title: Randomized controlled trial of exercise for chronic whiplash-associated disorders Evaluation of the Quality of Prognosis Studies in Systematic Reviews Randomised trial of a brief physiotherapy intervention compared with usual physiotherapy for neck pain patients: outcomes and patients' preference Can Chronic Disability Be Prevented?: A Randomized Trial of a Cognitive-Behavior Intervention and Two Forms of Information for Patients With Spinal Pain Population based intervention to change back pain beliefs: three year follow up population survey A Psycho-Educational Video Used in the Emergency Department Provides Effective Treatment for Whiplash Injuries Education of Patients After Whiplash Injury: Is Oral Advice Any Better Than a Pamphlet? Naprapathic Manual Therapy or Evidence-based Care for Back and Neck Pain: A Randomized, Controlled Trial Population based intervention to change back pain beliefs and disability: three part evaluation Randomized Trial of Therapeutic Massage for Chronic Neck Pain Does the presence of sensory hypersensitivity influence outcomes of physical rehabilitation for chronic whiplash? – A preliminary RCT The Treatment of Neck and Low Back Pain: Who Seeks Care? Who Goes Where? Impact of a Web-Based Stress Management and Health Promotion Program on Neck-Shoulder-Back Pain in Knowledge Workers? 12 Month Prospective Controlled Follow-Up Emergency department treatments and physiotherapy for acute whiplash: a pragmatic, two-step, randomised controlled trial Effectiveness of small daily amounts of progressive resistance training for frequent neck/shoulder pain: Randomised controlled trial The reliability of the Vernon and Mior neck disability index, and its validity compared with the short form-36 health survey questionnaire The annual incidence and course of neck pain in the general population: a population-based cohort study Efficacy of a Patient-Educational Booklet for Neck-Pain Patients With Workers' Compensation: A Randomized Controlled Trial A Randomized Controlled Trial of an Educational Intervention to Prevent the Chronic Pain of Whiplash Associated Disorders Following Rear-End Motor Vehicle Collisions Predictors of Poor Outcome in Patients With Neck Pain Treated by Physical Therapy The effectiveness of a 6-week Pilates programme on outcome measures in a population of chronic neck pain patients: a pilot study. Effects of a Media Campaign on Back Beliefs is Sustained 3 Years After Its Cessation 2001 Volvo Award Winner in Clinical Studies: Effects of a Media Campaign on Back Pain Beliefs and Its Potential Influence on Management of Low Back Pain in General Practice Managing Injuries of the Neck Trial (MINT): a randomised controlled trial of treatments for whiplash injuries. A new system for grading recommendations in evidence based guidelines Screening to Identify Patients at Risk: Profiles of Psychological Risk Factors for Early Intervention A randomized controlled intervention trial to relieve and prevent neck/shoulder pain. Sensitivity to Change and Internal Consistency of the Northwick Park Neck Pain Questionnaire and Derivation of a Minimal Clinically Important Difference Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability
abstract: Abstract Whiplash‐associated disorders are common and incur considerable expense in social and economic terms . There are no known effective treatments for those people whose pain and disability persist beyond 3 months . We conducted a r and omized , assessor‐blinded , controlled trial at two centres in Australia . All participants received 3 advice sessions . In addition the experimental group participated in 12 exercise sessions over 6 weeks . Primary outcomes were pain intensity , pain bothersomeness and function measured at 6 weeks and 12 months . Exercise and advice was more effective than advice alone at 6 weeks for all primary outcomes but not at 12 months . The effect of exercise on the 0–10 pain intensity scale was −1.1 ( 95%CI −1.8 to −0.3 , p = 0.005 ) at 6 weeks and −0.2 ( 0.6 to −1.0 , p = 0.59 ) at 12 months ; on the bothersomeness scale the effect was −1.0 ( −1.9 to −0.2 , p = 0.003 ) at 6 weeks and 0.3 ( −0.6 to 1.3 , p = 0.48 ) at 12 months . The effect on function was 0.9 ( 0.3 to 1.6 , p = 0.006 ) at 6 weeks and 0.6 ( −0.1 to 1.4 , p = 0.10 ) at 12 months . High levels of baseline pain intensity were associated with greater treatment effects at 6 weeks and high levels of baseline disability were associated with greater treatment effects at 12 months . In the short‐term exercise and advice is slightly more effective than advice alone for people with persisting pain and disability following whiplash . Exercise is more effective for subjects with higher baseline pain and disability Prognosis studies are investigations of future events or the evaluation of associations between risk factors and health outcomes in population s of patients ( 1 ) . The results of such studies improve our underst and ing of the clinical course of a disease and assist clinicians in making informed decisions about how best to manage patients . Prognostic research also informs the design of intervention studies by helping define subgroups of patients who may benefit from a new treatment and by providing necessary information about the natural history of a disorder ( 2 ) . There has recently been a rapid increase in the use of systematic review methods to synthesize the evidence on research questions related to prognosis . It is essential that investigators conducting systematic review s thoroughly appraise the method ologic quality of included studies to be confident that a study 's design , conduct , analysis , and interpretation have adequately reduced the opportunity for bias ( 3 , 4 ) . Caution is warranted , however , because inclusion of method ologically weak studies can threaten the internal validity of a systematic review ( 4 ) . This follows abundant empirical evidence that inadequate attention to biases can cause invalid results and inferences ( 5 - 9 ) . However , there is limited consensus on how to appraise the quality of prognosis studies ( 1 ) . A useful framework to assess bias in such studies follows the basic principles of epidemiologic research ( 10 , 11 ) . We focus on 6 areas of potential bias : study participation , study attrition , prognostic factor measurement , confounding measurement and account , outcome measurement , and analysis . The main objectives of our review of review s are to describe methods used to assess the quality of prognosis studies and to describe how well current practice s assess potential biases . Our secondary objective is to develop recommendations to guide future quality appraisal , both within single studies of prognostic factors and within systematic review s of the evidence . We hope this work facilitates future discussion and research on biases in prognosis studies and systematic review s. Methods Literature Search and Study Selection We identified systematic review s of prognosis studies by search ing MEDLINE ( 1966 to October 2005 ) using the search strategy recommended by McKibbon and colleagues ( 12 ) . This strategy combines broad search terms for systematic review s ( systematic review .mp ; meta- analysis .mp ) and a sensitive search strategy for prognosis studies ( cohort , incidence , mortality , follow-up studies , prognos * , predict * , or course ) . We also search ed the reference lists of included review s and method ologic papers to identify other relevant publications . We restricted our search to English- language publications . One review er conducted the search and selected the studies . Systematic review s , defined as review s of published studies with a comprehensive search and systematic selection , were included if they assessed the method ologic quality of the included studies by using 1 or more explicit criteria . We excluded studies if they were meta-analyses of independent patient data only , if their primary goal was to investigate the effectiveness of an intervention or specific diagnostic or screening tests , or if they included studies that were not done on humans . Data Extraction and Synthesis Individual items included in the quality assessment of the systematic review s were recorded as they were reported in the publication ( that is , the information that would be available to readers and future review ers ) . We review ed journal Web sites and contacted the authors of the systematic review s for additional information when authors made such an offer in their original papers . When review s assessed different study design s by using different sets of quality items , we extracted only those items used to assess cohort studies . We constructed a comprehensive list of distinct items that the review s used to assess the quality of their included studies . The full text of each review was screened . All items used by the review authors to assess the quality of studies were extracted into a computerized spreadsheet by 1 review er . Two experienced review ers , a clinical epidemiologist and an epidemiologist , independently synthesized the quality items extracted from the prognosis review s to determine how well the systematic review s assessed potential biases . We did this in 3 steps : 1 ) identified distinct concepts or domains addressed by the quality items ; 2 ) grouped each extracted quality item into the appropriate domain or domains ; and 3 ) identified the domains necessary to assess potential biases in prognosis studies . We then used this information to assess how well the review s ' quality assessment included items from the domains necessary to assess potential biases . After completing each of the first 3 steps , the review ers met to attempt to reach a consensus . The consensus process involved each review er presenting his or her observations and results , followed by discussion and debate . A third review er was available in cases of persistent disagreement or uncertainty . In the first step , all domains addressed by the quality items were identified . The first review er iteratively and progressively defined the domains as items were extracted from the included review s. The second review er defined domains from a r and om list of all extracted quality items . Limited guidance was provided to the review ers so that their assessment s and definitions of domains would be independent . The review ers agreed on a final set of domains that adequately and completely defined all of the extracted items . In the second step , review ers independently grouped each extracted item into the appropriate domains . Review ers considered each extracted item by asking , What is each particular quality item addressing ? or What are the review 's authors getting at with the particular quality assessment item ? . Items were grouped into the domain or domains that best represented the concepts being addressed . For example , the extracted items at least 80 % of the group originally identified was located for follow-up and follow-up was sufficiently complete or does n't jeopardize validity were each independently classified by both review ers as assessing the domain completeness of follow-up adequate , whereas the extracted item quantification and description of all subjects lost to follow-up was classified as assessing the domain completeness of follow-up described . In the third step , we identified the domains necessary to assess potential biases . Each review er considered the ability of the identified domains to adequately address , at least in part , 1 of the following 6 potential biases : 1 ) study participation , 2 ) study attrition , 3 ) prognostic factor measurement , 4 ) confounding measurement and account , 5 ) outcome measurement , and 6 ) analysis . Domains were considered to adequately address part of the framework if information garnered from that domain would inform the assessment of potential bias . For example , both review ers judged that the identified domain study population represents source population or population of interest assessed potential bias in a prognosis study , whereas the domain research question definition did not , although the latter is an important consideration in assessing the inclusion of studies in a systematic review . Finally , on the basis of our previous ratings , we looked at whether each review included items from the domains necessary to assess the 6 potential biases . We calculated the frequency of systematic review s by assessing each potential bias and the number of review s that adequately assessed bias overall . From this systematic synthesis , we developed recommendations for improving quality appraisal in future systematic review s of prognosis studies . We used Microsoft Access and Excel 2002 ( Microsoft Corp. , Redmond , Washington ) for data management and SAS for Windows , version 9.1 ( SAS Institute , Inc. , Cary , North Carolina ) for descriptive statistics . Role of the Funding Sources The funding sources , the Canadian Institutes of Health Research , the Canadian Chiropractic Research Foundation , the Ontario Chiropractic Association , and the Ontario Ministry of Health and Long Term Care , did not have a role in the collection , analysis , or interpretation of the data or in the decision to su bmi t the manuscript for publication . Results We identified 1384 potentially relevant articles . Figure 1 shows a flow chart of studies that were included and excluded . Figure 2 shows the number of review s identified by year of publication . We excluded 131 systematic review s of prognosis studies that did not seem to include any quality assessment of the included studies ; this represented 44 % of prognosis review s. We included 163 review s of prognosis studies in our analysis ( 13 - 175 ) . The most common topics were cancer ( 15 % ) , musculoskeletal disorders and rheumatology ( 13 % ) , cardiovascular ( 10 % ) , neurology ( 10 % ) , and obstetrics ( 10 % ) . Other review s included a wide range of health and health care topics . Sixty-three percent of the review s investigated the association between a specific prognostic factor and a particular outcome ; the remainder investigated multiple prognostic factors or models . The number of primary studies included in each systematic review ranged from 3 to 167 ( median , 18 [ interquartile range , 12 to 31 ] ) . A complete description of the included review s is available from the authors on request . Figure 1 . Flow diagram of inclusion and exclusion criteria of systematic review s. Figure 2 . Number of systematic review s of prognosis studies identified over time . Quality Items One hundred fifty-three review s provided adequate detail to allow extraction of quality items . Eight hundred eighty-two distinct quality items were extracted from the review s. Most review s developed their own set of quality items , with only a few applying criteria from previous review s. Most quality items Abstract Objectives Firstly , to compare the effectiveness of a brief physiotherapy intervention with “ usual ” physiotherapy for patients with neck pain . Secondly , to evaluate the effect of patients ' preferences on outcome . Design Non-inferiority r and omised controlled trial eliciting preferences independently of r and omisation . Setting Physiotherapy departments in a community setting in Yorkshire and north Lincolnshire . Participants 268 patients ( mean age 48 years ) with subacute and chronic neck pain , who were referred by their general practitioner and r and omly assigned to a brief physiotherapy intervention ( one to three sessions ) using cognitive behaviour principles to encourage self management and return to normal function or usual physiotherapy , at the discretion of the physiotherapist concerned . Main outcome measures The Northwick Park neck pain question naire ( NPQ ) , a specific measure of functional disability result ing from neck pain . Also , the short form 36 ( SF-36 ) question naire , a generic , health related , quality of life measure ; and the Tampa scale for kinesophobia , a measure of fear and avoidance of movement . Results At 12 months , patients allocated to usual physiotherapy had a small but significant improvement in NPQ scores compared with patients in the brief intervention group ( mean difference 1.99 , 95 % confidence interval 0.45 to 3.52 ; P = 0.01 ) . Although the result shows a significant inferiority of the intervention , the confidence interval shows that the effect could be in the non-inferiority range for the brief intervention ( below 1.2 points of NPQ score ) . Patients who preferred the brief intervention and received this treatment had similar outcomes to patients receiving usual physiotherapy . Conclusions Usual physiotherapy may be only marginally better than a brief physiotherapy intervention for neck pain . Patients with a preference for the brief intervention may do at least as well with this approach . Additional training for the physiotherapists in cognitive behaviour techniques might improve this approach further Study Design . A r and omized controlled design superimposed on treatment as usual was used to compare the effects of a cognitive-behavior intervention aim ed at preventing chronicity with two different forms of information . Objective . To develop a coping-oriented preventive intervention applicable in primary care , and to compare its impact with educational information . Summary of Background Data . Preventing long-term disability result ing from spinal pain has proved difficult . The information provided by health care professions and early interventions aim ed at preventing long-term disability may be important , but little scientific evidence exists concerning their use . Methods . A protocol for a six-session cognitive-behavior group intervention was developed on the basis of earlier research . The main focus was to prevent long-term disability by changing patients ’ behaviors and beliefs so they can cope better with their problems . Comparison groups received either a pamphlet shown earlier to have an effect , or a more extensive information package consisting of six installments . All the groups continued to receive treatment as usual in primary care . There were 243 patients with acute or subacute spinal pain who perceived that they were at risk for developing a chronic problem . These patients were r and omized to the cognitive-behavioral intervention or one of the two information groups . Because the aim was to prevent long-term disability , the key outcome variables at the 1-year follow-up assessment were sick absenteeism and health care use . Other variables were pain , function , fear-avoidance beliefs , and cognitions . Results . The comparison groups reported benefits . However , the risk for a long-term sick absence developing was lowered ninefold for the cognitive-behavior intervention group as compared with the risk for the information groups ( relative risk , 9.3 ) . Participants in the cognitive-behavior group also reported a significant decrease in perceived risk . In addition , the cognitive-behavior group demonstrated a significant decrease in physician and physical therapy use as compared with two groups receiving information , in which such use increased . All three groups tended to improve on the variables of pain , fear-avoidance , and cognitions . Conclusions . This study demonstrates that a cognitive-behavior group intervention can lower the risk of a long-term disability developing . These findings underscore the significance of early interventions that specifically aim to prevent chronic problems . This approach might be applied to primary care setting We previously reported the positive results of a  population based campaign design ed to alter beliefs about back pain in Victoria , Australia.1 2 The campaign consisted of television commercials which gave clear advice about back pain — for example , stay active and exercise , do not rest for prolonged periods , and stay at work . After the intervention , doctors ' and the community 's beliefs about back pain became significantly more positive , and the number of workers ' cl aims for compensation and medical payments for back pain had declined . To measure sustained change in beliefs about back pain three years after the campaign ended , we repeated telephone surveys in Victoria and in adjacent New South Wales as a control . We used computer assisted question naires given by telephone interview to a r and om sample of the population of Victoria and New South Wales in December Study Design . R and omized control trial conducted between June 2000 and September 2002 . Objective . To determine whether a short psycho-educational video shown in the Emergency Department shortly after the injury would produce follow-up pain reductions and reduced medical utilization . Summary of Background Data . Chronic pain following a whiplash injury is one example of the massive medical/legal problem of chronic muscular pain . Approaches using local pain sources ( trigger points ) have shown promise as treatment models for this type of pain . Methods . 1 ) Setting : Emergency Departments ( ED ) and urgent care ( UC ) facilities . 2 ) Patients : 126 patients entering EDs or UCs . 3 ) Intervention : Patients assigned to 12-minute video or care as usual . 4 ) Main Outcome Measures : Short Form Musculoskelatal Function Assessment ( SMFA ) , phone question naires assessing : narcotics use , ER use , UC use , surgical consultations , etc . Results and Conclusions . Patients viewing the video had dramatically lower pain ratings at a 1-month follow ( 6.09 [ 10.6 ] vs. 21.23 [ 17.4 ] , P < 0.001 ) and this pattern held for the 3- and 6-month follow-up period . Similarly , for 17 of 21 items asked at follow-up , the video group showed superior outcomes ( & khgr;2 ranged from 5 to 35 , P < 0.05 , all ) . For example , 4 % of video patients were using narcotics at 6 month post ED visit compared with 36 % of controls . The brief psycho-educational video had a profound effect on subsequent pain and medical utilization Study Design . R and omized parallel-group trial with 1-year follow-up . Objective . To evaluate whether education of patients communicated orally by a specially trained nurse is superior to giving patients a pamphlet after a whiplash injury . Summary of Background Data . Long-lasting pain and physical disability after whiplash injuries are related to both serious personal suffering and huge socio-economic costs . Pure educational interventions after such injuries seem generally as effective as more costly interventions , but it is unknown if the way advice is communicated is of any importance . Methods . Participants with relatively mild complaints after car collisions were recruited from emergency departments and GPs . A total of 182 participants were r and omized to either : ( 1 ) a 1 hour-educational session with a specially trained nurse , or ( 2 ) an educational pamphlet . Outcome parameters were neck pain , headache , disability , and return to work . Recovery was defined as scoring pain 0 or 1 ( 0–10 point scale ) and not being off sick at the time of the follow-ups . Results . After 3 , 6 , and 12 months 60 % , 58 % , and 66 % , respectively of the participants had recovered . Group differences were nonsignificant on all outcome parameters , even though the outcome tended to be better for the group receiving personal advice . Conclusion . Prognosis did not differ between patients who received personal education and those who got a pamphlet . However , a systematic tendency toward better outcome with personal communicated information was observed and the question how patients should be educated to reduce the risk of chronicity after whiplash is worth further investigation , since no treatment have been proven to prevent long-lasting symptoms , and all forms of advice or educational therapy are so cheap that even a modest effect justifies its use Objectives To compare naprapathic manual therapy with evidence -based care for back or neck pain regarding pain , disability , and perceived recovery . Naprapathy that is common in the Nordic countries and in some states in the United States is characterized by manual manipulations with a focus on soft and connective tissues , aim ing to decrease pain and disability in the musculoskeletal system . Methods Four hundred and nine patients with pain and disability in the back or neck lasting for at least 2 weeks , recruited at 2 large public companies in Sweden in 2005 , were included in this r and omized controlled trial . The 2 interventions were naprapathy , including spinal manipulation/mobilization , massage , and stretching ( Index Group ) and support and advice to stay active and how to cope with pain , according to the best scientific evidence available , provided by a physician ( Control Group ) .  Pain , disability , and perceived recovery were measured by question naires at baseline and after 3 , 7 , and 12 weeks . Results At 7-week and 12-week follow-ups , statistically significant differences between the groups were found in all outcomes favoring the Index Group . At 12-week follow-up , a higher proportion in the naprapathy group had improved regarding pain [ risk difference (RD)=27 % , 95 % confidence interval ( CI ) : 17 - 37 ] , disability ( RD=18 % , 95 % CI : 7 - 28 ) , and perceived recovery ( RD=44 % , 95 % CI : 35 - 53 ) . Separate analysis of neck pain and back pain patients showed similar results . Discussion This trial suggests that combined manual therapy , like naprapathy , might be an alternative to consider for back and neck pain patients Abstract Objective : To evaluate the effectiveness of a population based , state-wide public health intervention design ed to alter beliefs about back pain , influence medical management , and reduce disability and costs of compensation . Design : Quasi-experimental , non-r and omised , non-equivalent , before and after telephone surveys of the general population and postal surveys of general practitioners with an adjacent state as control group and descriptive analysis of cl aims data base . Setting : Two states in Australia . Participants : 4730 members of general population before and two and two and a half years after campaign started , in a ratio of 2:1:1 ; 2556 general practitioners before and two years after campaign onset . Main outcome measures : Back beliefs question naire , knowledge and attitude statements about back pain , incidence of workers ' financial compensation cl aims for back problems , rate of days compensated , and medical payments for cl aims related to back pain and other cl aims . Results : In the intervention state beliefs about back pain became more positive between successive surveys ( mean improvement in question naire score 1.9 ( 95 % confidence interval 1.3 to 2.5 ) , P<0.001 and 3.2 ( 2.6 to 3.9 ) , P<0.001 , between baseline and the second and third survey , respectively ) . Beliefs about back pain also improved among doctors . There was a clear decline in number of cl aims for back pain , rates of days compensated , and medical payments for cl aims for back pain over the duration of the campaign . Conclusions : A population based strategy of provision of positive messages about back pain improves population and general practitioner beliefs about back pain and seems to influence medical management and reduce disability and workers ' compensation costs related to back pain . What is already known on this topic The number of people with disability from back pain has risen rapidly in the past 50 years Most attempts to limit this disability include modification of occupational risk factors or dealing with the problem once it has developed Patients ' attitudes and beliefs play an important part in the development of such chronic disability What this study adds A population based primary prevention intervention that provided explicit advice about back pain improved beliefs about back pain in the general population and knowledge and attitudes in general practitioners The number of workers ' compensation cl aims for back pain decreased and the rate of days compensated and medical payments for back cl aims were Objectives Little is known about the effectiveness of therapeutic massage , one of the most popular complementary medical treatments for neck pain . A r and omized controlled trial was conducted to evaluate whether therapeutic massage is more beneficial than a self-care book for patients with chronic neck pain . Methods Sixty-four such patients were r and omized to receive up to 10 massages over 10 weeks or a self-care book .  Follow-up telephone interviews after 4 , 10 , and 26 weeks assessed outcomes including dysfunction and symptoms . Log-binomial regression was used to assess whether there were differences in the percentages of participants with clinical ly meaningful improvements in dysfunction and symptoms ( ie , > 5-point improvement on the Neck Disability Index ; > 30 % improvement from baseline on the symptom bothersomeness scale ) at each time point . Results At 10 weeks , more participants r and omized to massage experienced clinical ly significant improvement on the Neck Disability Index [ 39 % vs. 14 % of book group ; relative risk (RR)=2.7 ; 95 % confidence interval ( CI ) , 0.99 - 7.5 ] and on the symptom bothersomeness scale ( 55 % vs. 25 % of book group ; RR=2.2 ; 95 % CI , 1.04 - 4.2 ) . After 26 weeks , massage group members tended to be more likely to report improved function ( RR=1.8 ; 95 % CI , 0.97 - 3.5 ) , but not symptom bothersomeness ( RR=1.1 ; 95 % CI , 0.6 - 2.0 ) . Mean differences between groups were strongest at 4 weeks and not evident by 26 weeks . No serious adverse experiences were reported . Conclusions This study suggests that massage is safe and may have clinical benefits for treating chronic neck pain at least in the short term . A larger trial is warranted to confirm these results Abstract Patients with chronic whiplash associated disorders present with varied sensory , motor and psychological features . In this first instance it was question ed whether a multimodal program of physical therapies was an appropriate management to be broadly prescribed for these patients when it was known that some would have sensory features suggestive of a notable pain syndrome . A r and omised controlled trial was conducted with 71 participants with persistent neck pain following a motor vehicle crash to explore this question . Participants were r and omly allocated to receive either a multimodal physiotherapy program ( MPT ) or a self‐management program ( SMP ) ( advice and exercise ) . In the r and omisation process , participants were stratified according to the presence or not of widespread mechanical or cold hyperalgesia . The intervention period was 10 weeks and outcomes were assessed immediately following treatment . Even with the presence of sensory hypersensitivity in 72.5 % of subjects , both groups reported some relief of neck pain and disability ( Neck Disability Index ) and it was superior in the group receiving multimodal physiotherapy ( p = 0.04 ) . Post‐hoc observations however suggested that relief was marginal in the subgroup with both widespread mechanical and cold hyperalgesia . Further research is required to test the validity of this sub‐group observation and to test the effect of the intervention in the long term Background .Neck and low back pain are leading causes of morbidity and health care utilization . However , little is known about the characteristics that differentiate those who seek from those who do not seek health care for their pain . Objectives .The objectives of this study were to : 1 ) describe health care utilization for neck and back pain ; 2 ) determine the characteristics of individuals seeking health care for neck and back pain ; and 3 ) identify the characteristics of patients who consult medical doctors , chiropractors , or both .  Design . Population -based cross-sectional mailed survey . Subjects . Subjects were r and omly selected adults from the Saskatchewan Health Insurance and Registration File . Measures .Demographic , socio-economic , general health , comorbidity , health-related- quality -of-life , pain severity and health care utilization data were collected . The main outcome was whether subjects with prevalent neck or low back pain visited a  health care provider in the previous month . Results .Twenty-five percent of individuals with neck or low back pain visited a health care provider . Seeking health care was associated with disabling neck or back pain , digestive disorders , worse bodily pain and worse physical-role-functioning . Compared with medical patients , fewer chiropractic patients lived in rural areas or reported arthritis , but they reported better social and physical functioning . More patients consulting both providers reported disabling neck or back pain . Conclusions .Individuals seeking care for neck or back pain have worse health status than those who do not seek care . Patients consulting chiropractors alone report fewer comorbidities and are less limited in their activities than those consulting medical doctors Objective : To evaluate the influence of a web-based stress management program on  neck – shoulder – back pain and perceived pain-relatedness to stress in a prospect i ve and controlled study . Methods : Study points were baseline , after 6 months intervention and at 12 months follow-up on 226 news media employees in two study groups and one control group . Results : Between groups no significant differences were found at any study point . Within groups , the study group with less intensive program improved in pain-relatedness to stress at follow-up . Between baseline and after intervention , the group with more intensive program showed decreased low back pain , and the control group showed less pain-relatedness to stress . Within group differences varied according to pain localization and were inconsistent . Conclusion : Present web-based stress management program did not influence neck-shoulder-back pain or perceived pain-relatedness to stress in stress-intensive occupations BACKGROUND Little is known about the effectiveness of treatments for acute whiplash injury . We aim ed to estimate whether training of staff in emergency departments to provide active management consultations was more effective than usual consultations ( Step 1 ) and to estimate whether a physiotherapy package was more effective than one additional physiotherapy advice session in patients with persisting symptoms ( Step 2 ) . METHODS Step 1 was a pragmatic , cluster r and omised trial of 12 NHS Trust hospitals including 15 emergency departments who treated patients with acute whiplash associated disorder of grade s I-III . The hospitals were r and omised by clusters to either active management or usual care consultations . In Step 2 , we used a nested individually r and omised trial . Patients were r and omly assigned to receive either a package of up to six physiotherapy sessions or a single advice session . R and omisation in Step 2 was stratified by centre . Investigator-masked outcomes were obtained at 4 , 8 , and 12 months . Masking of clinicians and patients was not possible in all steps of the trial . The primary outcome was the Neck Disability Index ( NDI ) . Analysis was intention to treat , and included an economic evaluation . The study is registered IS RCT N33302125 . FINDINGS Recruitment ran from Dec 5 , 2005 to Nov 30 , 2007 . Follow-up was completed on Dec 19 , 2008 . In Step 1 , 12 NHS Trusts were r and omised , and 3851 of 6952 eligible patients agreed to participate ( 1598 patients were assigned to usual care and 2253 patients were assigned to active management ) . 2704 ( 70 % ) of 3851 patients provided data at 12 months . NDI score did not differ between active management and usual care consultations ( difference at 12 months 0·5 , 95 % CI -1·5 to 2·5 ) . In Step 2 , 599 patients were r and omly assigned to receive either advice ( 299 patients ) or a physiotherapy package ( 300 patients ) . 479 ( 80 % ) patients provided data at 12 months . The physiotherapy package at 4 months showed a modest benefit compared to advice ( NDI difference -3·7 , -6·1 to -1·3 ) , but not at 8 or 12 months . Active management consultations and the physiotherapy package were more expensive than usual care and single advice session . No treatment-related serious adverse events or deaths were noted . INTERPRETATION Provision of active management consultation did not show additional benefit . A package of physiotherapy gave a modest acceleration to early recovery of persisting symptoms but was not cost effective from a UK NHS perspective . Usual consultations in emergency departments and a single physiotherapy advice session for persistent symptoms are recommended . FUNDING NIHR Health Technology Assessment programme & NA ; Regular physical exercise is a cornerstone in rehabilitation programs , but adherence to comprehensive exercise remains low . This study determined the effectiveness of small daily amounts of progressive resistance training for relieving neck/shoulder pain in healthy adults with frequent symptoms ; 174 women and 24 men working at least 30 h per week and with frequent neck/shoulder pain were r and omly assigned to resistance training with elastic tubing for 2 or 12 minutes per day 5 times per week , or weekly information on general health ( control group ) . Primary outcomes were changes in intensity of neck/shoulder pain ( scale 0 to 10 ) , examiner‐verified tenderness of the neck/shoulder muscles ( total tenderness score of 0 to 32 ) , and isometric muscle strength at 10 weeks . Compared with the control group , neck/shoulder pain and tenderness , respectively , decreased 1.4 points ( 95 % confidence interval −2.0 to −0.7 , p < 0.0001 ) and 4.2 points ( 95 % confidence interval −5.7 to −2.7 , p < 0.0001 ) in the 2‐minute group and 1.9 points ( 95 % confidence interval −2.5 to −1.2 , p < 0.0001 ) and 4.4 points ( 95 % confidence interval −5.9 to −2.9 , p < 0.0001 ) in the 12‐minute group . Compared with the control group , muscle strength increased 2.0 Nm ( 95 % confidence interval 0.5 to 3.5 Nm , p = 0.01 ) in the 2‐minute group and 1.7 Nm ( 95 % confidence interval 0.2 to 3.3 Nm , p = 0.02 ) in the 12‐minute group . In conclusion , as little as 2 minutes of daily progressive resistance training for 10 weeks results in clinical ly relevant reductions of pain and tenderness in healthy adults with frequent neck/shoulder symptoms . Trial registration : www.is rct n.org/IS RCT N60264809 . In generally healthy adults with frequent neck/shoulder muscle pain , as little as 2 minutes of daily progressive resistance training reduces pain and tenderness Prospect i ve single cohort study . To evaluate the NDI by comparison with the SF36 health Survey Question naire . The NDI is a simple ten-item question naire used to assess patients with neck pain . The SF36 measures functional ability , well being and the overall health of patients . It is used as a gold st and ard in health economics to assess the health utility , gain and economic impact of medical interventions . One hundred and sixty patients with neck pain attending the spinal clinic completed self- assessment question naires .  A second question naire was completed in 34 patients after a period of 1–2 weeks . The internal consistency of the NDI and SF36 was calculated using Cronbach ’s alpha . The test – retest reliability was assessed using the Bl and and Altman method . The concurrent validity of the NDI with respect to the SF-36 was assessed using Pearson correlations . Both question naires showed robust internal consistency : Cronbach ’s alpha for the NDI scale was acceptable ( 0.864 , 95 % confidence limits 0.825–0.894 ) though slightly smaller than that of the SF36 . The correlations between each item of the NDI scores and the total NDI score ranged from 0.447 to 0.659 , ( all with P < 0.001 ) . The test – retest reliability of the NDI was high ( intra-class correlation 0.93 , 95 % confidence limits 0.86–0.97 ) and comparable with the best values found for SF36 . The correlations between NDI and SF36 domains ranged from −0.45 to −0.74 ( all with P < 0.001 ) . We have shown that the NDI has good reliability and validity and that it compares well with the SF36 in the spinal surgery out patient setting & NA ; Although neck pain is a common source of disability , little is known about its incidence and course . We conducted a population ‐based cohort study of 1100 r and omly selected Saskatchewan adults to determine the annual incidence of neck pain and describe its course . Subjects were initially surveyed by mail in September 1995 and followed‐up 6 and 12 months later . The age and gender st and ardized annual incidence of neck pain is 14.6 % ( 95 % confidence interval : 11.3 , 17.9 ) . Each year , 0.6 % ( 95 % confidence interval : 0.0–1.1 ) of the population develops disabling neck pain . The annual rate of resolution of neck pain is 36.6 % ( 95 % confidence interval : 32.7 , 40.5 ) and another 32.7 % ( 95 % confidence interval : 25.5 , 39.9 ) report improvement . Among subjects with prevalent neck pain at baseline , 37.3 % ( 95 % confidence interval : 33.4 , 41.2 ) report persistent problems and 9.9 % ( 95 % confidence interval : 7.4 , 12.5 ) experience an aggravation during follow‐up . Finally , 22.8 % ( 95 % confidence interval : 16.4 , 29.3 ) of those with prevalent neck pain at baseline report a recurrent episode . Women are more likely than men to develop neck pain ( incidence rate ratio=1.67 , 95 % confidence interval 1.08–2.60 ) ; more likely to suffer from persistent neck problems ( incidence rate ratio=1.19 , 95 % confidence interval 1.03–1.38 ) and less likely to experience resolution ( incidence rate ratio=0.75 , 95 % confidence interval 0.63–0.88 ) . Neck pain is a disabling condition with a course marked by periods of remission and exacerbation . Contrary to prior belief , most individuals with neck pain do not experience complete resolution of their symptoms and disability Study Design . A r and omized controlled trial of an educational booklet for patients with first-time neck pain . Objective . To assess the clinical impact of a novel educational book on patients ' functional outcomes and beliefs about neck pain . Summary of Background Data . Previous research has shown that a novel education booklet ( The Back Book ) had a positive impact on patients with low back pain ' beliefs and clinical outcomes . The current study sought to evaluate the efficacy of a similar education booklet ( The Neck Book ) for neck-pain patients . Methods . Workers ' compensation patients were given either the experimental booklet , a traditional booklet or no booklet . The primary outcome measures , collected at 2-weeks , 3-months , and 6-months after baseline , were The Fear Avoidance Beliefs Question naire and The Neck Pain and Disability Scale . Health-related functional measures were also collected at these intervals . Results . Only 34 % ( N = 187 ) of an original cohort of patients ( N = 522 ) had data for all of the follow-up periods . For these 187 patients , repeated- measures analyses of covariance , using the baseline measure as the covariate , revealed no significant differences among the 3 groups on any of the outcome measures at any of the follow-up periods . For example , at 6-months , the experimental booklet , traditional booklet , and no-booklet groups reported The Neck Pain and Disability Scale mean scores ( SDs ) of 31.3 ( 15.5 ) , 35.3 ( 17.0 ) , and 31.8 ( 15.6 ) , respectively . Similarly , there were no significant effects for The Fear Avoidance Beliefs Question naire scores—35.9 ( 21.5 ) , 40.3 ( 22.1 ) , and 38.0 ( 23.4 ) , respectively . Conclusion . This study demonstrates that the educational booklets studied were not associated with improved outcomes in patients with neck pain receiving workers ' compensation . Whether these results would apply to a nonworkers ' compensation population requires further study . The loss of many patients to follow-up also makes any other firm conclusions more difficult to determine Study Design . Concealed allocation , multicenter , single-blind , r and omized controlled clinical trial . Objective . To assess the efficacy of an educational video in the tertiary prevention of persistent WAD symptoms following rear-end motor vehicle collisions ( MVCs ) . Summary of Background Data . Whiplash-associated disorders ( WAD ) are an important and costly health problem . There is a lack of high quality evidence surrounding efficacy of treatments for WAD . Existing research supports active interventions and early return to regular activities . Methods . Consecutive patients presenting to four tertiary care emergency departments following rear-end MVCs were eligible . Following informed consent , patients were allocated , using central r and omization , to receive an educational video plus usual care or usual care alone . The video provided reassurance , and advice about posture , return to regular activities , exercises , and pain-relief methods . Data were collected by telephone using st and ardized question naires . The primary outcome was presence of Persistent WAD Symptoms at 24 weeks postinjury , based on the frequency and severity of neck , shoulder , or upper back pain . The absolute difference in proportion of patients with persistent WAD symptoms and rate ratios were calculated . Changes in pain scores were compared using the Mann-Whitney U test . Results . The  intervention ( n = 206 ) and control ( n = 199 ) groups were similar at baseline ( mean age 38.4 years ; 64 % female ) . Overall , the proportion of subjects with Persistent WAD Symptoms decreased from 89.1 % at baseline to 33.6 % at 24 weeks after injury . At 24 weeks , the proportion of subjects with persistent WAD symptoms in the intervention group was 7.9 % ( 95 % CI , −2.0 , 17.8 ) lower than the control group . The median improvement in pain score at 24 weeks was 3 for the intervention group and 2 for the control group ( P = 0.016 ) . Conclusion . The presence of persistent WAD symptoms following simple rear-end MVCs was high in this sample . The video group demonstrated a trend toward less severe WAD symptoms . We recommend evaluating other educational interventions that could reduce WAD symptoms Objectives This study evaluated predictors of poor outcome in patients with neck pain treated by physical therapy  , and sought to compare the findings of empirical data with physical therapy practitioners ' subjective perceptions about predictors of outcome . Methods This study was a secondary analysis of data from a r and omized controlled trial assessing physical therapy treatments for neck pain ( n=346 ) . A baseline question naire provided data on a number of potential risk factors of poor outcome at follow-up . Follow-up was conducted at 6 weeks and 6 months by postal question naire with outcome defined separately by perceived ( global ) change and minimal clinical ly important differences in the Northwick Park Neck Pain Question naire ( MCID-NPQ ) . Therapists ' perceptions of predictors for treatment outcome were captured using a separate question naire , and the ratings compared with ranks derived from the 6-month trial data . Results Baseline characteristics accounted for a much greater proportion of explained variance for global change compared with MCID-NPQ at 6 months . Independent biopsychosocial characteristics included manual social class , catastrophizing , anxiety and depression , low treatment expectations , severity of baseline neck pain/disability , presence of comorbid back pain , and older age . Physical therapist ranks correlated highly with those derived from the trial data . Conclusions Significant predictors of outcome were identified , particularly at 6 months , including psychosocial , functional , and demographic indicators . Our findings suggest that physical therapists are collectively aware of the relative importance of physical and psychosocial factors in predicting clinical outcome . However , a significant amount of variability in outcomes in our prognostic models remained largely unexplained , indicating that we need to explore further underlying factors to inform clinical decision-making Neck pain is becoming increasingly more common and multiple interventions have been advocated in its management . The literature supports the use of a variety of exercises including specific low load endurance exercises , scapular muscle retraining and neck and upper limb strengthening . Pilates is one form of exercise that is developing in popularity . This pilot uncontrolled study investigates whether a 6-week matwork based Pilates programme can change outcome measures in a group of chronic neck pain patients . Thirteen subjects were assessed on self-report tests ; neck disability index ( NDI ) , patient specific functional scale ( PSFS ) , numerical rating pain scale ( NRPS ) and one objective measure ; the abdominal drawing in test ( ADIT ) . A statistically significant improvement was obtained in the disability outcomes ( NDI and PSFS ) at both 6 and 12 weeks . The NRPS also demonstrated statistical improvement at 12 weeks but not at 6 . The minimal clinical ly important difference ( MCID ) is the score that reflects a change that is meaningful for the patient and this was achieved at 12-weeks for the NDI ( > 5 points ) , PSFS ( > 3 points ) and NRPS ( > 2 points ) . Only 2 subjects reached normal levels in the ADIT at 12-weeks . The results of this pilot study suggest that Pilates has a role to play in reducing pain and disability in neck pain patients Study Design . Quasi-experimental , nonr and omized , nonequivalent , parallel group-controlled study involving before and after telephone surveys of the general population . Objective . To measure the magnitude of any sustained change in population beliefs about back pain 3 years after cessation of a population -based intervention design ed to alter beliefs about back pain . Summary of Background Data . A media campaign , which ran between September 1997 and December 1999 in Victoria , Australia , provided simple evidence -based advice about back pain . Following the campaign , there were significant improvements in both community and physicians ' beliefs about back pain , as well as a decline in number of workers ' compensation back cl aims . Methods . The campaign 's impact on population beliefs about back pain and fear-avoidance beliefs was measured using telephone surveys . Demographically identical population groups in Victoria and the adjacent control state , New South Wales , were surveyed at 4 times : before , during , immediately after , and 3 years after the media campaign in Victoria ( surveys 1−4 , respectively ) . Back beliefs were measured using the Back Beliefs Question naire ( BBQ ) ( possible score 9–45 , for which a higher score indicates a more positive belief about low back trouble ) . Fear-avoidance beliefs were measured using the Fear-Avoidance Beliefs Question naire consisting of 2 subscales for physical activity and work activity ( possible scores 0–24 and 0–36 , respectively ) , for which a lower score indicates fewer fear-avoidance beliefs . Results . A total of 6230 individuals in the general population completed the surveys . Large statistically significant improvements in population beliefs about back pain were still observed in Victoria 3 years after cessation of the campaign ( mean scores on the BBQ were 26.5 , 28.4 , 29.7 , and 28.8 for surveys 1–4 , respectively ) . No changes were observed in New South Wales ( mean scores on the BBQ were 26.3 , 26.2 , 26.3 , and 26.1 for surveys 1–4 , respectively ) . Of those individuals who reported back pain during the previous year , fear-avoidance beliefs aboutphysical activity in Victoria were also significantly better than at baseline ( mean scores on the Fear-Avoidance Beliefs Question naire for physical activity were 14.0 , 12.5 , 11.6 , and 12.3 for surveys 1–4 , respectively ) . Conclusions . Significant sustained improvements in population beliefs about back pain were observed 3 years after cessation of a media campaign of provision of positive messages about back pain . This result provides further evidence that a primary preventive strategy of altering population beliefs about back pain may be a highly effective way for reducing back-related disability Study Design . Quasi-experimental , nonr and omized , nonequivalent , parallel group-controlled study involving before and after telephone surveys of the general population and postal surveys of general practitioners was conducted , with an adjacent state used as a control group . Objectives . To evaluate the effectiveness of a population -based intervention design ed to alter beliefs about back pain , influence medical management , and reduce disability and workers ’ compensation – related costs . Summary of Background Data . A multimedia campaign begun during 1997 in Victoria , Australia , positively advised patients with back pain to stay active and exercise , not to rest for prolonged periods , and to remain at work . Methods . The campaign ’s impact on population beliefs about back pain and fear-avoidance beliefs was measured in telephone surveys , and the effect of the campaign on the potential management of low back pain by general practitioners was assessed by eliciting their likely approach to two hypothetical scenarios in mailed surveys . Demographically identical population groups in Victoria and the control state , New South Wales , were surveyed at three times : before , during , and after intervention in Victoria . Results . The studies were completed by 4730 individuals in the general population and 2556 general practitioners . There were large statistically significant improvements in back pain beliefs over time in Victoria ( mean scores on the Back Beliefs Question naire , 26.5 , 28.4 , and 29.7 ) , but not in New South Wales ( 26.3 , 26.2 , and 26.3 , respectively ) . Among those who reported back pain during the previous year , fear-avoidance beliefs about physical activity improved significantly in Victoria ( mean scores on the Fear-Avoidance Beliefs Question naire for physical activity , 14 , 12.5 , and 11.6 ) , but not in New South Wales ( 13.3 , 13.6 , and 12.7 , respectively ) . General practitioners in Victoria reported significant improvements over time in beliefs about back pain management , as compared with their interstate colleagues . There were statistically significant interactions between state and time for 7 of 10 responses on management of acute low back pain , and for 6 of 10 responses on management of subacute low back pain . Conclusion . A population -based strategy of providing positive messages about back pain improves the beliefs of the general population and general practitioners about back pain and appears to influence medical management OBJECTIVES To examine the clinical effectiveness of a stepped care approach over a 12-month period after an acute whiplash injury ; to estimate the costs and cost-effectiveness of each strategy including treatments and subsequent health-care costs ; and to gain participants ' perspective on experiencing whiplash injury , NHS treatment , and recovery within the context of the Managing Injuries of the Neck Trial ( MINT ) . DESIGN Two linked , pragmatic , r and omised controlled trials . In Step 1 , emergency departments ( EDs ) were cluster r and omised to usual care advice ( UCA ) or The Whiplash Book advice (WBA)/active management advice . In Step 2 , participants were individually r and omised to either a single session of advice from a physiotherapist or a physiotherapy package of up to six sessions . An economic evaluation and qualitative study were run in parallel with the trial . SETTING Twelve NHS trusts in Engl and comprising 15 EDs . PARTICIPANTS People who attended EDs with an acute whiplash injury of whiplash-associated disorder grade s I-III were eligible for Step 1 . People who had attended EDs with whiplash injuries and had persistent symptoms 3 weeks after ED attendance were eligible for Step 2 . INTERVENTIONS In Step 1 , the control intervention was UCA and the experimental intervention was a psycho-educational intervention ( WBA/active management advice ) . In Step 2 the control treatment was reinforcement of the advice provided in Step 1 and the experimental intervention was a package of up to six physiotherapy treatments . MAIN OUTCOME The primary outcome was the Neck Disability Index ( NDI ) , which measures severity and frequency of pain and symptoms , and a range of activities including self-care , driving , reading , sleeping and recreation . Secondary outcomes included the mental and physical health-related quality -of-life ( HRQoL ) subscales of the Short Form question naire-12 items ( SF-12 ) and the number of work days lost . RESULTS A total of 3851 patients were recruited to Step 1 of the trial . 1598 patients attending EDs were r and omised to UCA , and 2253 were r and omised to WBA/active management . Outcome data were obtained at 12 months for 70 % and 80 % of participants at Step 1 and Step 2 , respectively . The majority of people recovered from the injury . Eighteen per cent of the Step 1 cohort had late whiplash syndrome . There was no statistically or clinical ly significant difference observed in any of the outcomes for participants attending EDs r and omised to UCA or active management advice [ difference in NDI 0.5 , 95 % confidence interval ( CI ) -1.8 to 2.8 ] . In Step 2 the physiotherapy package result ed in improvements in neck disability at 4 months compared with a single advice session , but these effects were small at the population level ( difference in NDI -3.2 , 95 % CI -5.8 to -0.7 ) . The physiotherapy package was accompanied by a significant reduction in the number of work days lost at 4-month follow-up ( difference -40.2 , 95 % CI -44.3 to -35.8 ) . CONCLUSIONS MINT suggests that enhanced psycho-educational interventions in EDs are no more effective than UCA in reducing the burden of acute whiplash injuries . A physiotherapy package provided to people who have persisting symptoms within the first 6 weeks of injury produced additional short-term benefits in neck disability compared with a single physiotherapy advice session . However , from a health-care perspective , the physiotherapy package was not cost-effective at current levels of willingness to pay . Both experimental treatments were associated with increased cost with no discernible gain in health-related quality of life . However , an important benefit of the physiotherapy package was a reduction in work days lost ; consequently , the intervention may prove cost-effective at the societal level . TRIAL REGISTRATION Current Controlled Trials IS RCT N33302125 . FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol . 16 , No. 49 . See the HTA programme website for further project information The Scottish Intercollegiate Guidelines Network ( SIGN ) develops evidence based clinical guidelines for the NHS in Scotl and . The key elements of the methodology are ( a ) that guidelines are developed by multidisciplinary groups ; ( b ) they are based on a systematic review of the scientific evidence ; and ( c ) recommendations are explicitly linked to the supporting evidence and grade d according to the strength of that evidence . Until recently , the system for grading guideline recommendations was based on the work of the US Agency for Healthcare Research and Quality ( formerly the Agency for Health Care Policy and Research ) . 1 2 However , experience over more than five years of guideline development led to a growing awareness of this system 's weaknesses . Firstly , the grading system was design ed largely for application to questions of effectiveness , where r and omised controlled trials are accepted as the most robust study design with the least risk of bias in the results . However , in many areas of medical practice r and omised trials may not be practical or ethical to undertake ; and for many questions other types of study design may provide the best evidence . Secondly , guideline development groups often fail to take adequate account of the method ological quality of individual studies and the overall picture presented by a body of evidence rather than individual studies or they fail to apply sufficient judgment to the overall strength of the evidence base and its applicability to the target population of the guideline . Thirdly , guideline users are often not clear about the implication s of the grading system . They misinterpret the grade of recommendation as relating to its importance , rather than to the strength of the supporting evidence , and may therefore fail to give due weight to low grade recommendations . # # # # Summary points A revised system of determining levels of evidence and grade s There is a serious need to provide effective early interventions that prevent the development of persistent pain and disability . Identifying patients at risk for this development is an important step . Our aim was to explore whether distinct subgroups of individuals with similar response patterns on a screening question naire exist . Moreover , the objective was to then relate these groups to future outcomes , for example , sick leave as an impetus for developing tailored interventions that might better prevent chronic problems . A total of 363 patients seeking primary care for acute or subacute spinal pain completed the Örebro Musculoskeletal Pain Screening Question naire  and were then followed to determine outcome . Cluster analysis was used to identify subgroups . Validity was tested using 3 methods including the split-half technique . The subgroups were compared prospect ively on outcome measures obtained 1 year later . Using pain intensity , fear-avoidance beliefs , function , and mood , we found 4 distinct profiles : Fear-Avoidant , Distressed Fear-Avoidant , Low Risk , and Low Risk-Depressed Mood . These 4 subgroups were also robust in all 3 of the validity procedures . The 4 subgroups were clearly related to outcome . Although the low risk profiles had virtually no one developing long-term sick leave , the Fear-Avoidant profile had 35 % and the Distressed Fear-Avoidant profile 62 % developing long-term sick leave . Our results suggest that fear-avoidance and distress are important factors in the development of pain-related disability and may serve as a key for early identification . Providing interventions specific to the factors isolated in the profiles should enhance the prevention of persistent pain and disability PURPOSE The objective of this study is to investigate the effect of three different workplace interventions on long-term compliance , muscle strength gains , and neck/shoulder pain in office workers . METHODS A 1-yr r and omized controlled intervention trial was done with three groups :  specific resistance training ( SRT , n = 180 ) , all-round physical exercise ( APE , n = 187 ) , and reference intervention ( REF , n = 182 ) with general health counseling . Physical tests were performed and question naires answered at pre- , mid- , and postintervention . The main outcome measures were compliance , changes in maximal muscle strength , and changes in intensity of neck/shoulder pain ( scale 0 - 9 ) in those with and without pain at baseline . RESULTS Regular participation was achieved by 54 % , 31 % , and 16 % of those of the participants who answered the question naire in SRT ( 78 % ) , APE ( 81 % ) , and REF ( 80 % ) , respectively , during the first half of the intervention period , and decreased to 35 % , 28 % and 9 % , respectively , during the second half . Shoulder elevation strength increased 9 - 11 % in SRT and APE ( P < 0.0001 ) . Participants with neck pain at baseline decreased the intensity of neck pain through SRT , from 5.0 + /- 0.2 to 3.4 + /- 0.2 ( P < 0.0001 ) , and through APE , from 5.0 + /- 0.2 to 3.6 + /- 0.2 ( P < 0.001 ) , whereas REF caused no change . For participants without shoulder pain at baseline , there was a significantly greater increase in pain over the 1-yr period in REF compared with SRT and APE ( P < 0.01 ) . CONCLUSION Compliance was highest in SRT but generally decreased over time . SRT and APE caused increased shoulder elevation strength , were more effective than REF to decrease neck pain among those with symptoms at baseline , and prevent development of shoulder pain in those without symptoms at baseline Objectives To estimate the sensitivity to change and internal consistency of the Northwick Park Neck Pain Question naire ( NPQ ) and derive its minimal clinical ly important difference ( MCID ) . Methods Data on 311 participants in a r and omized controlled trial of physical therapy for neck pain were analyzed , between baseline and 6-month follow-up . Cronbach α was used to estimate internal consistency . Three methods of evaluating the NPQ 's sensitivity to change were used ; Cohen 's effect size , st and ardized response mean , and Guyatt 's responsiveness statistic . The smallest change on the NPQ that can be construed as clinical ly important ( the MCID ) was obtained by ( 1 ) comparing values derived from different methods that account for the measurement error of the question naire with improvements in other neck pain-specific measures , and then ( 2 ) examining the impact of the addition of an independent measure ( “ anchor ” ) relating to participants ' subjective rating of improvement . Results Cronbach α was 0.79 for the whole scale . Using all participants , Cohen 's d was 0.78 , st and ardized response mean was 0.71 , and Guyatt 's responsiveness statistic was 0.93 . Using only participants who stated they had improved , the estimates were 1.35 , 1.27 , 1.45 , respectively . The MCID for the NPQ was determined as a 25 % reduction in score from baseline together with a patient 's global rating of their neck pain of at least “ better . ” Conclusions These results show high internal consistency and sensitivity to change for the NPQ , and provide an MCID that allows participants with varying levels of severity to demonstrate improvement There is growing evidence for the idea that in back pain patients , pain-related fear ( fear of pain/physical activity/(re)injury ) may be more disabling than pain itself . A number of question naires have been developed to quantify pain-related fears , including the Fear-Avoidance Beliefs Question naire ( FABQ ) , the Tampa Scale for Kinesiophobia ( TSK ) , and the Pain Anxiety Symptoms Scale ( PASS ) . A total of 104 patients , presenting to a rehabilitation center or a comprehensive pain clinic with chronic low back pain were studied in three independent studies aim ed at ( 1 ) replicating that pain-related fear is more disabling than pain itself ( 2 ) investigating the association between pain-related fear and poor behavioral performance and ( 3 ) investigating whether pain-related fear measures are better predictors of disability and behavioral performance than measures of general negative affect or general negative pain beliefs ( e.g. pain catastrophizing ) . All three studies showed similar results . Highest correlations were found among the pain-related fear measures and measures of self-reported disability and behavioral performance . Even when controlling for sociodemographics , multiple regression analyses revealed that the subscales of the FABQ and the TSK were superior in predicting self-reported disability and poor behavioral performance . The PASS appeared more strongly associated with pain catastrophizing and negative affect , and was less predictive of pain disability and behavioral performance . Implication s for chronic back pain assessment , prevention and treatment are discussed
target: Overall , as a therapeutic intervention , structured patient education was equal or less effective than other conservative treatments including massage , supervised exercise , and physiotherapy .
  However , structured patient education may provide small benefits when combined with physiotherapy .
  Either mode of delivery ( ie , oral or written education ) provides similar results in patients with recent WAD .
  Results suggest that structured patient education alone can not be expected to yield large benefits in clinical effectiveness compared with other conservative interventions for patients with WAD or NAD .
  Moreover , structured patient education may be of benefit during the recovery of patients with WAD when used as an adjunct therapy to physiotherapy or emergency room care .
  These benefits are small and short lived
background: BACKGROUND CONTEXT In 2008 , the Bone and Joint Decade 2000 to 2010 Task Force on Neck Pain and Its Associated Disorders recommended patient education for the management of neck pain .
  However , the effectiveness of education interventions has recently been challenged .
  PURPOSE To up date the findings of the Bone and Joint Decade 2000 to 2010 Task Force on Neck Pain and Its Associated Disorders and evaluate the effectiveness of structured patient education for the management of patients with whiplash-associated disorders ( WAD ) or neck pain and associated disorders ( NAD ) .
  OUTCOME MEASURES Self-rated recovery , functional recovery ( eg , disability , return to activities , work , or school ) , pain intensity , health-related quality of life , psychological outcomes such as depression or fear , or adverse effects .