Predictive capacity of physical and psychological factors in whiplash

In a previous post, Steve George discussed the findings from a recent study investigating GP vs. PT treatment in whiplash.

Attached is a recent manuscript from Michele Sterling et al from the Whiplash and Diagnostic Unit at The University of Queensland, Australia.

This study prospectively investigated the predictive capacities of specific variables e.g. high initial levels of pain and disability, older age, cold hyperalgesia, impaired sympathetic vasoconstriction and moderate post-traumatic stress symptoms in sixty-five subjects who continued to suffer from persistent whpilash injury in the long-term (2-3 years). It is these factors that have been shown to be associated with poor outcome at 6 months following whiplash injury.

Essentially, the results from this study demonstrated that those subjects within the moderate-severe category (based on NDI score of > 30-main outcome measure) continued to demonstrate physical and psychological impairments in the long-term- 2-3 years, The strength of these measures suggests that it is important to consider their assessment in the acute stage following whiplash injury.

Download M_Sterling_Long_term_whiplash.pdf

Jim

Comments

[Steven George]

Jim - thanks for sharing that article with the readers. The clinical application of quantitative sensory testing was recently reviewed at the American Pain Society annual meeting, and this study will certainly add to this rather small literature. In response to this article, one thing our group may start doing is looking at cold responses, as we typically only do heat.

Interesting study and thanks for sharing.

[Rob Landel]

So, how does one use this information? The most obvious use would seem to be to intervene in the risk factors wherever possible. But that seems a bit shallow, doesn't it? Or am I missing something? In any case, PT has little to offer towards the top 4 predictors.

Another comment: how surprising is it that high intial NDI scores predict poor outcomes, when the NDI is the outcome? If they start out higher, wouldn't it make sense that they would remain higher?

I'd appreciate any comments people may have on the above. This is my area of weakness when it comes to EBP: critically appraising the literature, and applying it.

Rob

[Jim Elliott]

Rob
Great points! There is much work that remains unfinished with regards to the clinical assessment of said risk factors. That said there is a large need to make the sensory measures (Quantitative Sensory Testing-QST) a bit more clinician friendly. There is some preliminary work towards this but it is realistically a few years away from being able to be implemented in the clinic. At the moment, collecting data with the NDI and Impact Events Scale (for post-traumatic stress) may be the best we can do with these patients who are suffering from an acute whiplash injury.

Regarding this study- it is interesting to note that it was only the pts with mod-sev symptoms (NDI > 30) who continued to present with specific physical and psychological impairments in the long-term whereas the recovered group (NDI - 9-29) demonstrated a parallel reduction in NDI scores and psychological distress over time. As such, this preliminary work suggests that the NDI is likely one of the best clinical tools we have to better classify these often recalcitrant pts in the clinic. Also, there are others who are currently investigating the outcomes of multi-modal PT treatment of acute whiplash pts based on the presence (or absence) of the above mentioned risk factors. Obviously, the ultimate goal is to better identify these patients, develop evidence based treatments and hopefully reduce the number of patients who transition from acute to chronic pain.
I'd appreciate any additional comments people may have in relation to this body of work.
Thanks