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Purpose: The inter-rater reliability of the Quebec Task Force (QTF) classification system for Whiplash-Associated Disorders (WAD) remains unknown. Our objective was to determine the inter-rater reliability of the WAD classification between an experienced chiropractic clinician and two chiropractic residents. Methods: We conducted an inter-rater reliability study using baseline clinical data from 80 participants assessed for inclusion in a randomized clinical trial of the conservative management of WAD grades I and II. We reported reliability using Cohen's kappa (k) and 95% confidence intervals (CI). Results: The mean duration of WAD symptoms was 7.6 days (s.d.=5.2). In our study, the interrater reliability of the WAD grade classification varied from k=0.04 (95% CI -0.04 to 0.12) to k=0.80 (95% CI 0.67 to 0.94). Conclusion: Inter-rater reliability of the WAD classification varied greatly across raters and may be associated with the experience of the raters and with their understanding of the criteria. Our results suggest that clinicians may benefit from training to standardize how they classify WAD. Furthermore, our results need to be tested in a different sample of patients and with a range of clinicians from different clinical disciplines. [ABSTRACT FROM AUTHOR]

Purpose: There is significant evidence in the literature that low or relatively low cortisol concentrations near the time of an accident are associated with more severe forms of whiplash-associated disorders. We hypothesized that treating patients that were involved in a motor vehicle accident with hydrocortisone would alleviate the incidence and severity of these disabling disorders. Methods: A prospective, randomized, double-blind, placebo-controlled clinical trial. Blunt trauma patients that underwent a motor vehicle crash were allocated into a study group that received a single bolus of hydrocortisone and a control group that received saline. The patients were followed for 1 month. The incidence and severity of whiplash associated disorder, functional disturbances, and post-traumatic stress disorder were compared between the two groups. The analyses were repeated for sub-divisions into groups of high and low admission cortisol. Results: The more severe forms of whiplash-associated disorders on the day of accident were associated with low cortisol levels; mean cortisol concentration of the lower grade of whiplash patients (13.09 ± 7.35 µg%) was higher than that of whiplash syndrome of the severe forms (8.33 ± 3.45 µg), p = 0.001. There were no differences between study and control groups regarding whiplash-associated disorders, functional tests, and severity of stress disorder 1 month after the accident. Significant differences were evident between high and low cortisol sub-groups. Those who had low cortisol level on admission and received hydrocortisone had worse outcomes. Conclusion: Steroid treatment of patients with whiplash might be harmful to those who present with low cortisol concentrations (< 9.5 μg/dL). Trial registration: Clinical Trials: Association between low cortisol levels and whiplash syndrome. Date of registration: March 18, 2014. Date the first participant was enrolled: May 10, 2014. Trial registration number: NCT02090309. URL: https://clinicaltrials.gov/ct2/show/NCT02090309. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to improve head-neck kinematic predictions of a contemporary finite element (FE) head-neck model, assessed in rear impact scenarios (3-10 g), by including an accurate representation of the skin, adipose tissue, and passive muscle mechanical properties. The soft tissues of the neck have a substantial contribution to kinematic response, with the contribution being inversely proportional to the impact severity. Thus accurate representation of these passive tissues is critical for the assessment of kinematic response and the potential for crash induced injuries. Contemporary Human Body Models (HBMs) often incorporate overly stiff mechanical properties of passive tissues for numerical stability, which can affect the predicted kinematic response of the head and neck.Methods: Soft tissue material properties including non-linearity, compression-tension asymmetry, and viscoelasticity were implemented in constitutive models for the skin, adipose, and passive muscle tissues, based on experimental data in the literature. A quasi-linear viscoelastic formulation was proposed for the skin, while a phenomenological hyper-viscoelastic model was used for the passive muscle and adipose tissues. A head-neck model extracted from a contemporary FE HBM was updated to include the new tissue models and assessed using head rotation angle for rear impact scenarios (3 g, 7 g, and 10 g peak accelerations), and compared to postmortem human surrogate (PMHS) data for 7 g impacts.Results: The head rotation angle increased with the new material models for all three rear impact cases: (3 g: +43%, 7 g: +52%, 10 g: +71%), relative to the original model. The increase in head rotation was primarily attributed to the improved skin model, with the passive muscle being a secondary contributor to the increase in response. A 52% increase in head rotation for the 7 g impact improved the model response with respect to PMHS data, placing it closer to the experimental average, compared to the original model.Conclusions: The improved skin, adipose tissue, and passive muscle material model properties, based on published experimental data, increased the neck compliance in rear impact, with improved correspondence to published PMHS test data for medium severity impacts. Future studies will investigate the coupled effect of passive and active muscle tissue for low severity impacts. [ABSTRACT FROM AUTHOR]

1. Understand the unique challenges and complexities associated with providing palliative care to patients with substance use disorder as a serious illness, including the physical, emotional, and social aspects that contribute to their suffering. 2. Describe strategies to unstructure and rebuild care plans collaboratively with patients, taking into consideration their values and goals, to effectively address the specific needs and preferences of patients with SUD as a serious illness within a palliative care framework. We discuss integrating palliative care principles when caring for patients with advanced substance use disorder (SUD) as a serious illness. Emphasizing shared decision-making and a nonjudgmental approach, it addresses the challenges of providing compassionate care to patients with serious SUD. We highlight how un-structuring care plans and rebuilding them collaboratively to align with patients' values and goals, enhances care. Patients living with substance use disorders (SUD) often face complex physical, emotional, and social challenges that can be uncomfortable for healthcare providers. Advanced SUDs are serious illnesses with significant complications, leading to high morbidity and mortality rates. SUDs' psychosocial complexity and physical symptoms can be difficult to treat within a traditional biomedical paradigm. This presentation explores how palliative care principles, such as nonabandonment of patient suffering, a nonjudgmental approach, and eliciting/respecting patient values, can be used to provide compassionate, patient-centered care. This presentation begins with a case study of a patient with sickle cell disease, complex pain, street fentanyl use, and PTSD. We draw on evidence-based research from both palliative care and addiction literatures and experiences from palliative care providers who have implemented patient-centered care for individuals with SUD. We then describe a harm reduction, destigmatizing approach that utilizes trauma-informed care to holistically evaluate and support patients. We also examine stigmas of addiction that often hinder effective care delivery. For example, overly structured treatment approaches may be unrealistic, interrupting both effective care planning and therapeutic relationships. Palliative care providers are uniquely situated to un-structure the care plan and re-build it, centering patient goals and strengths. This approach—and the nonjudgmental and supportive environment it creates—can empower patients to create meaningful interventions and lead their own care journeys. This talk argues that by embracing the uncomfortable aspects of SUD, providers can encourage patients to actively engage their care to find relief from suffering, improve therapeutic relationships and build trust. Facilitating meaningful interventions that align with patient values can be a bridge to improved morbidity and mortality outcomes. Diversity, Equity, Inclusion, Belonging, JusticeManaging Suffering and Distress [ABSTRACT FROM AUTHOR]

Abstract Background Studies aimed at improving the provision of evidence-based care (EBC) for the management of acute whiplash injuries have been largely successful. However, whether EBC is broadly provided and whether delivery of EBC varies based on risk of non-recovery, is uncertain. Receiving EBC should improve recovery, though this relationship has yet to be established. Further, mitigating the effect of EBC is the relationship with the practitioner, a phenomenon poorly understood in WAD. This study aimed to determine the proportion of individuals with whiplash, at differing baseline risk levels, receiving EBC. This study also aimed to determine whether receiving EBC and the therapeutic relationship were associated with recovery at 3 months post injury. Methods Participants with acute whiplash were recruited from public hospital emergency departments, private physiotherapy practices, and State Insurance Regulatory Authority (SIRA) databases. Participants completed questionnaires at baseline (demographics, risk of non-recovery) and 3-months (treatment received, risk identification, therapeutic relationship) post injury. Primary health care providers (HCPs) treating these participants also completed questionnaires at 3-months. Recovery was defined as neck disability index ≤4/50 and global perceived effect of ≥4/5. Results Two-hundred and twenty-eight people with acute whiplash, and 53 primary care practitioners were recruited. The majority of the cohort reported receiving EBC, with correct application of the Canadian C-spine rule (74%), and provision of active treatments (e.g. 89% receiving advice) high. Non-recommended (passive) treatments were also received by a large proportion of the cohort (e.g. 50% receiving massage). The therapeutic relationship was associated with higher odds of recovery, which was potentially clinically significant (OR 1.34, 95% CI 1.18–1.62). EBC was not significantly associated with recovery. Conclusions Guideline-based knowledge and practice has largely been retained from previous implementation strategies. However, recommendations for routine risk identification and tailored management, and reduction in the provision of passive treatment have not. The therapeutic relationship was identified as one of several important predictors of recovery, suggesting that clinicians must develop rapport and understanding with their patients to improve the likelihood of recovery.

Abstract Background Whiplash is a common traumatic cervical injury which is most often a consequence of rear-end motor vehicle accidents. It has been estimated that up to 50% of the whiplash patients suffer from chronic symptoms, resulting in extensive individual and societal burden. Several measurement instruments are used for initial assessment of whiplash and evaluation of response to treatment. However, a comprehensive assessment of the performance of these measures is lacking. Furthermore, there is no consensus on the most relevant outcome domains and their corresponding measurement instruments of choice. This systematic review aims to identify, describe, and critically appraise the performance properties of health-related measurement instruments in whiplash population. Methods The following literature databases will be searched from their date of establishment: PubMed, Embase®, MEDLINE, CINAHL Complete, PsycINFO, and HAPI. All original articles evaluating the reliability, validity, responsiveness, and feasibility of health-related measurement instruments in whiplash will be included, without additional restriction on their intended use, source of data, and structure. Risk of bias will be assessed using the COSMIN Risk of Bias checklist. Findings of the studies will be judged against the criteria for good measurement properties, and results from all studies will be qualitatively summarized to generate an overall quality of findings. Overall quality of evidence will be determined using a modified GRADE approach, which will be used in conjunction with the overall quality of results for generation of recommendations. Two reviewers will perform all steps of the review independently. Discrepancies will be discussed between the reviewers, and in case of remaining disagreement, the senior reviewer will make the final decision. Discussion This systematic review will summarize the body of literature on health-related measurement instruments in whiplash, aiming to facilitate the selection of high-quality measurement instrument for researchers and physicians. Findings of this study will guide the ongoing efforts for development of a core outcome set. Systematic review registration PROSPERO reference number CRD42018070901

Abstract Background A considerable number of patients with whiplash-associated disorders (WAD) report variable and indefinite symptoms involving the whole body, despite there being no evidence of direct injuries to organs other than the neck. However, little is known about their management or underlying mechanism. This study examined the effect of intensive physical therapy at the cervical muscles in patients with WAD reporting whole-body indefinite symptoms. Methods A total of 194 hospitalized patients with WAD who were resistant to outpatient care by reporting whole-body indefinite symptoms between May 2006 and May 2017 were enrolled in this observational study. All patients underwent daily physical therapies by low-frequency electric stimulation therapy and far-infrared irradiation to the cervical muscles during hospitalization. Self-rated records in the medical interview sheets on 22 representative whole-body symptoms at admission and discharge were compared. Results The number of symptoms was markedly decreased by the physical therapies during hospitalization. Almost all symptoms showed recovery rates of more than 80% at discharge as compared to those at admission. Although the percentage of patients reporting at least four of the 22 representative indefinite symptoms was 99.0% at admission, it decreased to 7.7% at discharge. Sixteen percent of patients recovered completely without any residual symptoms. The mean number of symptoms significantly decreased from 13.1 at admission to 2.0 at discharge. Notably, symptoms other than those in the neck or shoulder recovered to a greater extent than those in the neck or shoulder. Conclusions This study, for the first time, examined the management of whole-body indefinite symptoms in patients with WAD. The intensive physical therapy markedly improved the symptoms, suggesting the involvement of cervical muscles in the pathogenesis. Trial registration UMIN000035435 (Retrospectively registered on Jan 3, 2019).

Abstract Objective To describe the development of a preventive educational video for patients exposed to whiplash trauma following motor vehicle accidents. Methods The development followed a systematic approach and was theory-driven supplemented with available empirical knowledge. The specific content was developed by a multidisciplinary group involving health professionals and visual production specialists. Results A 14-min educational video was created. The video content focuses on stimulating adaptive recovery expectations and preventing maladaptive illness beliefs. The video presents a multifactorial model for pain incorporating physiological and cognitive-behavioural aspects, advice on pain relief, and exercises. Subjects interviewed for a qualitative evaluation found the video reassuring and that it aligned well with verbal information received in the hospital. Conclusions The development of the visual educational intervention benefitted from a systematic development approach entailing both theoretical and research-based knowledge. The sparse evidence on educational information for acute whiplash trauma posed a challenge for creating content. Further knowledge is required regarding what assists recovery in the early stages of whiplash injuries in order to improve the development of educational interventions.

The number of whiplash injuries in rear-end collisions is still high worldwide. Since the 1990s, many researchers have studied the mechanisms of injury occurrence in which were focused in the early stage of the rear impact. However, the current situation is that it has not led to a significant reduction in the number of injuries. The authors created a head-neck FEM model with muscles and accurately reproduced the head-neck behaviors of male and female volunteers in the rear impact tests. Then, using the same model, it was clarified that the difference in muscle strength is a large factor in the gender difference in frequency of whiplash injuries. In this paper, we focused on nerve damage, which is the cause of chronic whiplash, and examined the possibility of nerve root damage in the early stage of rear impact. It is generally known that living soft tissues such as nerves have viscoelastic behavior. Using animal axons and nerve root characteristics, it was found that a hyperbolic relationship was established between the velocity and the deformation under compression load on nerve root. The higher the loading rate, the stronger the locality at the compression site, and the greater the possibility of damage even if the deformation is small. Next, we studied the possibility of nerve root damage during a rear impact using a C4-C5 spinal unit FEM model including nerve root model (nerve-spinal unit model). First, in the same model, it was confirmed that there is no nerve root damage during a daily head extension. Then, using male head-neck behavior data in rear impact, it was confirmed that there is a possibility of nerve root damage when the compression speed of the vertebral body increases. Finally, we also analyzed using female data and found that there was a higher possibility of nerve root damage than in male.

Copyright of Turkish Journal of Trauma & Emergency Surgery / Ulusal Travma ve Acil Cerrahi Dergisi is the property of KARE Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Study Design: A longitudinal, 20-year comparative study of patients with whiplash-associated disorders (WAD).Objective: The aim of this study was to clarify the long-term impact of WAD on patient symptoms and on magnetic resonance imaging (MRI) findings of the cervical spine, in comparison with asymptomatic volunteers.Summary Of Background Data: The long-term impact of WAD has not been fully elucidated.Methods: Between 1993 and 1996, we conducted a cross-sectional comparative study of 508 acute WAD patients and 497 asymptomatic volunteers, all of whom underwent MRI on cervical spine and physical examinations. For this 20-year follow-up comparative study, 75 WAD patients and 181 control subjects aged <60 years were recruited from the original cohort. The MRI findings, including discs' signal intensities, posterior disc protrusions, anterior dural compressions, spinal cord disc space narrowing, and foraminal stenoses, were evaluated using two to four numerical grades. The results of the WAD patients and control subjects were compared.Results: In this follow-up, the prevalence of shoulder stiffness (72.0% vs. 45.9%), headache (24.0% vs. 12.2%), and arm pain (13.3% vs. 3.9%) were significantly greater in WAD patients than in control subjects. The multiregression analysis revealed that a history of WAD was associated with shoulder stiffness (odds ratio [OR]: 3.36), headache (OR: 2.39), and arm pain (OR: 3.82). Although MRI findings in WAD patients were more degenerated than in control subjects in the initial study, all MRI findings were similar at the 20-year follow-up. There were no significant correlations between clinical cervical symptoms and progression in each MR finding in either group.Conclusion: After 20 years, whiplash injuries significantly impacted the residual symptoms of shoulder stiffness, headache, and arm pain when compared with initially asymptomatic volunteers. The progression of degenerative changes in the cervical intervertebral discs after 20 years revealed no association with existing whiplash injuries, neither did the residual cervical-related symptoms.Level of Evidence: 3. [ABSTRACT FROM AUTHOR]

Study Design: Population-based cross-sectional study.Objective: The aim of this study was to gain a better understanding of changes in muscle morphology in patients with chronic idiopathic neck pain (CINP) and chronic whiplash-associated disorder (CWAD).Summary Of Background Data: Worldwide, neck pain (NP) is a common health problem with high socioeconomic burden. A high percentage of these patients evolves toward chronic symptoms. Efficacy of treatments for these complaints remains variable. In current literature, changes in muscle morphology (muscle fat infiltration and cross-sectional area) have been reported in patients with NP, both CWAD and CINP. However, no strong conclusions could be made.Methods: In this study, magnetic resonance imaging was used to obtain data on muscle morphology from 14 cervical flexor and extensor muscles in 117 female subjects with NP (CWAD = 37; CINP = 45) and healthy controls (HC = 35).Results: The CWAD group had a significantly larger muscle fat infiltration in some extensor (semispinalis and splenius capitis, trapezius, obliquus capitis inferior) and flexor (sternocleidomastoid) muscles compared to the CINP and/or HC group. A significantly larger (muscle) cross-sectional area was found in some extensor (levator scapulae, semispinalis capitis, trapezius) and flexor (longus colli, longus capitis, sternocleidomastoid) muscles in the HC group compared to the CINP and/or CWAD group. No clear associations were found between group differences and factors as pain duration, kinesiophobia, and disability.Conclusion: The results in this study suggest changes in muscle morphology in both NP cohorts. These results show some similarities with earlier findings in this research domain. Further studies based on controlled longitudinal designs are needed to facilitate data compilation, to draw stronger conclusions, and to integrate them into the treatment of patients with chronic NP.Level of Evidence: 4. [ABSTRACT FROM AUTHOR]

Background and Aim: Although post-motor vehicle collision (MVC) pain and symptoms are largely convergent among those with mild traumatic brain injury (mTBI) and whiplash associated disorder (WAD), and patients oftentimes report initial neck and head complaints, the clinical picture of mTBI and WAD has been primarily studied as separate conditions which may result in an incomplete clinical picture. As such, this study was conducted to explore the role of pain and post-traumatic psychological features in explaining both head and neck-related symptom variability in a cohort of post-collision patients. This is with the goal of disentangling if contributory factors are uniquely related to each diagnosis, or are shared between the two.Methods: Patients recruited in the very early acute phase (<72 h) returned for clinical and psychological assessment at 6 months post-accident. In order to determine which factors were unique and which ones were overlapping the same potential contributors: mean head pain, mean neck pain, female gender, number of post-collision painful body areas, PTSD, and depression were included in the regression models for both neck disability index (NDI) and Rivermead post-concussion symptoms questionnaire (RPQ).Results: Of 223 recruited participants, 70 returned for a follow-up visit (age range 18-64, mean(SD) 37.6 (11.9), 29F). This cohort primarily met the criteria for mTBI, but also fulfilled the criteria for whiplash, reinforcing the duality of injury presentation. Correlations existed between the NDI and RPQ scores (Spearman's ρ=0.66, p<0.001), however overlap was only partial. Regression analysis showed that after the removal of area-of-injury pain neck related disability (r = 0.80, p <0.001) was explained solely by number of painful body areas (ß=0.52, p <0.001). In contrast, post-concussion syndrome symptoms (r = 0.86, p<0.001) are influenced by clinical pain, painful body areas (ß=0.31, p = 0.0026), female gender (ß=0.19, p = 0.0053), and psychological factors of depression (ß=0.31, p = 0.0028) and PTSD symptoms (ß=0.36, p = 0.0013).Conclusions: It seems that while mechanisms of neck- and head-related symptoms in post-collision patients do share a common explanatory feature, of residual body pain, they are not entirely overlapping. In that psychological factors influence post-concussion syndrome symptoms, but not post-whiplash neck disability. [ABSTRACT FROM AUTHOR]

Background: Psychological variables contribute to pain- and injury-related outcomes. We examined the hypothesis that anatomical spread and intensity of persistent pain relate to anxiety-related variables: generalised anxiety, fear of pain and pain catastrophising. Methods: An online survey was used to gather data from 413 women with persistent pain (low back pain, n = 139; fibromyalgia syndrome, n = 95; neck pain, n = 55; whiplash, n = 41; rheumatoid arthritis, n = 37; migraine, n = 46). The spread and intensity of pain were assessed using the McGill pain chart and a Numerical Rating Scale. A Bayesian Structural Equation Model assessed if the intensity and spread of pain increased with anxiety-related variables. Men were also surveyed (n = 80), but the sample size was only sufficient for analysing if their data were consistent with the model for women. Results: Across subgroups of women, one standard deviation increase in catastrophising, generalised anxiety and fear corresponded to 27%, 7% and −1% additional pain areas and a 1.1, 0 and –0.1 change in pain intensity (on 0–10 scale), respectively. Overall, our clinical significance criterion – a 30% shift in pain variable in relation to one standard deviation increase in psychological variable – was not met. However, in subgroups it was met for pain spread (low back pain, neck pain and migraine) and pain intensity (migraine and neck pain) in relation to pain catastrophising. The model generally had low goodness-of-fit to men. Conclusion: These data support a meaningful relationship between some anxiety-related variables and pain in women for some conditions. Since the model did not consistently fit the men, we may conclude that the relationships are moderated by sex. Clinician attention to psychological variables as potential contributing factors can be justified; however, research is needed to understand the relationship and whether psychological treatment can reduce pain. [ABSTRACT FROM AUTHOR]

• Large trial studying a contemporary neuroscience therapy for chronic whiplash. • Trial integrating stress management in the neuroscience approach for whiplash. • Assess if a contemporary neuroscience therapy can decrease central sensitization. • This trial may provide new improved treatment guidelines for chronic whiplash. • This trial may be used as a basis for recommendations to health authorities. To address the need for a better treatment of chronic whiplash associated disorders (WAD), a contemporary neuroscience approach can be proposed. To examine the effectiveness of a contemporary neuroscience approach, comprising pain neuroscience education, stress management, and cognition-targeted exercise therapy versus conventional physical therapy for reducing disability (primary outcome measure) and improving quality of life and reducing pain, central sensitization, and psychological problems (secondary outcome measures) in people with chronic WAD. The study is a multi-center, two-arm randomized, controlled trial with 1-year follow-up and will be performed in two university-based and one regional hospital. People with chronic WAD (n = 120) will be recruited. The experimental group will receive pain neuroscience education followed by cognition-targeted exercise therapy, and stress management. The control group will receive biomedically focused education followed by graded and active exercise therapy focusing on muscle endurance, strength, and flexibility, and ergonomic principles. The treatment will have a duration of 16 weeks. Functional status (Neck Disability Index) is the primary outcome measure. Secondary outcome measures include quality of life, pain, central sensitization, and psychological and socio-economic factors. In addition, electroencephalography will measure brain activity at rest and during a conditioned pain modulation paradigm. Assessments will take place at baseline, immediately post-treatment and at 6 and 12 months follow-up. This study will examine whether a contemporary neuroscience approach is superior over conventional physical therapy for improving functioning, quality of life, and reducing pain, central sensitization, and psychological problems in people with chronic WAD. [ABSTRACT FROM AUTHOR]

• Prolonged Exposure (PE) may be targeted to facilitate moral healing in the course of PTSD treatment. • Emergent conceptualizations of moral injury are compatible with the PE model. • In vivo and imaginal exposure procedures may be expanded to meet patient needs. • This case example demonstrates positive functional outcomes in a soldier with PTSD and moral injury. Prolonged Exposure (PE) is a highly effective treatment for posttraumatic stress disorder (PTSD) across a variety of delivery formats and samples. However, for military service members, the treatment tends to be less effective than for civilians. One explanation for the reduced response to PE in military service members is the frequency, intensity, and heterogeneity of combat trauma. Combat trauma may yield a variety of posttraumatic responses, including moral injury, or the psychosocial-spiritual suffering consequent of exposure to moral injurious events. Despite rapidly increasing research on combat-related moral injury, little clinical guidance exists on how or if moral injury may be addressed via trauma-focused treatments such as PE. This case report describes the facilitation of moral healing for a U.S. Army soldier with combat-related PTSD in a 3-week intensive outpatient PE program. While PTSD symptoms were reduced from pre- to posttreatment, even more substantial treatment gains were observed in the soldier's functional changes, engagement with values-based activities, and his reported willingness to embrace moral pain. Although not explicit in the PE manual, targeting these latter outcomes in PE can facilitate moral healing in service members with PTSD. This case report provides a detailed description of how PE procedures were targeted to address moral injury and where theory-driven augmentations were included to facilitate moral healing. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To compare the accuracy of a whiplash-specific risk screening tool (WhipPredict) with that of the modified generic short-form Orebro Musculoskeletal Pain Screening Questionnaire (SF-OMPSQ) for predicting poor recovery in patients following whiplash injury. STUDY DESIGN: Inception cohort study. METHODS: Two hundred two participants with acute whiplash completed the WhipPredict and modified SF-OMPSQ at baseline. Poor recovery was measured at 6 and 12 months using the Neck Disability Index (greater than 10%), numeric pain-rating scale (greater than 3/10), global perceived recovery (less than +4), and inability to return to preinjury work level. Accuracy statistics were calculated to predict poor recovery. RESULTS: Seventy-one percent (n = 143) of participants completed the 6-month assessment and 56% (n = 113) completed the 12-month assessment. At baseline, agreement between the WhipPredict and modified SF-OMPSQ was fair (prevalence-ad-justed and bias-adjusted K = 0.26; 95% confidence interval: 0.12,0.39). Depending on the outcome, 20% to 72% of people had not recovered at 6 months and 12% to 71% had not recovered at 12 months. At 6 and 12 months, the WhipPredict tool showed high sensitivity (88%-96%) and low specificity (all outcomes less than 31%) on all 4 separate outcomes. The modified SF-OMPSQ showed moderate sensitivity (67%-75%) for the Neck Disability Index, numeric pain-rating scale, and global perceived recovery, high sensitivity for return to work (81%-90%), and moderate specificity (54%-77%) for all 4 outcomes. CONCLUSION: Both tools showed acceptable accuracy in predicting poor recovery. The WhipPredict tool is recommended to correctly identify patients who will not recover but may falsely classify those who recover well. Using the modified SF-OMPSQ will result in fewer patients falsely categorized as being at risk of poor recovery and may result in some people being undertreated. [ABSTRACT FROM AUTHOR]

Copyright of Praxis of Otorhinolaryngology / Kulak Burun Boğaz Uygulamaları is the property of Official Journal of ENT-HNS Society of Istanbul and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

An otherwise healthy 21-yr-old female hockey player sustained a cervical whiplash injury during competition after being checked and falling backward onto the ice. Initial assessment revealed right-sided hemiparesis and sensory abnormalities. Magnetic resonance imaging and computed tomography of the brain and spine were unremarkable. Most of her right upper limb symptoms resolved in 24 hrs, with complete resolution in 5 days. Over 6 wks, she regained right lower limb strength with mild residual sensory deficits. Repeat magnetic resonance imaging of the cervical spine was unremarkable. At 18 wks, sensory symptoms resolved, with the exception of mildly decreased lower limb proprioception. The athlete was cleared to return to noncontact drills but not competition. The differential diagnosis included transient quadriplegia and/or hemiplegia ("cervical cord neuropraxia"), which typically resolves in 48 hrs, and incomplete spinal cord injury without radiographic abnormality, which is more likely to present with persistent symptoms. This case includes features of both diagnoses, making management challenging as return to play guidelines are nonspecific. Further research is needed to develop well-defined guidelines for spinal cord injury without radiographic abnormality and cervical cord neuropraxia return-to-play decisions. [ABSTRACT FROM AUTHOR]

Background: Work resumption is a big challenge in the rehabilitation process for individuals with whiplash-associated disorders (WAD). To better meet the needs of individuals with WAD in their return to work process, more knowledge on their experiences and perspectives is needed. The aim of this study was to explore the experiences of work ability and the work situation of individuals who participated in a neck-specific exercise programme for chronic WAD.Methods: This qualitative study has an exploratory and descriptive design based on data collected through open-ended interviews with 17 individuals with chronic WAD. Data were analysed inductively using conventional content analysis.Results: Analysis of the data yielded the following five categories related to the participants' narratives on their experiences of work ability and their work situation: Return to work - a process of setbacks and bureaucracy; The need to be understood by health care professionals, and to receive a treatment plan; Individual resources are important for work ability; The consequences of reduced work ability; and Working conditions are important for work ability.Conclusion: Individuals with chronic WAD often struggle to return to work. Emotional and practical support from stakeholders is imperative and needs to be strengthened. Participating in a neck-specific exercise programme, including being acknowledged and receiving information about WAD, could positively affect the work ability of WAD sufferers. This study has provided management strategies to improve the ability to work for individuals with chronic WAD, and highlights the need to incorporate a healthy and sustainable return to work in the rehabilitation of individuals with WAD, thereby making their return to work a success. [ABSTRACT FROM AUTHOR]

Abstract: Many people with chronic whiplash-associated disorders (WAD) have also symptoms of posttraumatic stress disorder (PTSD), but this is rarely considered in usual predominantly exercise-based interventions. We aimed to investigate the effectiveness of combined trauma-focused cognitive behavioural therapy (TF-CBT) and exercise compared with supportive therapy (ST) and exercise for people with chronic WAD and PTSD. A randomised controlled multicentre trial with concealed allocation, assessor blinding, and blinded analysis was conducted. One hundred three participants with chronic WAD (>3 months and <5 years, grade II) and PTSD were randomised to TF-CBT and exercise (n = 53) or ST and exercise (n = 50). Both interventions comprised 10 weeks of TF-CBT or ST, followed by 6 weeks of exercise. Outcomes were measured at baseline, 10, 16 weeks, 6, and 12 months after randomisation. Analysis was intention to treat using linear mixed models. There was no difference between the interventions on the primary outcome of neck pain-related disability at any time point. At 16 weeks, the treatment effect on the 0 to 100 Neck Disability Index was 0.59 (95% confidence interval [CI] 5.51 to -4.33), at 6 months 1.18 (95% CI 6.15 to -3.78), and at 12 months 1.85 (95% CI 6.81 to -3.11). In addition, there was no difference between the interventions for most secondary outcomes at any time. Exceptions were in favour of TF-CBT and exercise, where improvements in PTSD symptoms were found at 16 weeks. From 16 weeks onwards, both groups achieved a clinically important improvement in neck pain-related disability. However, both groups remained moderately disabled. [ABSTRACT FROM AUTHOR]

Whiplash-associated disorder (WAD) is the most common complaint and purported cause of chronic disability associated with motor vehicle collisions in North America. However, its construct validity remains controversial. This narrative review of the literature summarises the evidence underlying the most commonly theorised biological and psychosocial mechanisms of WAD pathogenesis. While the face validity of WAD is good, empirical evidence supporting the various constructs suggesting a causal link between a trauma mechanism and the development of symptoms is poor. Because individual expectations of recovery are outcome-predictive, future research is necessary to develop a better understanding of how to enhance expectancies in order to help affected motorists gain a greater sense of control over their health and wellbeing. [ABSTRACT FROM AUTHOR]

Posttraumatic stress disorder (PTSD) and physical health problems, particularly somatic symptom disorder, are highly comorbid. Studies have only examined this co‐occurrence at the disorder level rather than assessing the associations between specific symptoms. Using network analysis to identify symptoms that act as bridges between these disorders may allow for the development of interventions to specifically target this comorbidity. We examined the association between somatization and PTSD symptoms via network analysis. This included 349 trauma‐exposed individuals recruited through the National Centre for Mental Health PTSD cohort who completed the Clinician‐Administered PTSD Scale for DSM‐5 and the Patient Health Questionnaire–15. A total of 215 (61.6%) individuals met the DSM‐5 diagnostic criteria for PTSD. An exploratory graph analysis identified four clusters of densely connected symptoms within the overall network: PTSD, chronic pain, gastrointestinal issues, and more general somatic complaints. Sleep difficulties played a key role in bridging PTSD and somatic symptoms. Our network analysis demonstrates the distinct nature of PTSD and somatization symptoms, with this association connected by disturbed sleep. [ABSTRACT FROM AUTHOR]

"Whiplash Injury" describes those injury deriving from the sharp whipping movement of both head and neck, produced at the moment of a traffic accident, particularly following collision from behind, head-on or side collisions. The use of safety belts has led to a reduction in deaths deriving from front-end collisions, but also to an increase in cases of typical whiplash. There are two types of forces that cause whiplash injuries in rear-end car crashes: external forces applied to the body by the seat and head restraint, and internal forces generated by the activation of body's muscles. The combination of these forces causes differential motion of the cervical spine, which results in neck tissues' strain. This event can affect all neck structures: facet joints capsule, muscles, intervertebral disks, nerves and vessels. We report a case of a 68-year-old woman. The subject, while driving her car, hit head-on a car moving in the opposite direction and died immediately. At autopsy the major findings were limited to multiple rib fractures and fracture of the fifth cervical vertebra with epidural hematoma. This case demonstrates that, even in the absence of direct traumatism, a potentially lethal epidural hematoma may occur as a result of whiplash. [ABSTRACT FROM AUTHOR]

Introduction: Chronic pain is a significant problem for service members and veterans with mild traumatic brain injury (mTBI). While the root cause of pain is not clearly understood, comorbidities may contribute to how their pain disrupts their functional status, a construct termed "pain interference." The purpose of this study is to examine the associations between mTBI, other comorbidities, and pain interference.Materials and Methods: The sample comprised participants with mTBI(s) from The Chronic Effects of Neurotrauma Consortium multicenter observational study. Potential concussive events were identified using a modified Ohio State University traumatic brain injury (TBI) Identification interview and then further with a structured interview. Pain interference was measured with the TBI quality-of-life pain interference score, which was categorized into insignificant, moderate, and high pain interference. Comorbidities of interest included anxiety, depression, post-traumatic stress disorder, insomnia, and arthritis. Multivariable relationships were analyzed using logistic regression.Results: The analysis sample included 346 participants with mTBI(s). In adjusted analysis, those with high pain interference were more likely to have history of ≥ 3 TBIs (odds ratio (OR) 3.1, 95% confidence interval [CI] 1.4, 6.9) and to have clinical levels of post-traumatic stress disorder (OR 5.4, 95% CI 1.9, 15.7), depression (OR 2.5, 95% CI, 1.0, 6.1), anxiety (OR 4.9, 95% CI, 2.0, 11.7), and sleep disturbances (OR 6.1, 95% CI 2.0, 19.0) versus those with insignificant pain interference.Conclusion: These results identify clinical features of veterans and service members with mTBI(s) who are at highest risk for pain-related disability. These findings also demonstrate the need to consider mental health and sleep problems in their pain evaluation and treatment approach. [ABSTRACT FROM AUTHOR]

Objective: This study examined the prevalence of chronic pain alone, posttraumatic stress disorder (PTSD) alone, and both chronic pain and PTSD among U.S. Army soldiers during the postdeployment year.Methods: The sample was 576,425 active duty soldiers returning from deployment in Afghanistan or Iraq between October 1, 2008, and September 30, 2014. Bivariate statistics were used to compare health care utilization among subgroups. Multivariate logistic regression with additional covariates was used to identify predictors of receiving an opioid days' supply of >30 days in the postdeployment year among soldiers with chronic pain, focusing on the effect of PTSD alone and on an interaction of PTSD with nonpharmacologic treatments (including therapeutic exercise, chiropractic treatment, acupuncture, and biofeedback).Results: In total, 12.2% of the soldiers received a chronic pain diagnosis, 5.1% a PTSD diagnosis, and 1.8% had both. Among soldiers with both conditions, 80.3% received nonpharmacologic treatment, and 31.4% received an opioid days' supply of >30 days. Among soldiers with chronic pain, comorbid PTSD and lack of nonpharmacologic treatment was associated with increased odds of receiving an opioid days' supply of >30 days (odds ratio [OR]=1.4, 95% confidence interval [CI]=1.3-1.6). PTSD combined with specific nonpharmacologic treatment modalities had a variable relationship with opioid receipt, and only PTSD with acupuncture or biofeedback was associated with reduced odds (OR=0.8, 95% CI=0.7-0.9).Conclusions: Soldiers having both chronic pain and PTSD have significant health care needs. Although these soldiers accessed mental health care and received nonpharmacologic treatment, additional interventions are needed to mitigate protracted opioid utilization. [ABSTRACT FROM AUTHOR]

Post-traumatic stress disorder (PTSD) is an often disabling mental disorder whose management typically focuses on reducing PTSD symptoms. Chronic pain and other comorbidities that commonly accompany PTSD symptoms may also be independently associated with disability. Using data from the 2012–2013 National Epidemiologic Survey on Alcohol and Related Conditions, we examined the independent association of PTSD symptom severity, pain interference, non-PTSD psychiatric and substance use disorders (SUD), and medical illnesses with each of four domains of function: mental health-related quality of life and physical functioning assessed with the Mental Health Composite Score (MCS) and Physical Function Score (PFS) of the Short Form-12; perceived social support from the Interpersonal Support and Evaluation List-12 (ISEL-12); and self-reported past year employment. Among 1779 individuals representing 11 million U.S. adults who met the Diagnostic and Statistical Manual-5 (DSM-5) criteria for Past Year PTSD, the MCS (41.2; SD 12.5), PFS (44.8; SD 13.2) and ISEL-12 (33.6; SD 7.2) indicated substantial disability when compared to population norms, and only 63.6% were employed. Multiple regression showed the MCS had a modest negative association with PTSD symptoms, pain interference, psychiatric multimorbidity and medical comorbidity although not with SUD. PFS and employment had significant negative associations with pain interference and medical comorbidity. ISEL-12 had a weak negative association with PTSD symptoms and non-PTSD psychiatric comorbidity. Common comorbidities thus significantly influence disability associated with PTSD, often more strongly than PTSD symptoms. PTSD treatment may require integrative multimorbidity management beyond a focus on PTSD symptoms. • In a national sample of patients with PTSD, we observed high prevalence of comorbidities and pain interference along with profound disability. • Comorbidities and pain interference had similar or larger negative associations than PTSD symptoms with mental well-being. • Pain interference and medical co-morbidity dominated negative relationships with physical wellbeing and employment. • SSubstance use disorders had minimal association only with employment. [ABSTRACT FROM AUTHOR]

Sexual violence is a major public health and human rights issue affecting more than 40% of women in the United States during their lifetimes. Although men and women experience sexual assault, women are at greatest risk. Populations uniquely impacted by sexual assault include adolescents; lesbian, gay, bisexual, transgender, and queer people; and active-duty military service members. Health consequences of sexual assault include sexually transmitted infections, risk of unintended pregnancy, high rates of mental health conditions (e.g., posttraumatic stress disorder), and development of chronic medical conditions (e.g., chronic pelvic pain). Family physicians care for sexual assault survivors at the time of the assault and years after, and care should follow a survivor-centered and trauma-informed framework. Multiple organizations recommend screening all women for a history of sexual violence; however, the U.S. Preventive Services Task Force recommends only universal intimate partner violence screening in women of reproductive age. A validated tool, such as the Two-Question Screening Tool, can be implemented. Initial care should include treatment of physical injuries, prophylaxis for sexually transmitted infections, immunizations, and the sensitive management of psychological issues. Clinicians must comply with state and local requirements for the use of evidence-gathering kits. Many hospitals have developed collection protocols and employ certified Sexual Assault Nurse Examiners or Sexual Assault Forensic Examiners. Prevention of sexual violence requires a comprehensive approach to address individual, relational, community, and societal factors. [ABSTRACT FROM AUTHOR]

Aims: To assess, by systematic review of the literature, (1) the prevalence and incidence of temporomandibular disorder (TMD) pain after whiplash trauma, and (2) whether treatment modalities commonly used for TMD are equally effective in patients with solely TMD pain and those with TMD/whiplash-associated disorders (WAD) pain. Methods: A systematic literature search of the PubMed, Cochrane Library, and Bandolier databases was conducted from January 1966 through October 2012. The systematic search identified 125 articles. After an initial screening of abstracts, 45 articles were reviewed in full text. Two investigators evaluated the methodological quality of each identified study. Results: Eight studies on prevalence/incidence of TMD pain in WAD and four studies on interventions in TMD pain and WAD met the inclusion criteria. The reported median prevalence of TMD pain after whiplash trauma was 23% (range 2.4% to 52%) and the incidence ranged from 4% to 34%. For healthy controls, the reported median prevalence was 3% (range 2.5% to 8%) and the incidence ranged from 4.7% to 7%. For patients with a combination of TMD pain and WAD, treatment modalities conventionally used for TMD, such as jaw exercises and occlusal splints, had less of an effect (median improvement rate of 48%, range 13% to 68%) compared to TMD patients without a whiplash injury (75%, range 51% to 91%). Conclusion: There is some evidence that prevalence and incidence of TMD pain is increased after whiplash trauma. The poorer treatment outcome suggests that TMD pain after whiplash trauma has a different pathophysiology compared to TMD pain localized to the facial region. [ABSTRACT FROM AUTHOR]

Abstract Background Patients are free to choose conventional or Korean medicine treatment under the dual medical system in Korea, and the prevalence of patients who choose Korean medicine treatment for whiplash-associated disorders (WADs) is high. This study analyzed the sociodemographic characteristics and medical service use in this population to provide healthcare providers with basic usage information of complementary and alternative medicine for WAD. Methods A total of 8291 outpatients who registered under automobile insurance coverage and visited the main branch of Jaseng Hospital of Korean Medicine from April 1, 2014 to August 10, 2016 were included. Data on sociodemographic characteristics, symptoms, and accident and treatment-related details were collected from electronic medical records. Univariate and multivariate regression analyses were performed to identify baseline factors predictive of total treatment duration. Results The most prevalent demographic of patients who chose Korean medicine for WAD treatment was males in their thirties whose initial visit to the hospital was 16.1 ± 94.1 days from the accident. Neck pain accompanied by low back pain (57.0%) was the most common complaint, and for singular pain, neck pain (13.5%) was the most prevalent. Baseline numeric rating scale (NRS) pain levels were generally moderate (4–6) regardless of area. Patients received 7.2 ± 10.2 sessions of treatment for 32.6 ± 55.3 days. The most commonly prescribed treatment modalities in order of highest frequency were acupuncture, cupping, pharmacopuncture, and herbal medicine, which collectively accounted for > 90% of treatments. Acupuncture was administered 29.0 ± 40.8 times, and cupping 14.0 ± 18.7 times as the two highest frequency treatments. In multivariate regression analysis, longer treatment periods were found to be associated with higher NRS, older age, and delayed initial visits at baseline. Conclusions This study highlights the characteristics and Korean medicine use of WAD patients. These results are particularly relevant and informative for consideration of personal preferences and effective prioritization in further insurance coverage.

Objective: to review the available scientific knowledge on whether a strategy combining therapeutic exercise and/or education or self-management techniques is a more effective than any other therapeutic intervention in whiplash injuries. Material and method: a literature search was conducted in Pubmed Central, Web of Science and PEDro with the following inclusion criteria: randomized controlled trials published between 2012 and 2017, classifying the pathology according to the Quebec Task Force and comparing at least one intervention based on thera-peutic exercise and /or education or self-management techniques. Results: we obtained 3.587 results, 13 of which were included to the narrative synthesis. The quality of the studies included varied between medium and high. These studies analyzed a variety of outcome measures that included: cervical function, disability, pain, cervical and global physical function, psychological variables, adherence and satisfaction. Conclusions: specific cervical exercise together with educational and self-management strategies improved the analyzed outcome measures and seem to be an effective therapeutic strategy. They could be used together, displacing unimodal strategies and passive modalities, which should be used as coadjuvants and not as therapeutic axes. Neck-specific exercise is superior to global exercise and to waiting list, but we cannot establish any specific program to be superior to another. [ABSTRACT FROM AUTHOR]

Introduction: traffic accidents cause 50 million injuries per year in the world, being 'cervical whiplash' one of the most common. This disorder affect structures such as upper limb nerve trunks, leading to changes in neural mechanosensitivity. Objective: to assess impairment mechanosensitivity of median, ulnar and radial nerves in subjects with whiplash associated disorder, compared to healthy asymptomatic subjects. Material and method: cross-sectional comparative study of cross association, with a total of 20 participants (10 symptomatic). A single experimental session was scheduled for each subject, where a researcher performed the upper limb neurodynamic tests, and another measured the ROM of the last parameter of each test with goniometry and the PPT of each nerve trunk with algometry. Results: the results of the mean ROM were: 106.82 ± 11.46 for the median, 57.94 ± 8.99 for the ulnar and 45.16 ± 11.08 for the radial, for the cases; while for the control group it was: 115.55 ± 10, 59.83 ± 7.36 and 70.64 ± 21.99, respectively. Regarding the UDP, the mean of the results was: 2.05 ± 0.52 of the median, 1.98 ± 0.68 of the ulnar and 2.08 ± 0.74 of the radial for the group of cases; while for the control group it was: 2.38 ± 0.67, 3.43 ± 0.83 and 3.55 ± 1.15 respectively. The study showed statistically significant differences for the shoulder ROM (p = 0.004), as well as for the UDP of the ulnar (p <0.001) and radial (p = 0.003). Conclusion: subjects with whiplash show less range of shoulder mobility, as well as greater sensitivity of the ulnar and radial nerves. [ABSTRACT FROM AUTHOR]

Introduction After the 1990 to 1991 conflict in the Persian Gulf, many Gulf War Veterans began reporting numerous unexplained symptoms including, but not limited to, systemic pain, fatigue, flu-like symptoms, and difficulty with memory/concentration. These symptom clusters are now referred to as Gulf War Illness (GWI). Although the etiology of GWI is still debated, as many as 250,000 former service members have been continually suffering from GWI since 1991, making the need for treatment urgent. A broad variety of treatments have been considered for GWI, but there has not been a broad and comprehensive assessment of what is known and not known about GWI treatment. We conducted a systematic review to catalogue the types of treatments that have been examined for GWI, to evaluate the effectiveness and harms of these interventions, and to identify promising and ongoing areas of future GWI treatment research. Materials and Methods We searched electronic databases, trial registries, and reference lists through September 2019 for randomized controlled trial and nonrandomized controlled trial and cohort studies directly comparing interventions for Veterans with GWI to each other, placebo, or usual care. We abstracted data on study design, demographics, interventions, and outcomes. Two reviewers independently assessed studies for inclusion, quality, and strength of evidence (SOE) using prespecified criteria. We resolved discordant ratings by discussion and consensus. Results We identified 12 randomized controlled trials, each of which examined a different intervention for GWI. We found moderate SOE that cognitive behavioral therapy and exercise, separately and in combination, were associated with improvements in several GWI symptom domains. There was low SOE of benefit from two mindfulness-based interventions and continuous positive airway pressure (CPAP). Mindfulness-based stress reduction improved pain, cognitive functioning, fatigue, depression, and posttraumatic stress disorder (PTSD), whereas mind-body bridging improved fatigue, depression, posttraumatic stress disorder, and sleep, although pain and other outcomes did not improve. Continuous positive airway pressure improved overall physical health, pain, cognitive functioning, fatigue, mental health, and sleep quality in a small study of Veterans with sleep-disordered breathing and GWI. We found moderate SOE that doxycycline is ineffective for GWI in mycoplasma DNA-positive Veterans and increases the risk of adverse events compared with placebo. We also found 33 ongoing, single-arm pilot, or unpublished studies examining a variety of interventions. Conclusion Cognitive behavioral therapy (moderate SOE), exercise (moderate SOE), and mindfulness-based interventions (low SOE) may be effective in improving several symptom domains in patients with GWI. Doxycycline was ineffective and associated with harms (moderate SOE). Larger, more rigorous studies are needed to confirm the benefits found in completed trials. A wide array of treatments are being assessed in ongoing trials. A sufficient evidence base will need to be developed to guide clinicians about which treatments are most likely to be effective in clinical practice and which treatments should be avoided. [ABSTRACT FROM AUTHOR]