title: Predicting nonrecovery among whiplash patients in the emergency room and in an insurance company setting Efficacy of postural and neck-stabilization exercises for persons with acute whiplash-associated disorders: a systematic review. Seniority of the first-treating doctor does not influence the outcome of acute whiplash injury: a prospective cohort study Neck injury and fibromyalgia-- are they really associated? Are early MRI findings correlated with long-lasting symptoms following whiplash injury? A prospective trial with 1-year follow-up Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial Management of acute whiplash: A randomized controlled trial of multidisciplinary stratified treatments Outcomes at 12 Months After Early Magnetic Resonance Imaging in Acute Trauma Patients With Persistent Midline Cervical Tenderness and Negative Computed Tomography Early coping strategies do not influence the prognosis after whiplash injuries. Review article: Methodology for the ‘rapid review’ series on musculoskeletal injuries in the emergency department Predictors of persistent neck pain after whiplash injury Clinical clearance of the cervical spine in patients with distracting injuries: It is time to dispel the myth Multicentre prospective validation of use of the Canadian C-Spine Rule by triage nurses in the emergency department Are non-steroidal anti-inflammatory drugs effective for the management of neck pain and associated disorders, whiplash-associated disorders, or non-specific low back pain? A systematic review of systematic reviews by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration External validation of a clinical prediction rule to predict full recovery and ongoing moderate/severe disability following acute whiplash injury. Heat or cold packs for neck and back strain: a randomized controlled trial of efficacy. Can Primary Care for Back and/or Neck Pain in the Netherlands Benefit From Stratification for Risk Groups According to the STarT Back Tool Classification? The Rapid and Progressive Degeneration of the Cervical Multifidus in Whiplash: An MRI Study of Fatty Infiltration Derivation of a clinical prediction rule to identify both chronic moderate/severe disability and full recovery following whiplash injury
abstract: Purpose To construct and vali date a prediction instrument for early identification of patients with a high risk of delayed recovery after whiplash injuries ( PPS-WAD ) in an insurance company setting . Methods Prospect i ve cohort study . On the basis of a historic cohort ( n = 130 ) of patients with a whiplash injury identified in an emergency room ( ER , model-building set ) , we used logistic regression to construct an instrument consisting of two demographic variables ( i.e. questions of educational level and work status ) and the patient-rated physical and mental status during the acute phase to predict self-reported nonrecovery after 6 months . We evaluated the instrument ’s ability to predict nonrecovery in a new cohort ( n = 204 ) of patients originating from an insurance company setting ( IC , validation set ) . Results The prediction instrument had low reproducibility when the setting was changed from the ER cohort to the IC cohort . The overall percentage of correct predictions of nonrecovery in the ER cohort was 78 % compared with 62 % in the IC cohort . The sensitivity and specificity in relation to nonrecovery were both 78 % in the ER cohort . The sensitivity and specificity in the insurance company setting was lower , 67 and 50 % . Conclusion Clinical decision rules need validation before they are used in a new setting . An instrument consisting of four questions with an excellent possibility of identifying patients with a high risk of nonrecovery after a whiplash injury in the emergency room was not as useful in an insurance company setting . The importance and type of the risk factors for not recovering probably differ between the setting s , as well as the individuals PURPOSE We systematic ally review ed r and omized and quasi-r and omized clinical trials in the literature to assess the efficacy of neck stabilization and postural exercises on pain , neck range of motion , and time off work in adults with acute whiplash-associated disorders . METHODS Electronic data bases , reference lists of relevant Cochrane review s , reference lists of studies selected for inclusion , and tables of contents of relevant journals were systematic ally search ed for r and omized and quasi-r and omized controlled trials . Two independent review ers selected studies for inclusion , assessed method ological quality , and extracted data . Because of the heterogeneity of the interventions , a qualitative synthesis was performed using " levels of evidence " as recommended by van Tulder et al. RESULTS Eight studies representing five clinical trials were selected for inclusion . Two trials were grade d as high quality , two as moderate quality , and one as low quality . Many of these studies had mixed results , demonstrating significant differences on some outcome measures but not on others . CONCLUSIONS There is moderate evidence to support the use of postural exercises for decreasing pain and time off work in the treatment of patients with acute whiplash-associated disorders . However , no evidence exists to support the use of postural exercises for increasing neck range of motion . There is conflicting evidence in support of neck stabilization exercises in the treatment of patients with acute whiplash-associated disorders The aim of the prospect i ve cohort study was to investigate the outcome of acute whiplash injury first treated either by junior doctors ( JD ) [ ≤3 postgraduate years ( PGY ) ] or more experienced doctors ( MED ) ( > 3 PGY ) . At baseline , crash-related data and health parameters including the SF36 were evaluated in whiplash patients ( WP ) , who fulfilled criteria for whiplash-associated disorders grade I – II and presented up to 48 h after motor vehicle accident to our Emergency Department . 81 WP were recruited and treated by either one of 14 JD ( 35 WP ) or one of 22 MED ( 46 WP ) . The follow-up examination included the course of pain intensity [ numeric rating scale ( NRS ) 0–10 ] by the use of a 28 days-pain-diary  and the incidence of symptoms ( st and ardized-telephone-interview at 1 , 3 , and 6 months post trauma ) in terms of neck pain NRS > 2 , analgesic medication , work-off , and utilization of further medical services as well as SF36 evaluated at the end of the study . Although the entry population seemed similar , all outcome parameters were comparable between the JD- and MED-group ( p > 0.05 ) . Therefore , we conclude that seniority of the first-treating physician does not influence the outcome of acute whiplash injury OBJECTIVE To investigate whether  whiplash injury may be a trigger for the onset of fibromyalgia ( FM ) . METHODS One hundred fifty-three patients presenting to the emergency room with the diagnosis of whiplash injury were examined . The control group included 53 patients hospitalized with fractures of the limbs , spine , and ribs due to road accident . The study and control groups were interviewed shortly after presenting and then followed prospect ively . Patients complaining of musculoskeletal symptoms during followup were examined and a count of 18 tender points was conducted . FM was diagnosed if the patient fulfilled currently accepted 1990 American College of Rheumatology criteria . RESULTS The mean followup period for the study and control groups was 14.5 months ( range 12 - 18 ) and 9 months ( range 6 - 14 ) , respectively . There were no differences between the groups with regard to age , sex , marital , education , or employment status . During the followup period only one patient in the study group and no patients in the control group developed signs and symptoms of FM . Three patients in the study group ( 2 % ) and 15 patients in the control group ( 16 % ) filed insurance cl aims ; none was associated with FM . CONCLUSION Whiplash injury and road accident trauma were not associated with an increased rate of FM after more than 14.5 months of followup Neck pain is the cardinal symptom following whiplash injuries . The trauma mechanism could theoretically lead to both soft tissue and bone injury that could be visualised by means of MRI . From previous quite small trials it seems that MRI does not demonstrate significant tissue damage . Large prospect ively followed cohorts are needed to identify possible clinical ly relevant MRI findings . The objective of this trial was to evaluate ( 1 ) the predictive value of cervical MRI  after whiplash injuries and ( 2 ) the value of repeating MRI examinations after 3 months including sequences with flexion and extension of the cervical spine . Participants were included after rear-end or frontal car collisions . Patients with fractures or dislocations diagnosed by st and ard procedures at the emergency unit were not included .  MRI scans of the cervical spine were performed at baseline and repeated after 3 months . Clinical follow-ups were performed after 3 and 12 months . Outcome parameters were neck pain , headache , neck disability and working ability .  A total of 178 participants had a cervical MRI scan on average 13 days after the injury . Traumatic findings were observed in seven participants . Signs of disc degeneration were common and most frequent at the C5–6 and C6–7 levels . Findings were not associated with outcome after 3 or 12 months . The population had no considerable neck trouble prior to the whiplash injury and the non-traumatic findings represent findings to be expected in the background population . Trauma-related MRI findings are rare in a whiplash population screened for serious injuries in the emergency unit and not related to a specific symptomatology . Also , pre-existing degeneration is not associated with prognosis Summary Background Back pain remains a challenge for primary care internationally . One model that has not been tested is stratification of the management according to the patient 's prognosis ( low , medium , or high risk ) . We compared the clinical effectiveness and cost-effectiveness of stratified primary care ( intervention ) with non-stratified current best practice ( control ) . Methods 1573 adults ( aged ≥18 years ) with back pain ( with or without radiculopathy ) consultations at ten general practice s in Engl and responded to invitations to attend an assessment clinic . Eligible participants were r and omly assigned by use of computer-generated stratified blocks with a 2:1 ratio to intervention or control group . Primary outcome was the effect of treatment on the Rol and Morris Disability Question naire ( RMDQ ) score at 12 months . In the economic evaluation , we focused on estimating incremental quality -adjusted life years ( QALYs ) and health-care costs related to back pain . Analysis was by intention to treat . This study is registered , number IS RCT N37113406 . Findings 851 patients were assigned to the intervention ( n=568 ) and control groups ( n=283 ) . Overall , adjusted mean changes in RMDQ scores were significantly higher in the intervention group than in the control group at 4 months ( 4·7 [ SD 5·9 ] vs 3·0 [ 5·9 ] , between-group difference 1·81 [ 95 % CI 1·06–2·57 ] ) and at 12 months ( 4·3 [ 6·4 ] vs 3·3 [ 6·2 ] , 1·06 [ 0·25–1·86 ] ) , equating to effect sizes of 0·32 ( 0·19–0·45 ) and 0·19 ( 0·04–0·33 ) , respectively . At 12 months , stratified care was associated with a mean increase in generic health benefit ( 0·039 additional QALYs ) and cost savings ( £ 240·01 vs £ 274·40 ) compared with the control group . Interpretation The results show that a stratified approach , by use of prognostic screening with matched pathways , will have important implication s for the future management of back pain in primary care . Funding Arthritis Research UK Objective To evaluate the effectiveness of an active strategy to implement the vali date d Canadian C-Spine Rule into multiple emergency departments . Design Matched pair cluster r and omised trial . Setting University and community emergency departments in Canada . Participants 11 824 alert and stable adults presenting with blunt trauma to the head or neck at one of 12 hospitals . Interventions Six hospitals were r and omly allocated to the intervention and six to the control . At the intervention sites , active strategies were used to implement the Canadian C-Spine Rule , including education , policy , and real time reminders on radiology requisitions . No specific intervention was introduced to alter the behaviour of doctors requesting cervical spine imaging at the control sites . Main outcome measure Diagnostic imaging rate of the cervical spine during two 12 month before and after periods . Results Patients were balanced between control and intervention sites . From the before to the after periods , the intervention group showed a relative reduction in cervical spine imaging of 12.8 % ( 95 % confidence interval 9 % to 16 % ; 61.7 % v 53.3 % ; P=0.01 ) and the control group a relative increase of 12.5 % ( 7 % to 18 % ; 52.8 % v 58.9 % ; P=0.03 ) . These changes were significant when both groups were compared ( P<0.001 ) . No fractures were missed and no adverse outcomes occurred . Conclusions Implementation of the Canadian C-Spine Rule led to a significant decrease in imaging without injuries being missed or patient morbidity . Final imaging rates were much lower at intervention sites than at most US hospitals . Widespread implementation of this rule could lead to reduced healthcare costs and more efficient patient flow in busy emergency departments worldwide . Trial registration Clinical trials NCT00290875 Summary This r and omised trial showed that multiprofessional stratified management had no effect beyond usual care in reducing transition rates to chronicity in patients with acute whiplash . ABSTRACT Acute whiplash is a heterogeneous disorder that becomes persistent in 40 % to 60 % of cases . Estimates of recovery have not changed in recent decades . This r and omized , single‐blind , controlled trial tested whether multidisciplinary individualized treatments for patients with acute whiplash ( < 4 weeks postinjury ) could reduce the incidence of chronicity at 6 mo by 50 % compared to usual care . Participants ( n = 101 ) were recruited from accident and emergency centres and the community . It was hypothesized that better recovery rates were achievable if the heterogeneity was recognised and patients received individualised interventions . Patients r and omized to pragmatic intervention ( n = 49 ) could receive pharmaceutical management ( ranging from simple medications to opioid analgesia ) , multimodal physiotherapy and psychology for post‐traumatic stress according to their presentations . The treatment period was 10 wks with follow‐up at 11 weeks and 6 and 12‐months . The primary outcome was neck pain and disability ( Neck Disability Index ( NDI ) ) . Analysis revealed no significant differences in frequency of recovery ( NDI ≤8 % ) between pragmatic and usual care groups at 6 months ( OR 95 % , CI = 0.55 , 0.23–1.29 ) , P = 0.163 ) or 12 mo ( OR 95 % , CI = 0.65 , 0.28–1.47 , P = 0.297 ) . There was no improvement in current nonrecovery rates at 6 mo ( 63.6 % , pragmatic care ; 48.8 % , usual care ) , indicating no advantage of the early multiprofessional intervention . Baseline levels of pain and disability had a significant bearing on recovery both at 6 and 12 mo in both groups , suggesting that future research focus on finding early effective pain management , particularly for the subgroup of patients with initial high levels of pain and  disability , towards improving recovery rates Study Design . A prospect i ve observational cohort study of alert , neurologically intact trauma patients presenting to the emergency department with midline cervical tenderness . Screening cervical magnetic resonance imaging ( MRI ) had been conducted after negative computed tomography ( CT ) when tenderness was persistent . Objective . To determine the association of acute findings and demographic characteristics with any long-term neck disability , and with time to return to work in such patients . Summary of Background Data . The relationship between acute findings and outcomes in these patients is unknown , and we hypothesized that outcomes at 12 months would correlate with acute clinical signs and symptoms , MRI findings , and mechanisms of injury . Methods . Patients at a Level 1 trauma center with persistent midline cervical tenderness in the absence of evidence of intoxication , painful distracting injury , persistently abnormal neurology , or acute CT findings , who underwent early cervical MRI under the institutional protocol , were review ed in the outpatient spine clinic after discharge . In addition , the factors associated with neck disability and time to return to work were examined at follow-up at 12 months after presentation . Results . There were 162 of 178 patients available for follow-up at 12 months ( 91 % ) . Of these , 46 % had MRI-identified cervical spine injury at their initial examination , and 22 % had required clinical management , including 2.5 % with operative stabilization . Neck disability was present in 43 % of patients and was associated with depressive symptoms , workers ' compensation , and low annual income . Delay in return to work was associated with the presence of minor limb/other fractures and depressive symptoms , whereas patients on high annual incomes were found to return to work more quickly . Conclusion . Surprisingly in these acute trauma patients , MRI-detected injury , clinical factors , and injury mechanism were not found to be associated with long-term patient outcomes . As a result , a trial of a more targeted , individual return to work plan , including strategies aim ed at improving physical and psychological function , may now be justified to optimize long-term recovery , reduce health re source costs , and maximize economic productivity through early return to work This is a 1-year prospect i ve study to investigate the prognostic value of coping strategies such as catastrophising for persistent pain after a whiplash injury . A consecutive series of 96 patients who were seen in the emergency room in the acute phase after the injury were followed prospect ively for 1 year . Age , gender and whether or not pain in the neck preceded the accident was recorded . Cases involving fractures or dislocations of the cervical spine , head trauma or pre-existing neurological disorders were not included . The mean interval between the accident and the initial examination was 3+/-2(S.D. ) days . Coping was measured using the  Coping Strategies Question naire ( CSQ ) . The outcome parameter was self-reported neck pain at 1 year after the motor vehicle accident . At 1 year , 34 % of the patients had neck pain . Women developed chronic neck pain more often than men ( 71 % versus 29 % ) ; they also had significantly higher coping activity , such as diverting attention , praying or hoping ( p<0.05 ) ,  catastrophising and increasing behavioural activities ( p<0.0001 ) . Women reported pain in the neck or shoulder more often before the accident and this was the only statistically significant predictor of chronic symptoms when analysed by logistic regression ( odds ratio 4.5 ) . To conclude , we found no evidence that the different coping patterns during the early phase after a whiplash injury influenced the prognosis Musculoskeletal injuries are a common presentation to the ED , with significant costs involved in the management of these injuries , variances in care within the ED and associated morbidity . A series of rapid review papers were completed to guide best practice for the assessment and management of common musculoskeletal injuries presenting to the ED . This paper presents the methodology used across the rapid review s. PubMed , CINAHL , EMBASE , TRIP and the grey literature , including relevant organisational websites , were search ed in 2015 . The search was repeated consistently for each topic area ( injuries of the foot and ankle , knee , h and and wrist , elbow , shoulder , lumbar spine and cervical spine ) . English- language primary studies , systematic review s and guidelines that were published in the last 10 years and addressed acute musculoskeletal injury management were considered for inclusion . Data extraction of each included article was conducted , followed by a quality appraisal . The extracted data from each article was synthesis ed to group similar evidence together . For each rapid review , the evidence has been organised in a way that a clinician can direct their attention to a specific component of the clinical cycle of care in the ED , such as the assessment , diagnostic tests , management and follow-up considerations from ED . The series of rapid review s are design ed to foster evidence -based practice within the ED , targeting the injuries most commonly presenting . The review s provide clinicians in EDs with rapid access to the best current evidence , which has been synthesis ed and organised to assist decision-making Objective : To establish the aetiological influences of  persistent neck pain following a motor vehicle collision and to construct a model for use in the emergency department for identifying patients at high risk of persistent symptoms . Design : Prospect i ve cohort study . Patients recruited from hospital emergency departments were sent a question naire to gather information on various exposures . They were followed up at 1 , 3 , and 12 months to identify those with persistent symptoms . Main outcome measure : Persistent neck pain ( pain at 1 , 3 , and 12 months after collision ) . Results : The baseline survey included 765 patients . Subsequently , 480 completed a question naire at each follow up time point , of whom 128 ( 27 % ) reported neck pain on each occasion . Few collision specific factors predicted persistent neck pain . In contrast , a high level of general psychological distress , pre-collision history of widespread body pain , type of vehicle , whiplash associated symptoms , and initial neck disability best predicted the persistence of symptoms . Furthermore , these factors , in combination , accounted for more than a fivefold increase in the risk of persistent neck pain . Conclusion : The greatest predictors of persistent neck pain following a motor vehicle collision relate to psychological distress and aspects of pre-collision health rather than to various attributes of the collision itself . With these factors , and those relating to initial injury severity , it is possible to identify a subgroup of patients presenting with neck pain with the highest risk of persistent symptoms . Thus , it is possible to identify whiplash patients with a poor prognosis and to provide closer follow up and specific attention to management in these individuals OBJECTIVE The purpose of this study was to prospect ively assess the sensitivity and efficacy of clinical examination for screening of cervical spine ( c-spine ) injury in awake and alert blunt trauma patients with concomitant “ distracting injuries . ” METHODS During the 24-month period from December 2009 to December 2011 , all blunt trauma patients older than 13 years were prospect ively evaluated with a st and ard cervical spine examination protocol by the trauma surgery team at a Level 1 trauma center . Awake and alert patients with a Glasgow Coma Score ( GCS ) ≥14 underwent clinical examination of the cervical spine . Clinical examination was performed regardless of “ distracting injuries . ” Patients without complaints of pain or tenderness on physical exam had their cervical collar removed , and the c-spine was considered clinical ly cleared of injury . All awake and alert patients with “ distracting injuries , ” including those clinical ly cleared and those with complaints of c-spine pain or tenderness underwent computerized tomographic ( CT ) scanning of the entire c-spine . “ Distracting injuries ” were categorized into three anatomic regions : head injuries , torso injuries and long bone fractures . Patients with minor distracting injuries were not considered to have a “ distracting injury . ” RESULTS During the 24-month study period , 761 blunt trauma patients with GCS ≥14 and at least one “ distracting injury ” had been entered into the study protocol . Two-hundred ninety-six ( 39 % ) of the patients with “ distracting injuries ” had a positive c-spine clinical examination , 85 ( 29 % ) of whom were diagnosed with c-spine injury . Four hundred sixty-four ( 61 % ) of the patients with “ distracting injuries ” were initially clinical ly cleared , with one patient ( 0.2 % ) diagnosed with a c-spine injury . This yielded an overall sensitivity of 99 % ( 85/86 ) and negative predictive value greater than 99 % ( 463/464 ) for cervical spine clinical examination in awake and alert blunt trauma patients with “ distracting injuries . ” CONCLUSIONS In the awake and alert blunt trauma patient with “ distracting injuries , ” clinical examination is a sensitive screening method for cervical spine injury . Radiological assessment is unnecessary for safe clearance of the asymptomatic cervical spine in awake and alert blunt trauma patients with “ distracting injuries . ” These findings suggest the concept of “ distracting injury ” in the context of cervical spine clinical examination is invalid . Exp and ing the utility of cervical spine clinical examination to patients with “ distracting injuries ” allows for significant reduction of both healthcare cost and radiation exposure . LEVEL OF EVIDENCE Diagnostic study , level Objectives : The Canadian C-Spine Rule for imaging of the cervical spine was developed for use by physicians . We believe that nurses in the emergency department could use this rule to clinical ly clear the cervical spine . We prospect ively evaluated the accuracy , reliability and acceptability of the Canadian C-Spine Rule when used by nurses . Methods : We conducted this three-year prospect i ve cohort study in six Canadian emergency departments . The study involved adult trauma patients who were alert and whose condition was stable . We provided two hours of training to 191 triage nurses . The nurses then assessed patients using the Canadian C-Spine Rule , including determination of neck tenderness and range of motion , reapplied immobilization and completed a data form . Results : Of the 3633 study patients , 42 ( 1.2 % ) had clinical ly important injuries of the cervical spine . The kappa value for interobserver assessment s of 498 patients with the  Canadian C-Spine Rule  was 0.78 . We calculated sensitivity of 100.0 % ( 95 % confidence interval [ CI ] 91.0%–100.0 % ) and specificity of 43.4 % ( 95 % CI 42.0%–45.0 % ) for the Canadian C-Spine Rule as interpreted by the investigators . The nurses classified patients with a sensitivity of 90.2 % ( 95 % CI 76.0%–95.0 % ) and a specificity of 43.9 % ( 95 % CI 42.0%–46.0 % ) . Early in the study , nurses failed to identify four cases of injury , despite the presence of clear high-risk factors . None of these patients suffered sequelae , and after retraining there were no further missed cases . We estimated that for 40.7 % of patients , the cervical spine could be cleared clinical ly by nurses . Nurses reported discomfort in applying the Canadian C-Spine Rule in only 4.8 % of cases . Conclusion : Use of the Canadian C-Spine Rule by nurses was accurate , reliable and clinical ly acceptable . Widespread implementation by nurses throughout Canada and elsewhere would diminish patient discomfort and improve patient flow in overcrowded emergency departments Abstract Purpose To evaluate the effectiveness of non-steroidal anti-inflammatory drugs ( NSAIDs ) for the management of neck pain and associated disorders ( NAD ) , whiplash-associated disorders , and non-specific low back pain ( LBP ) with or without radiculopathy . Methods We systematic ally search ed six data bases from 2000 to 2014 . R and om pairs of independent review ers critically appraised eligible systematic review s using the Scottish Intercollegiate Guidelines Network criteria . We included systematic review s with a low risk of bias in our best evidence synthesis . Results We screened 706 citations and 14 systematic review s were eligible for critical appraisal . Eight systematic review s had a low risk of bias . For recent-onset NAD , evidence suggests that intramuscular NSAIDs lead to similar outcomes as combined manipulation and soft tissue therapy . For NAD ( duration not specified ) , oral NSAIDs may be more effective than placebo . For recent-onset LBP , evidence suggests that : ( 1 ) oral NSAIDs lead to similar outcomes to placebo or a muscle relaxant ; and ( 2 ) oral NSAIDs with bed rest lead to similar outcomes as placebo with bed rest . For persistent LBP , evidence suggests that : ( 1 ) oral NSAIDs are more effective than placebo ; and ( 2 ) oral NSAIDs may be more effective than acetaminophen . For recent-onset LBP with radiculopathy , there is inconsistent evidence on the effectiveness of oral NSAIDs versus placebo . Finally , different oral NSAIDs lead to similar outcomes for neck and LBP with or without radiculopathy . Conclusions For NAD , oral NSAIDs may be more effective than placebo . Oral NSAIDs are more effective than placebo for persistent LBP , but not for recent-onset LBP . Different oral NSAIDs lead to similar outcomes for neck pain and LBP STUDY DESIGN Retrospective secondary analysis of data . OBJECTIVES To investigate the external validity of the whiplash clinical prediction rule ( CPR ) . BACKGROUND We recently derived a whiplash CPR to consoli date previously established prognostic factors for poor recovery from a whiplash injury and predicted 2 recovery pathways . Prognostic factors for full recovery were being less than 35 years of age and having an initial Neck Disability Index ( NDI ) score of 32 % or less . Prognostic factors for ongoing moderate/severe pain and disability were being 35 years of age or older , having an initial NDI score of 40 % or more , and the presence of hyperarousal symptoms . Validation is required to confirm the reproducibility and accuracy of this CPR . Clinician feedback on the usefulness of the CPR is also important to gauge acceptability . METHODS A secondary analysis of data from 101 individuals with acute whiplash-associated disorder who had previously participated in either a r and omized controlled clinical trial or prospect i ve cohort study was performed using accuracy statistics . Full recovery was defined as NDI score at 6 months of 10 % or less , and ongoing moderate/severe pain and disability were defined as an NDI score at 6 months of 30 % or greater . In addition , a small sample of physical therapists completed an anonymous survey on the clinical acceptability and usability of the tool . Results The positive predictive value of ongoing moderate/severe pain and disability was 90.9 % in the validation cohort , and the positive predictive value of full recovery was 80.0 % . Surveyed physical therapists reported that the whiplash CPR was simple , underst and able , would be easy to use , and was an acceptable prognostic tool . CONCLUSION External validation of the whiplash CPR confirmed the reproducibility and accuracy of this dual-pathway tool for individuals with acute whiplash-associated disorder . Further research is needed to assess prospect i ve validation , the impact of inclusion on practice , and to examine the efficacy of linking treatment strategies with predicted prognosis . LEVEL OF EVIDENCE Prognosis , level 1b OBJECTIVES Acute back and neck strains are very common . In addition to administering analgesics , these strains are often treated with either heat or cold packs . The objective of this study was to compare the analgesic efficacy of heat and cold in relieving pain from back and neck strains . The authors hypothesized that pain relief would not differ between hot and cold packs . METHODS This was a r and omized , controlled trial conducted at a university-based emergency department ( ED ) with an annual census of 90,000 visits . ED patients > 18 years old with acute back or neck strains were eligible for inclusion . All patients received 400 mg of ibuprofen orally and then were r and omized to 30 minutes of heating pad or cold pack applied to the strained area . Outcomes of interest were pain severity before and after pack application on a vali date d 100-mm visual analog scale ( VAS ) from 0 ( no pain ) to 100 ( worst pain ) , percentage of patients requiring rescue analgesia , subjective report of pain relief on a verbal rating scale ( VRS ) , and future desire for similar packs . Outcomes were compared with t-tests and chi-square tests . A sample of 60 patients had 80 % power to detect a 15-mm difference in pain scores . RESULTS Sixty patients were r and omized to heat ( n = 31 ) or cold ( n = 29 ) therapy . Mean ( + /-st and ard deviation [ SD ] ) age was 37.8 ( + /-14.7 ) years , 51.6 % were female , and 66.7 % were white . Groups were similar in baseline patient and pain characteristics . There were no differences between the heat and cold groups in the severity of pain before ( 75 mm [ 95 % CI = 66 to 83 ] vs. 72 mm [ 95 % CI = 65 to 78 ] ; p = 0.56 ) or after ( 66 mm [ 95 % CI = 57 to 75 ] vs. 64 mm [ 95 % CI = 56 to 73 ] ; p = 0.75 ) therapy . Pain was rated better or much better in 16/31 ( 51.6 % ) and 18/29 ( 62.1 % ) patients in the heat and cold groups , respectively ( p = 0.27 ) . There were no between-group differences in the desire for and administration of additional analgesia . Twenty-five of 31 ( 80.6 % ) patients in the heat group and 22 of 29 ( 75.9 % ) patients in the cold group would use the same therapy if injured in the future ( p = 0.65 ) . CONCLUSIONS The addition of a 30-minute topical application of a heating pad or cold pack to ibuprofen therapy for the treatment of acute neck or back strain results in a mild yet similar improvement in the pain severity . However , it is possible that pain relief is mainly the result of ibuprofen therapy . Choice of heat or cold therapy should be based on patient and practitioner preferences and availability OBJECTIVE To evaluate whether current Dutch primary care clinicians offer tailored treatment to patients with low back pain ( LBP ) or neck pain ( NP ) according to their risk stratification , based on the Keele STarT ( Subgroup Targeted Treatment ) Back-Screening Tool ( SBT ) . DESIGN Prospect i ve cohort study with 3-month follow-up . SETTING Primary care . PARTICIPANTS General practitioners ( GPs ) and physiotherapists included patients ( N=284 ) with nonspecific LBP , NP , or both . INTERVENTIONS Patients completed a baseline question naire , including the Dutch SBT , for either LBP or NP . A follow-up measurement was conducted after 3 months to determine recovery ( using Global Perceived Effect Scale ) , pain ( using Numeric Pain Rating Scale ) , and function ( using Rol and Disability Question naire or Neck Disability Index ) . A question naire was sent to the GPs and physiotherapists to evaluate the provided treatment . MAIN OUTCOME MEASURES Prevalence of patients ' risk profile and clinicians ' applied care , and the percentage of patients with persisting disability at follow-up . A distinction was made between patients receiving the recommended treatment and those receiving the nonrecommended treatment . RESULTS In total , 12 GPs and 33 physiotherapists included patients . After 3 months , we analyzed 184 patients with LBP and 100 patients with NP . In the LBP group , 52.2 % of the patients were at low risk for persisting disability , 38.0 % were at medium risk , and 9.8 % were at high risk . Overall , 24.5 % of the patients with LBP received a low-risk treatment approach , 73.5 % a medium-risk , and 2.0 % a high-risk treatment approach . The specific agreement between the risk profile and the received treatment for patients with LBP was poor for the low-risk and high-risk patients ( 21.1 % and 10.0 % , respectively ) , and fair for medium-risk patients ( 51.4 % ) . In the NP group , 58.0 % of the patients were at low risk for persisting disability , 37.0 % were at medium risk , and 5.0 % were at high risk . Only 6.1 % of the patients with NP received the low-risk treatment approach . The medium-risk treatment approach was offered the most ( 90.8 % ) , and the high-risk approach was applied in only 3.1 % of the patients . The specific agreement between the risk profile and received treatment for patients with NP was poor for low-risk and medium-risk patients ( 6.3 % and 48.0 % , respectively ) ; agreement for high-risk patients could not be calculated . CONCLUSIONS Current Dutch primary care for patients with nonspecific LBP , NP , or both does not correspond to the recommended stratified-care approach based on the SBT , as most patients receive medium-risk treatment . Most low-risk patients are overtreated , and most high-risk patients are undertreated . Although the stratified-care approach has not yet been vali date d in Dutch primary care , these results indicate there may be substantial room for improvement Study Design . Single-center prospect i ve longitudinal study . Objective . To study the ( 1 ) temporal development of muscle fatty infiltrates ( MFI ) in the cervical multifidi after whiplash , ( 2 ) differences in multifidi MFI between those who recover or report milder pain – related disability and those who report moderate/severe symptoms at 3 months , and ( 3 ) predictive value of multifidi MFI outcomes . Summary of Background Data . The temporal development of MFI on conventional magnetic resonance image has been shown to be associated with specific aspects of pain and psychological factors . The replication of such findings has yet to be explored longitudinally . Methods . Thirty-six subjects with whiplash injury were enrolled at less than 1 week postinjury and classified at 3 months using percentage scores on the Neck Disability Index as recovered/mild ( 0%–28 % ) or severe ( ≥30 % ) . A fat/water magnetic resonance imaging measure , patient self-report of pain-related disability , and post-traumatic stress disorder were collected at less than 1 week , 2 weeks , and 3 months postinjury . The effects of time and group ( per Neck Disability Index ) and the interaction of time by group on MFI were determined . Receiver operating characteristic curve analysis was used to determine a cut-point for MFI at 2 weeks to predict outcome at 3 months . Results . There was no difference in MFI across groups at enrolment . MFI values were significantly higher in the severe group than those in the recovered/mild group at 2 weeks and 3 months . The receiver operating characteristic curve analysis indicated that MFI levels of 20.5 % or above result ed in a sensitivity of 87.5 % and a specificity of 92.9 % for predicting outcome at 3 months . Conclusion . Consistent with previous evidence , muscle degeneration occurs soon after injury but only in those patients with poor functional recovery . This study provides further evidence that ( 1 ) multifidi MFI occur in t and em with known predictive risk factors ( older age , pain-related disability , and post-traumatic stress disorder ) and ( 2 ) routine imaging protocol s may need to be reconsidered in the vast majority of patients after whiplash . Level of Evidence : Summary A clinical prediction rule comprising relevant biopsychosocial factors was derived to predict both  chronic moderate/severe disability and full recovery following whiplash injury . Abstract Recovery following a whiplash injury is varied : approximately 50 % of individuals fully recover , 25 % develop persistent moderate/severe pain and disability , and 25 % experience milder levels of disability . Identification of individuals likely to develop moderate/severe disability or to fully recover may help direct therapeutic re sources and optimise treatment . A clinical prediction rule ( CPR ) is a research ‐generated tool used to predict outcomes such as likelihood of developing moderate/severe disability or experiencing full recovery from whiplash injury . The purpose of this study was to assess the plausibility of developing a CPR . Participants from 2 prospect i ve , longitudinal studies that examined prognostic factors for poor functional recovery following whiplash injury were used to derive this tool . Eight factors , previously identified as predictor variables of poor recovery , were included in the analyses : initial neck disability index ( NDI ) , initial neck pain ( visual analogue scale ) , cold pain threshold , range of neck movement , age , gender , presence of headache , and posttraumatic stress symptoms ( Posttraumatic Diagnostic Scale [ PDS ] ) . An increased probability of developing chronic moderate/severe disability was predicted in the presence of older age and initially higher levels of NDI and hyperarousal symptoms ( PDS ) ( positive predictive value [ PPV ] = 71 % ) . The probability of full recovery was increased in younger individuals with initially lower levels of neck disability ( PPV = 71 % ) . This study provides initial evidence for a CPR to predict both chronic moderate/severe disability and full recovery following a whiplash injury . Further research is needed to vali date the tool , determine the acceptability of the proposed CPR by practitioners , and assess the impact of inclusion in practice
target: Consistent evidence was found to support the use of ' red flags ' to screen for serious pathologies , judicious use of imaging through clinical decision rule application and promotion of functional exercise coupled with advice and reassurance .
background: Neck pain and whiplash injuries are a common presentation to the ED , and a frequent cause of disability globally .
  This rapid review investigated best practice for the assessment and management of musculoskeletal neck pain in the ED .