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To investigate the effectiveness in individuals with chronic whiplash-associated disorders (WADs) of neck-specific exercise (NSE) supervised by a physiotherapist twice a week for 12 weeks versus neck-specific exercise with internet support and four physiotherapy visits (NSEIT) regarding dizziness, unsteadiness and balance, and to investigate the differences between WAD grades. This is a secondary analysis of a prospective randomised multicentre study (RCT) with concealed allocation (ClinicalTrials.gov Protocol ID: NCT03022812). The outcomes were dizziness measured on the Dizziness Handicap Inventory (DHI); dizziness at rest and during activity and unsteadiness using visual analogue scales; and standing on one leg with eyes closed (SOLEC). Participants (n = 140) were randomised to NSE or NSEIT. Measurements were obtained at baseline, and at three- and 15-month follow-ups by assessor-blinded investigators. There were no significant differences between NSEIT and NSE in any of the outcomes (p>0.38). Both NSEIT and NSE improved over time (p<0.02; effect size (ES) = 0.74-1.01) in DHI score and dizziness during activity. There was a significant group-by-time interaction effect in dizziness (at rest: p = 0.035; ES: 0.66; and during activity: p = 0.016; ES: 1.24) between WAD grades. Individuals with WAD grade 3 had dizziness/unsteadiness to a greater extent and improved in all outcomes over time (p<0.04) compared to those with WAD grade 2, except for SOLEC. There were no significant group differences between NSEIT and NSE. Both groups decreased in terms of self-reported dizziness (DHI, dizziness during activity), with medium to large effect size. Those with WAD grade 3 have dizziness/unsteadiness to a greater extent than those with WAD grade 2. Despite improvements, many participants still reported dizziness at 15-month follow-up, and additional balance training and/or vestibular exercise may be investigated for potential additional effect.

Neck-specific exercises (NSE) supervised by a physiotherapist twice a week for 12 weeks have shown good results in chronic whiplash-associated disorders (WADs), but the effect of exercise delivered via the internet is unknown. This study examined whether NSE with internet support (NSEIT) and 4 physiotherapy sessions for 12 weeks were noninferior to the same exercises supervised by a physiotherapist twice a week for 12 weeks (NSE). In this multicenter randomized controlled noninferiority trial with masked assessors, we recruited adults aged 18-63 years with chronic WAD grade II (ie, neck pain and clinical musculoskeletal signs) or III (ie, grade II plus neurological signs). Outcomes were measured at baseline and at 3- and 15-month follow-ups. The primary outcome was change in neck-related disability, measured with the Neck Disability Index (NDI; 0%-100%), with higher percentages indicating greater disability. Secondary outcomes were neck and arm pain intensity (Visual Analog Scale [VAS]), physical function (Whiplash Disability Questionnaire [WDQ] and Patient-Specific Functional Scale [PSFS]), health-related quality of life (EQ-5D-3L and EQ VAS), and self-rated recovery (Global Rating Scale [GRS]). The analyses were conducted on an intention-to-treat basis and with the per-protocol approach as sensitivity analyses. Between April 6, 2017, and September 15, 2020, 140 participants were randomly assigned to the NSEIT group (n=70) or the NSE group (n=70); 63 (90%) and 64 (91%), respectively, were followed up at 3 months, and 56 (80%) and 58 (83%), respectively, at 15 months. NSEIT demonstrated noninferiority to NSE in the primary outcome NDI, as the 1-sided 95% CI of the mean difference in change did not cross the specified noninferiority margin (7 percentage units). There were no significant between-group differences in change in NDI at the 3- or 15-month follow-up, with a mean difference of 1.4 (95% CI -2.5 to 5.3) and 0.9 (95% CI -3.6 to 5.3), respectively. In both groups, the NDI significantly decreased over time (NSEIT: mean change -10.1, 95% CI -13.7 to -6.5, effect size=1.33; NSE: mean change -9.3, 95% CI -12.8 to -5.7, effect size=1.19 at 15 months; P<.001). NSEIT was noninferior to NSE for most of the secondary outcomes except for neck pain intensity and EQ VAS, but post hoc analyses showed no differences between the groups. Similar results were seen in the per-protocol population. No serious adverse events were reported. NSEIT was noninferior to NSE in chronic WAD and required less physiotherapist time. NSEIT could be used as a treatment for patients with chronic WAD grades II and III. ClinicalTrials.gov NCT03022812; https://clinicaltrials.gov/ct2/show/NCT03022812.

Introduction Cervical kinesthesia is an important part of movement control and of great importance for daily function. Previous research on kinesthesia in whiplash-associated disorders (WAD) has focused on grades I-II. More research is needed on WAD grade III. The aim of this study was to investigate cervical kinesthesia in individuals with WAD grades II-III before and after a neck-specific exercise intervention and compare them to healthy controls. Methods A prospective, case-control study with a treatment arm ( n  = 30) and a healthy control arm ( n  = 30) was conducted in Sweden. The WAD group received a neck-specific exercise program for 12 weeks. The primary outcome to evaluate kinesthesia was neck movement control (the Fly test). Secondary outcomes were neck disability, dizziness and neck pain intensity before and after the Fly test. Outcomes were measured at baseline and post-treatment. The control arm underwent measurements at baseline except for the dizziness questionnaire. A linear mixed model was used to evaluate difference between groups (WAD and control) and over time, with difficulty level in the Fly test and gender as factors. Results Between-group analysis showed statistically significant differences in three out of five kinesthetic metrics ( p  = 0.002 to 0.008), but not for the WAD-group follow-up versus healthy control baseline measurements. Results showed significant improvements for the WAD-group over time for three out of five kinaesthesia metrics ( p  < 0.001 to 0.008) and for neck disability ( p  < 0.001) and pain ( p  = 0.005), but not for dizziness ( p  = 0.70). Conclusions The exercise program shows promising results in improving kinesthesia and reducing neck pain and disability in the chronic WAD phase. Future research might benefit from focusing on adding kinesthetic exercises to the exercise protocol and evaluating its beneficial effects on dizziness or further improvement in kinesthesia. Impact statement Kinesthesia can be improved in chronic WAD patients without the use of specific kinesthetic exercises. Trial registration ClinicalTrials.gov (NCT03664934), first registration approved 11/09/2018.

Abstract Objective Central sensitization is present in different pain conditions, including chronic whiplash-associated disorders. In the absence of a gold standard method of assessment to determine the presence of central sensitization, quantitative sensory testing is currently understood as an optimal proxy. Laboratory sensory testing is, however, not feasible in clinical practice, and the Central Sensitization Inventory was developed as an alternative. The aim of the current study was to evaluate the convergent validity of the Central Sensitization Inventory in chronic whiplash-associated patients by determining the association between the Central Sensitization Inventory and quantitative sensory testing, pain intensity, fatigue, and psychosocial factors. Methods A total of 125 chronic whiplash-associated patients completed multiple questionnaires and were subjected to pressure pain thresholds and temporal summation. Results . The Central Sensitization Inventory showed a strong association with constructs of general psychopathology, anxiety, distress, depression, and somatization in chronic whiplash-associated disorders. Moderate correlations were found with fatigue and intrusive and avoidant phenomena after a variety of traumatic events. No significant association was found between the Central Sensitization Inventory and pressure pain thresholds and temporal summation, nor between the Central Sensitization Inventory and other pain measurements. Conclusions Overall, we found that the Central Sensitization Inventory is better in identifying the psychosocial factors related to central sensitization in chronic whiplash-associated disorders than the central nervous system adaptations. Thus, the convergent validity of the Central Sensitization Inventory appears to be only partially present in chronic whiplash-associated disorders.

The purpose was to examine the participants' pain severity, pain interference, health-related quality of life (HRQoL), needs, access and use of healthcare services, and the difference between those reporting whiplash injury ( >12 months) with and without chronic pain and those without whiplash injury but with chronic pain. This is a cross-sectional cohort study. The survey was sent by email to a sample of 12,400 individuals, aged 18-78 years. The response rate was 45% (  = 5,557), of whom 929 (16.7%) experienced whiplash injury after an accident. Participants with whiplash injury (59%) were more likely to report chronic pain (≥3 months) than those without whiplash injury (36.3%) (  > 0.001). The participants with whiplash injury and chronic pain (  = 543, 59%) were significantly more likely to have more severe pain, lower HRQoL, be disabled, and live outside the capital area compared to those with whiplash injury but without chronic pain (  = 386, 41%). Whiplash injury was more common among younger individuals and women. Participants with whiplash injury had higher pain severity, pain interference and lower HRQoL compared to those without whiplash injury. Participants with whiplash injury were more likely to have chronic pain and most of them had constant pain.

Background The current study investigated Whiplash Associated Disorders (WAD) and health related quality of life (HRQOL) from the perspective of Swedish patients. Another aim was to assess medicine consumption and income loss due to WAD. Method The present study was a planned secondary analysis using baseline data from a prospective, multicentre randomized controlled trial. The study participants were WAD patients, victims of four-wheel motor vehicle collisions at least six months but not more than five years ago. Neck Disability Index and HRQOL were measured. HRQOL was measured by the EQ-5D instrument. Cross tabulations, Box Plots, and regression analyses were performed. Trial registration section The study was registered before data collection started (ClinicalTrials.gov Protocol ID: NCT03022812, initial release 12/20/2016). Results There were 137 WAD participants (78.8% women), and almost three-fourths (74.5%) were married. The majority (54.7%) of the WAD patients were in white-collar jobs, followed by blue-collar jobs (35%) and students /unemployed (10.2%). Both consumption of medicine for neck pain and income loss due to WAD have a negative relation with the Neck Disability Index (NDI). On average, EQ-VAS for WAD women is 58.21 (± 17.625), and for men, it is 61.11 (± 16.444). WAD patients with a university education have the highest EQ-VAS average of 60.42 (± 17.738). Conclusions The low HRQOL seen in WAD patients in this study should warrant the attention of the medical fraternity, researchers and policymakers.

Background Objective Studies of cross-sectional area (CSA) (morphology) and muscle fat infiltration (MFI) (composition) in ventral neck muscles is scarce in patients with chronic whiplash associated disorders (WAD), especially for men and those with severe WAD compared with matched healthy controls. The aim was to compare CSA and MFI of sternocleidomastoid (SCM), longus capitis (LCA) and longus colli (LCO) in patients with chronic right-sided dominant moderate (Neck Disability Index: NDI < 40) or severe WAD (NDI ≥ 40), compared to age- and sex-matched healthy controls. Methods Cross-sectional case–control study with blinded investigators. Thirty-one patients with chronic WAD (17 women and 14 men, mean age 40 years) (SD 12.6, range 20–62)) and 31 age- and sex-matched healthy controls underwent magnetic resonance imaging of ventral neck muscles segmental level C4. Results Unique to the severe group was a larger magnitude of MFI in right SCM ( p  = 0.02) compared with healthy controls. There was no significant difference between the groups with regards to the other muscles and measures. Conclusions Individuals with severe right-sided dominant WAD have a higher MFI in the right SCM compared to healthy controls. No other differences were found between the groups. The present study indicates that there are changes in the composition of muscles on the side of greatest pain.

ObjectiveThe aim of this meta-analysis was to determine the psychological impact associated with motor vehicle crash (MVC)-related physical injuries.DesignSystematic review and meta-analysis.Data sourcesMultiple search engines included MEDLINE (via OVID), PsycINFO and Embase, and studies were sourced from scientific journals, conference papers and doctoral theses.Study selectionA high-yield search strategy was employed. Terms like ‘psychological distress’, ‘depression’, ‘PTSD’ and ‘motor vehicle accident’ were employed. These key words were run primarily and secondary searches were then conducted in association with the major injury types. Studies needed to compare psychological distress in people injured in an MVC with uninjured controls who had not recently experienced an MVC.Data extractionSearches resulted in the identification of 2537 articles, and after eliminating duplicates and studies not meeting inclusion criteria, 24 studies were selected involving 4502 injured participants. These studies were entered into separate meta-analyses for mild to moderate traumatic brain injury (mTBI), whiplash-associated disorder (WAD) and spinal cord injury (SCI).ResultsElevated psychological distress was associated with MVC-related injuries with a large summary effect size in WAD (0.90), medium to large effect size in SCI (0.69) and small to medium effect size in mTBI (0.23). No studies meeting inclusion criteria were found for burns, fractures and low back injury. Increased psychological distress remains elevated in SCI, mTBI and WAD for at least 3 years post-MVC.ConclusionsRehabilitation strategies are needed to minimise distress subsequent to MVC-related physical injuries and the scientific robustness of studies requires improvement.

Objective Although the presence of neuropathic pain (NP) components has been reported in whiplash-associated disorders (WAD), no studies have analyzed the usefulness of NP screening questionnaires to detect NP components in WAD. This study aimed to assess the usefulness of 3 NP screening tools (Douleur Neuropathique 4 [DN4], self-administered Leeds Assessment of Neuropathic Symptoms and Signs [S-LANSS], and painDETECT questionnaire [PDQ]) to detect the presence of NP components in acute WAD. Design A cross-sectional study. Setting Hospital. Subjects Of 188 eligible individuals, 50 people (68% women, mean age = 40.3 ± 12.5 years) with acute WAD (52% Grade III) were included. Methods Specialized physicians initially screened participants for the presence of NP components according to clinical practice and international recommendations. After physician assessment, blinded investigators used NP screening questionnaires (DN4, S-LANSS, and PDQ) to assess participants within 2 weeks of their accident. The diagnostic accuracy of these tools was analyzed and compared with the reference standard (physicians’ assessments). Results The 3 screening questionnaires showed excellent discriminant validity (area under the curve: ≥0.8), especially S-LANSS (area under the curve: 0.9; P < .001). DN4 demonstrated the highest sensitivity (87%), followed by S-LANSS (75%), while S-LANSS and PDQ showed the highest specificity (85% and 82%, respectively). These tools demonstrated a strong correlation with the reference standard (S-LANSS: rho = 0.7; PDQ: rho = 0.62; DN4: rho = 0.7; all, P < .001). Conclusions The DN4, S-LANSS, and PDQ show excellent discriminant validity to detect the presence of NP components in acute WAD, especially S-LANSS. Initial screening with these tools might improve management of WAD.

BackgroundKinesiophobia and pain catastrophising may be associated with patients’ transition from having acute to chronic pain following a whiplash injury.ObjectiveTo systematically review and critically appraise the literature to determine whether kinesiophobia and pain catastrophising are associated with greater likelihood of patients developing chronic pain and disability following a whiplash injury.DesignA systematic review of the literatureData sourcesElectronic searches of PubMed, AMED, CINAHL, PsycINFO, and PubPsych, and grey literature were undertaken from inception to September 2017.Eligibility criteria for selecting studiesStudy selection was based on longitudinal studies evaluating how kinesiophobia and/or pain catastrophising at baseline are associated with pain intensity, disability or both after a whiplash injury.ResultsWe included 14 longitudinal studies that described 12 independent cohorts with a total sample of 2733 participants with whiplash-associated disorder. Kinesiophobia at baseline was not associated with pain intensity over time (three studies). Whether kinesiophobia at baseline was associated with disability was unclear as results were conflicting (six studies). There were also conflicting results when we examined the association between pain catastrophising and both pain intensity (five studies) and disability (eight studies).Summary/conclusionsKinesiophobia at baseline was not associated with pain intensity over time. There were conflicting results for the remaining analyses. The size of the associations was small. The overall quality of the evidence was very low.Trial registration numberCRD42016053864.