Ross Darnell

Physical and psychological factors predict outcome following whiplash injury.

&NA; Predictors of outcome following whiplash injury are limited to socio‐demographic and symptomatic factors, which are not readily amenable to secondary and tertiary intervention. This prospective study investigated the predictive capacity of early measures of physical and psychological impairment on pain and disability 6 months following whiplash injury. Motor function (ROM; kinaesthetic sense; activity of the superficial neck flexors (EMG) during cranio‐cervical flexion), quantitative sensory testing (pressure, thermal pain thresholds, brachial plexus provocation test), sympathetic vasoconstrictor responses and psychological distress (GHQ‐28, TSK, IES) were measured in 76 acute whiplash participants. The outcome measure was Neck Disability Index scores at 6 months. Stepwise regression analysis was used to predict the final NDI score. Logistic regression analyses predicted membership to one of the three groups based on final NDI scores (<8 recovered, 10–28 mild pain and disability, >30 moderate/severe pain and disability). Higher initial NDI score (1.007–1.12), older age (1.03–1.23), cold hyperalgesia (1.05–1.58), and acute post‐traumatic stress (1.03–1.2) predicted membership to the moderate/severe group. Additional variables associated with higher NDI scores at 6 months on stepwise regression analysis were: ROM loss and diminished sympathetic reactivity. Higher initial NDI score (1.03–1.28), greater psychological distress (GHQ‐28) (1.04–1.28) and decreased ROM (1.03–1.25) predicted subjects with persistent milder symptoms from those who fully recovered. These results demonstrate that both physical and psychological factors play a role in recovery or non‐recovery from whiplash injury. This may assist in the development of more relevant treatment methods for acute whiplash.

development of motor system dysfunction following whiplash injury

&NA; Dysfunction in the motor system is a feature of persistent whiplash associated disorders. Little is known about motor dysfunction in the early stages following injury and of its progress in those persons who recover and those who develop persistent symptoms. This study measured prospectively, motor system function (cervical range of movement (ROM), joint position error (JPE) and activity of the superficial neck flexors (EMG) during a test of cranio‐cervical flexion) as well as a measure of fear of re‐injury (TAMPA) in 66 whiplash subjects within 1 month of injury and then 2 and 3 months post injury. Subjects were classified at 3 months post injury using scores on the neck disability index: recovered (<8), mild pain and disability (10–28) or moderate/severe pain and disability (>30). Motor system function was also measured in 20 control subjects. All whiplash groups demonstrated decreased ROM and increased EMG (compared to controls) at 1 month post injury. This deficit persisted in the group with moderate/severe symptoms but returned to within normal limits in those who had recovered or reported persistent mild pain at 3 months. Increased EMG persisted for 3 months in all whiplash groups. Only the moderate/severe group showed greater JPE, within 1 month of injury, which remained unchanged at 3 months. TAMPA scores of the moderate/severe group were higher than those of the other two groups. The differences in TAMPA did not impact on ROM, EMG or JPE. This study identifies, for the first time, deficits in the motor system, as early as 1 month post whiplash injury, that persisted not only in those reporting moderate/severe symptoms at 3 months but also in subjects who recovered and those with persistent mild symptoms.

Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial

Objective To compare the clinical efficacy of foot orthoses in the management of patellofemoral pain syndrome with flat inserts or physiotherapy, and to investigate the effectiveness of foot orthoses plus physiotherapy. Design Prospective, single blind, randomised clinical trial. Setting Single centre trial within a community setting in Brisbane, Australia. Participants 179 participants (100 women) aged 18 to 40 years, with a clinical diagnosis of patellofemoral pain syndrome of greater than six weeks’ duration, who had no previous treatment with foot orthoses or physiotherapy in the preceding 12 months. Interventions Six weeks of physiotherapist intervention with off the shelf foot orthoses, flat inserts, multimodal physiotherapy (patellofemoral joint mobilisation, patellar taping, quadriceps muscle retraining, and education), or foot orthoses plus physiotherapy. Main outcome measures Global improvement, severity of usual and worst pain over the preceding week, anterior knee pain scale, and functional index questionnaire measured at 6, 12, and 52 weeks. Results Foot orthoses produced improvement beyond that of flat inserts in the short term, notably at six weeks (relative risk reduction 0.66, 99% confidence interval 0.05 to 1.17; NNT 4 (99% confidence interval 2 to 51). No significant differences were found between foot orthoses and physiotherapy, or between physiotherapy and physiotherapy plus orthoses. All groups showed clinically meaningful improvements in primary outcomes over 52 weeks. Conclusion While foot orthoses are superior to flat inserts according to participants’ overall perception, they are similar to physiotherapy and do not improve outcomes when added to physiotherapy in the short term management of patellofemoral pain. Given the long term improvement observed in all treatment groups, general practitioners may seek to hasten recovery by prescribing prefabricated orthoses. Trial registration Australian Clinical Trials Registry ACTRN012605000463673 and ClinicalTrials.gov NCT00118521.

Fatty Infiltration in the Cervical Extensor Muscles in Persistent Whiplash-Associated Disorders: A Magnetic Resonance Imaging Analysis

Study Design. Cross-sectional investigation of muscle changes in patients suffering from persistent whiplash-associated disorders (WAD). Objectives. To quantitatively compare the presence of fatty infiltrate in the cervical extensor musculature in a cohort of chronic whiplash patients (WAD II) and healthy control subjects across muscle and cervical segmental level. Summary of Background Data. Magnetic resonance imaging (MRI) can be regarded as the gold standard for muscle imaging; however, there is little knowledge about in vivo features of neck extensor muscles in patients suffering from persistent WAD and how fat content alters across the factors of muscle, vertebral segments, age, self-reported pain and disability, compensation status, body mass index, and duration of symptoms. Methods. A reliable MRI measure for fatty infiltrate was performed of the cervical extensor muscles bilaterally in 113 female subjects (79 WAD, 34 healthy control; 18–45 years, 3 months to 3 years post injury). The measure was performed on all subjects for the rectus capitis posterior minor and major, multifidus, semispinalis cervicis and capitis, splenius capitis, and upper trapezius. Results. The WAD subjects had significantly larger amounts of fatty infiltrate for all of the cervical extensor muscles compared with healthy control subjects (all P < 0.0001). In addition, the amount of fatty infiltrate varied by both cervical level and muscle, with the rectus capitis minor/major and multifidi at C3 having the largest amount of fatty infiltrate (P < 0.0001). Intramuscular fat was independent of age, self-reported pain/disability, compensation status, body mass index, and duration of symptoms. Conclusion. There is significantly greater fatty infiltration in the neck extensor muscles, especially in the deeper muscles in the upper cervical spine, in subjects with persistent WAD when compared with healthy controls. Future studies are required to investigate the relationships between muscular alterations and symptoms in patients suffering from persistent WAD.

Prevalence of hypertension in children after early repair of coarctation of the aorta: a cohort study using casual and 24 hour blood pressure measurement

Objective: To study the prevalence of hypertension in a cohort of patients using the current strategy of repair in early childhood. Patients: The cohort of patients with coarctation of the aorta born between 1983 and 1992. Intervention: Casual (mean of three resting readings) and 24 hour blood pressure were measured in 119 children and compared with data from 1034 normal controls. The arch repair and left ventricular parameters were assessed using Doppler echocardiography. Results: Median ages at first intervention and at blood pressure measurement were 0.2 years (interquartile range 0.04–2.0) and 12.0 years (9.0–14.5), respectively. Doppler velocity in the descending aorta was significantly associated with blood pressure (r = 0.28, p = 0.002 for casual systolic blood pressure (SBP); r = 0.26, p = 0.005 for mean 24 hour SBP). Patients were classified as having “no” (n = 70) or “mild” (n = 49) arch obstruction. Casual SBP was > 95th centile in 28% (34 of 119) overall and in 21% (15 of 70) of the no arch obstruction group. Mean 24 hour SBP was > 95th centile in 30% (36 of 119) overall and in 19% (13 of 70) of the no obstruction group. The sensitivity and specificity of casual SBP in detecting increased 24 hour SBP were 66% and 88%, respectively. Conclusions: This unique study of a large cohort of patients treated for coarctation in early childhood showed that a disappointingly high prevalence of hypertension is already apparent in children aged 7–16 years in the absence of significant arch obstruction, whether assessed by 24 hour or by casual blood pressure measurement.

Cervical Musculoskeletal Impairment in Frequent Intermittent Headache. Part 1: Subjects With Single Headaches

Musculoskeletal disorders are considered the underlying cause of cervicogenic headache, but neck pain is commonly associated with migraine and tension-type headaches. This study tested musculoskeletal function in these headache types. From a group of 196 community-based volunteers with headache, 73 had a single headache classifiable as migraine (n = 22), tension-type (n = 33) or cervicogenic headache (n = 18); 57 subjects acted as controls. Range of movement, manual examination of cervical segments, cervical flexor and extensor strength, the cranio-cervical flexion test (CCFT), cross-sectional area of selected extensor muscles at C2 (ultrasound imaging) and cervical kinaesthetic sense were measured by a blinded examiner. In all but one measure (kinaesthetic sense), the cervicogenic headache group were significantly different from the migraine, tension-type headache and control groups (all P < 0.001). A dicriminant function analysis revealed that collectively, restricted movement, in association with palpable upper cervical joint dysfunction and impairment in the CCFT, had 100% sensitivity and 94% specificity to identify cervicogenic headache. There was no evidence that the cervical musculoskeletal impairments assessed in this study were present in the migraine and tension-type headache groups. Further research is required to validate the predictive capacity of this pattern of impairment to differentially diagnose cervicogenic headache.

Fatty infiltrate in the cervical extensor muscles is not a feature of chronic insidious onset neck pain

AIM To investigate the presence of fatty infiltrate in the cervical extensor musculature in patients with insidious-onset neck pain to better understand the possible pathophysiology underlying such changes in chronic whiplash-associated disorders (WAD). MATERIALS AND METHODS A sample of convenience of 23 women with persistent insidious-onset neck pain (mean age 29.2+/-6.9 years) was recruited for the study. Magnetic resonance imaging (MRI) was used to quantify fatty infiltration in the cervical extensor musculature. Quantitative Sensory Testing (QST; pressure and thermal pain thresholds) was performed as sensory features are present in chronic whiplash. Self-reported pain and disability, as well as psychological distress, were measured using the Neck Disability Index (NDI) and the General Health Questionnaire-28 (GHQ-28), respectively. RESULTS Measures were compared with those of a previous dataset of chronic whiplash patients (n=79, mean age 29.7+/-7.8 years). Using a classification tree, insidious-onset neck pain was clearly identified from whiplash (p<0.001), based on the presence of MRI fatty infiltrate in the cervical extensor musculature (0/102 individuals) and altered temperature thresholds (cold; 3/102 individuals). CONCLUSION Fatty infiltrates in the cervical extensor musculature and widespread hyperalgesia were not features of the insidious-onset neck pain group in this study; whereas these features have been identified in patients with chronic WAD. This novel finding may enable a better understanding of the underlying pathophysiological processes in patients with chronic whiplash.

Predictors of short and long term outcome in patellofemoral pain syndrome: a prospective longitudinal study

BackgroundPatellofemoral pain syndrome (PFP) is a common musculoskeletal condition that has a tendency to become chronic and problematic in a proportion of affected individuals. The objective of this study was to identify prognostic factors that may have clinical utility in predicting poor outcome on measures of pain and function in individuals with PFP.MethodsA prospective follow-up study was conducted of 179 participants in a randomised clinical trial. Nine baseline factors (age, gender, body mass index, arch height, duration of knee pain, worst pain visual analogue scale, Kujala Patellofemoral Score (KPS), functional index questionnaire (FIQ), step down repetitions) were investigated for their prognostic ability on outcome assessed at six, 12 and 52 weeks (worst pain, KPS and FIQ). Factors with significant univariate associations were entered into multivariate linear regression models to identify a group of factors independently associated with poor outcome.ResultsLong symptom duration was the most consistent predictor of poor outcome over 52 weeks rated on the KPS and the FIQ (β-0.07, 95% confidence interval -0.1 to -0.03, p < 0.000; and -0.02, -0.03 to -0.01, p < 0.000, respectively). Worse KPS at baseline was predictive of outcome at six, 12 and 52 weeks. Gender, body mass index and arch height were generally not associated with outcome (univariate analysis), while age, worst pain, FIQ and step downs were excluded during multivariate analyses.ConclusionsPatients presenting with PFP of long duration who score worse on the KPS have a poorer prognosis, irrespective of age, gender and morphometry. These results suggest that strategies aimed at preventing chronicity of more severe PFP may optimise prognosis.

The association between degenerative hip joint pathology and size of the gluteus maximus and tensor fascia lata muscles

The aim of this study was to obtain, using Magnetic Resonance Imaging (MRI), muscle volume measurements for the gluteus maximus (upper: UGM and lower: LGM portions) and tensor fascia lata (TFL) muscles in both healthy subjects (n=12) and those with unilateral osteoarthritis (OA) of the hip (mild: n=6, and advanced: n=6). While control group subjects were symmetrical between sides for the muscles measured, subjects with hip joint pathology showed asymmetry in GM muscle volume dependent on stage of pathology. The LGM demonstrated atrophy around the affected hip in subjects with advanced pathology (p<0.05), however asymmetry of the UGM (p<0.01) could be attributed largely to hypertrophy on the unaffected side, based on between group comparisons of muscle volume. TFL showed no significant asymmetry, or difference compared to the normal control group. This study highlights the functional separation of UGM and LGM, and the similarities of the UGM and TFL, both superficial abductors appearing to maintain their size around the affected hip. Further research is required to determine the specific changes occurring in the deeper abductor muscles. This information may assist in the development of more targeted and effective exercise programmes in the management of OA of the hip.

Comparison of sensorimotor disturbance between subjects with persistent whiplash-associated disorder and subjects with vestibular pathology associated with acoustic neuroma.

OBJECTIVE To determine if differences exist in reported symptoms and in outcomes of sensorimotor tests (cervical joint position error [JPE], neck-influenced eye movement control, postural stability) between subjects with persistent whiplash and subjects with unilateral vestibular pathology associated with acoustic neuroma. DESIGN Repeated measures, case controlled. SETTING Tertiary institution and metropolitan hospital. PARTICIPANTS Twenty subjects with persistent whiplash, 20 subjects with acoustic neuroma, and 20 control subjects. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Symptom descriptors, Dizziness Handicap Inventory (short form), measures of cervical JPE, the smooth pursuit neck torsion (SPNT) test, and forceplate measures of postural stability in comfortable and narrow stances. RESULTS The results showed differences in SPNT (P=.00), selected measures of postural stability (P<.04), and reported symptoms between the whiplash and vestibular groups. There was no between-group difference in cervical JPE (P>.27) or dizziness handicap (P>.69). CONCLUSIONS This study showed differences in sensorimotor disturbances between subjects with discreet whiplash and those with vestibular pathology associated with acoustic neuroma. The results support the SPNT test as a test of cervical afferent dysfunction. Further research into cervical JPE as a discreet test of cervical afferentation is warranted.