R.A.B. Oostendorp

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.

Recognition of central sensitization in patients with musculoskeletal pain: Application of pain neurophysiology in manual therapy practice.

Central sensitization plays an important role in the pathophysiology of numerous musculoskeletal pain disorders, yet it remains unclear how manual therapists can recognize this condition. Therefore, mechanism based clinical guidelines for the recognition of central sensitization in patients with musculoskeletal pain are provided. By using our current understanding of central sensitization during the clinical assessment of patients with musculoskeletal pain, manual therapists can apply the science of nociceptive and pain processing neurophysiology to the practice of manual therapy. The diagnosis/assessment of central sensitization in individual patients with musculoskeletal pain is not straightforward, however manual therapists can use information obtained from the medical diagnosis, combined with the medical history of the patient, as well as the clinical examination and the analysis of the treatment response in order to recognize central sensitization. The clinical examination used to recognize central sensitization entails the distinction between primary and secondary hyperalgesia.

Acute low back pain: pain-related fear and pain catastrophizing influence physical performance and perceived disability.

Abstract Pain‐related fear and pain catastrophizing are associated with disability and actual performance in chronic pain patients. In acute low back pain (LBP), little is known about the prediction of actual performance or perceived disability by pain‐related fear and pain catastrophizing. This experimental, cross‐sectional study aimed at examining whether pain‐related fear and pain catastrophizing were associated with actual performance and perceived disability. Ninety six individuals with an episode of acute LBP performed a dynamic lifting task to measure actual performance. Total lifting time was used as outcome measure. The results show that pain‐related fear, as measured with the Tampa Scale for Kinesiophobia, was the strongest predictor of this physical task. Using the Roland Disability Questionnaire as a measure of perceived disability, both pain‐related fear and pain catastrophizing, as measured with the Pain Catastrophizing Scale, were significantly predictive of perceived disability and more strongly than pain intensity was. The results of the current study suggest that pain‐related fear is an important factor influencing daily activities in individuals suffering an episode of acute LBP. The study results have important clinical implications, especially in the development of preventive strategies for chronic LBP.

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.

Fear of movement/(re)injury, disability and participation in acute low back pain

Fear of movement/(re)injury and its associated avoidance behavior have shown to be strongly associated with functional disability in chronic low back pain. In acute low back pain disability, the role of pain‐related fear has received little research attention so far. Measures of pain‐related fear such as the Tampa Scale for Kinesiophobia (TSK) are increasingly being used in primary care. The aim of the present study was: (1) to further investigate the factor structure of the TSK in a population of acute low back pain (LBP) patients in primary care by means of a confirmatory factor analysis (CFA); (2) to examine the relationship between fear of movement/(re)injury and disability, as well as participation in daily and social life activities in 615 acute LBP patients seen by general practitioners and physical therapists in primary care settings; and (3) to examine whether disability mediates the association between pain‐related fear and participation. CFA, and a subsequent explorative factor analysis on the TSK revealed a two‐factor model. The factors consisted of items associated with ‘harm’, and items representing the ‘avoidance of activity’. Both constructs were significantly associated with disability and participation. Additionally, and in contrast to what is often observed in chronic pain, disability, and to a lesser degree participation, were also associated with pain intensity. Finally, the association between pain‐related fear, pain intensity and participation was indeed mediated by disability. The results suggest that early on in the development of LBP disability, the successful reduction of pain‐related fear and disability might foster increased participation in daily and social life activities.

Adjuvant physical therapy versus occupational therapy in patients with reflex sympathetic dystrophy/complex regional pain syndrome type I

OBJECTIVE To investigate the effectiveness and cost of physical therapy (PT) or occupational therapy (OT) in patients with reflex sympathetic dystrophy (RSD). DESIGN Prospective randomized controlled trial, with 1 year follow-up. SETTING Two university hospitals. PATIENTS One hundred thirty-five patients who had been suffering from RSD of one upper extremity for less than 1 year. INTERVENTIONS Patients were assigned to PT, OT, or a control group (social work). MAIN OUTCOME MEASURES Improvement in impairment level sumscore (ISS) over 1 year (Students t test). A difference of 5 ISS points between the groups was defined as being clinically relevant. Furthermore, severity of disability and handicap was measured and tested exploratively (Wilcoxon; alpha = .05), and cost-effectiveness of the groups was calculated. RESULTS PT and, to a lesser extent, OT resulted in a significant and also more rapid improvement in the ISS as compared with controls (6 and 4 ISS points, respectively). On a disability level, a positive trend was found in favor of OT. On a handicap level, no differences were found between the groups. PT had an advantage over OT regarding the cost-effectiveness ratio. CONCLUSION In different ways PT and OT each contribute to the recovery from RSD of the upper extremity.

Fear of movement/(re)injury predicting chronic disabling low back pain: a prospective inception cohort study

Study Design. Prospective inception cohort study. Objective. To investigate prospectively whether pain-related fear predicts future perceived disability and participation in patients with acute low back pain (LBP). Summary of Background Data. There are indications that fear of movement/(re)injury, as measured by the Tampa Scale for Kinesiophobia, is present early in an episode of LBP, and that it might be a predictor of future perceived disability and participation. Methods. A cohort of 555 patients with acute LBP included by general practitioners and physical therapists in primary care settings was followed for 6 months. Results. Results indicate that baseline fear of movement/(re)injury was predictive of future perceived disability and, to a lesser extent (and together with duration and radiation), of participation. Conclusions. The results suggest that interventions aimed at reducing pain-related fear in the acute stage of LBP might prevent restrictions of activity and participation because of pain, and might be a way of preventing the transition from acute to chronic LBP.

A systematic review of bio-psychosocial risk factors for an unfavourable outcome after lumbar disc surgery

The objective of this systematic review is to summarize scientific evidence concerning the predictive value of bio-psychosocial risk factors with regard to the outcome after lumbar disc surgery. Medical and psychological databases were used to locate potentially relevant articles, which resulted in the selection of 11 studies. Each of these studies has a prospective design that examined the predictive value of preoperative variables for the outcome of lumbar disc surgery. Results indicated that socio-demographic, clinical, work-related as well as psychological factors predict lumbar disc surgery outcome. Findings showed relatively consistently that a lower level of education, a higher level of preoperative pain, less work satisfaction, a longer duration of sick leave, higher levels of psychological complaints and more passive avoidance coping function as predictors of an unfavourable outcome in terms of pain, disability, work capacity, or a combination of these outcome measures. The results of this review provide preliminary opportunities to select patients at risk for an unfavourable outcome. However, further systematic and methodologically high quality research is required, particularly for those predictors that can be positively influenced by multidisciplinary interventions.

Continued disability and pain after lumbar disc surgery: the role of cognitive-behavioral factors.

Abstract Cognitive‐behavioral factors are considered important in the development of chronic disability and pain in patients with low back pain. In a prospective cohort study of 277 patients undergoing surgery for lumbosacral radicular syndrome, the predictive value of preoperatively measured cognitive‐behavioral factors (fear of movement/(re)injury, passive pain coping, and negative outcome expectancies) for disability and pain intensity at 6 weeks and 6 months after surgery was investigated, taking into account the effect of possible confounding variables. Higher levels of cognitive‐behavioral factors were found to be associated with a worse outcome at both 6 weeks and 6 months. These associations remained significant after controlling for possible confounding variables (preoperative disability and pain intensity, age, gender, educational level, duration of complaints, neurological deficits, and intake of analgesics) and pain intensity 3 days postoperatively. In multiple regression analyses, the cognitive‐behavioral factors independently predicted different outcomes. Fear of movement/(re)injury predicted more disability and more severe pain at 6 weeks and more severe pain at 6 months; passive pain‐coping strategies predicted more disability at 6 months; and negative outcome expectancies predicted more disability and more severe pain at both 6 weeks and 6 months. The findings support the potential utility of preoperative screening measures that include cognitive‐behavioral factors for predicting surgical outcome, as well as studies to examine the potential benefits of cognitive‐behavioral treatment to improve surgical outcome.

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.