute of Sports Medicine from August 1999 to August 2002 with inversion ankle sprain were included. Exclusion criteria were fracture, ankle surgery, or concurrent lower limb problems. A control group, matched for age and sex, was recruited from patients attending the clinic for upper limb injuries in the same time period. Current ankle symptoms, ankle related disability, and current health status were ascertained through a structured telephone interview. Results: Nineteen patients and matched controls were recruited and interviewed. The mean age in the ankle group was 20 (range 13–28). Twelve patients (63%) were male. Average follow up was 29 months. Only five (26%) ankle injured patients had recovered fully, with no pain, swelling, giving way, or weakness at follow up. None of the control group reported these symptoms (p<0.0001). Assessments of quality of life using short form-36 questionnaires (SF36) revealed a difference in the general health subscale between the two groups, favouring the control arm (p<0.05). There were no significant differences in the other SF36 subscales between the two groups. Conclusion: Most patients who sustained an inversion ankle injury at sport and who were subsequently referred to a sports medicine clinic had persistent symptoms for at least two years after their injury. This reinforces the importance of prevention and early effective treatment.

Clinical skills in junior medical officers: a comparison of self‐reported confidence and observed competence

Background  The intern year is a key time for the acquisition of clinical skills, both procedural and cognitive. We have previously described self‐reported confidence and experience for a number of clinical skills, finding high levels of confidence among Australian junior doctors. This has never been correlated with an objective measure of competence.

Hypermobility and sports injuries in junior netball players

Objective: To evaluate the incidence of hypermobility in young female netball players and to determine the relation between hypermobility, previous injuries sustained in netball or other sports, and the use of protective equipment. Methods: Under 16 year old female netball players from a local suburban netball association were assessed for joint hypermobility using the validated Beighton score (0–9, with higher scores indicating increasing hypermobility). Player profiles and details of sporting injuries, both netball and non-netball, and the use of protective equipment were gathered by means of a self completed questionnaire. Parental and child consent was obtained. Results: Two hundred netball players were recruited for the study. Twenty one percent of the subjects with a Beighton hypermobility score of 0–2 had sustained previous netball injuries compared with 37% with Beighton scores of 3–4, and 43% with scores of 5–9. These differences were significant (p<0.025). Injuries were most common in the ankle (42%), knee (27%), and fingers (15%). Thirty nine players (19%) wore protective equipment, and within this group 30 (77%) had sustained previous injuries. No association was detected between hypermobile joints and non-netball sporting injuries. Conclusions: In this study hypermobility was significantly associated with an increased prevalence of injuries in junior netball players. A targeted interventional approach may help to reduce injuries in this susceptible group.

An Evidence-Based Approach to the Treatment of Acute Whiplash Injury

This review has two components. The first is a selective, narrative background of some of the issues surrounding acute whiplash. The latter part is a more systematic review of the available evidence concerning the management of acute whiplash as it stood in March 2001.

Cutaneous vasculitis associated with infliximab in the treatment of rheumatoid arthritis

A 62-year-old woman was diagnosed with seropositive rheumatoid arthritis (RA) in 1984. At diagnosis, antinuclear antibody (ANA) titre was 1:40. There were no antibodies to double-stranded DNA (dsDNA) or extractable nuclear antigens (ENA). The erythrocyte sedimentation rate (ESR) was 43 mm/h. Initial therapy was i.m. gold and prednisone. Six years later, methotrexate (MTX) was added for disease control. Intercurrent medical problems included pernicious anaemia, hypertension and hypercholesterolaemia. Her other medications were folic acid, enalapril, simvastatin, alendronate, calcium and i.m. vitamin B 12 . In 2002, she had ongoing active disease. She was enrolled in an infliximab study (full report pending). All patients received infliximab, at varying doses, for the second 6 months of the study. At study entry, she had a positive Mantoux test. Pyridoxine and isoniazid were commenced for chemoprophylaxis against reactivation of possible latent tuberculosis. In March 2003, she received either 3 mg/kg or 10 mg/kg of infliximab by infusion in addition to her usual therapy. Further infusions were programmed for 4 weeks, 8 weeks and 8 weekly thereafter. The patient experienced mild infusion reactions which settled with anti-histamines and her RA improved significantly. In May 2003, she was admitted with a 3-day history of new onset bilateral lower limb rash and swelling, 2 days of mild nausea, vomiting and diarrhoea, and a 1-day history of throbbing frontal headaches. Examination revealed a diffuse palpable, purpuric rash extending from ankles to shins, with associated pitting oedema. (Fig. 1) Livedo reticularis was noted across her back and anterior thighs. There was no active synovitis. She was febrile to 38.3 ° C. The remainder of her examination was unremarkable. Full blood count and serum biochemistry were normal, ESR 64 mm/h, C-reactive protein 108 mg/L, ANA titre 1:640 (homogeneous pattern), dsDNA titre 14 kIU/L (0–7 kIU/L), no anti-ENA or anti-histone antibodies, normal complement levels, positive for antibodies to anti-neutrophil cytoplasm but negative for antibodies to proteinase-3 and myeloperoxidase, ferritin 540 mmol/L (0–200), polyclonal hypergammaglobulinaemia on serum electrophoresis, and negative hepatitis B and C serology. Urinalysis showed proteinuria <0.06 g/L (longstanding) with negative urine cultures. Blood cultures were negative. Chest X-ray, electrocardiogram and trans-thoracic echocardiogram were normal. The gastrointestinal symptoms settled with symptomatic management. Skin biopsy confirmed leucocytoclastic vasculitis (LCV). Direct immunofluorescence was negative. In light of the raised ANA, antidsDNA antibody, elevated inflammatory markers, fever, vasculitic rash and livedo reticularis, LCV due to a lupus-like syndrome was diagnosed. Infliximab, isoniazid and pyridoxine were ceased. MTX and gold were withheld and the prednisone dose increased. One month post-discharge, the cutaneous vasculitis had resolved completely (ANA titre 1:160 and antidsDNA antibody titre 7). Gold and then MTX were reintroduced with impunity. Prednisone was weaned. The patient remains well.

Attitudes of doctors toward community medicine: Differences between graduates from innovative and traditional medical schools

Background: As the importance of community medicine in undergraduate medical curricula is increasingly emphasized, it is important to measure the long‐term impact of these courses on graduates’ attitudes towards community medicine. Purpose: To compare the attitudes of general practitioners from a community‐oriented medical school with those from a traditional undergraduate background. Methods: We developed a valid and reliable 35 item questionnaire assessing six key areas of community medicine. Results: We found general practitioners from the community‐oriented medical school had more positive attitudes towards community medicine overall, and towards holistic and collaborative care. General practitioners, who were younger and female, had more positive attitudes on some dimensions. Conclusions: This study provides some evidence to support the notion that medical educators have the potential to reinforce, or shape, the attitudes that students bring to medical school.

Whiplash after motor vehicle crashes

Best approach mirrors that for acute low back pain—education, exercise, and return to usual activities

EVOLVE: The Australian Rheumatology Association's 'top five' list of investigations and interventions doctors and patients should question

The EVOLVE (evaluating evidence, enhancing efficiencies) initiative aims to drive safer, higher‐quality patient care through identifying and reducing low‐value practices.

Radiological Imaging in Arthritis: Current Status and Limitations

Knowledge of the rheumatic disease has grown immeasurably since the early twentieth century, changing the criteria and classification of the diseases. The rheumatic diseases have broadly been classified according to positivity for rheumatoid factor. The immunological and genetic basis of these diseases has been refined, and the pathophysiology elucidated to a large extent. These changes have been reflected in the advances in imaging of the rheumatic diseases, particularly with the increasing adoption of MRI. MRI criteria have become accepted as part of the early disease classification, allowing the commencement of therapy before the radiological or clinical evidence of disease manifests, thus allowing treatment at a potentially reversible stage. The evidence for these changes in the paradigm of imaging the rheumatic disease will be presented and assessed together with potential shortcomings.