Neck exercises, physical and cognitive behavioural-graded activity as a treatment for adult whiplash patients with chronic neck pain: Design of a randomised controlled trial Neck Collar, “Act-as-Usual” or Active Mobilization for Whiplash Injury?: A Randomized Parallel-Group Trial Whiplash injuries. A trial of early management. Work Disability After Whiplash: A Prospective Cohort Study Chronic neck pain and whiplash: a case-control study of the relationship between acute whiplash injuries and chronic neck pain. Characterization of Acute Whiplash-Associated Disorders Clinical assessment of prognostic factors for long-term pain and handicap after whiplash injury: a 1-year prospective study. Pain Thresholds and Tenderness in Neck and Head Following Acute Whiplash Injury: A Prospective Study Impairment in the cervical flexors: a comparison of whiplash and insidious onset neck pain patients. Management of acute whiplash: A randomized controlled trial of multidisciplinary stratified treatments Development and delivery of a physiotherapy intervention for the early management of whiplash injuries: the Managing Injuries of Neck Trial (MINT) Intervention. Risk Factors for Prolonged Disability After Whiplash Injury: A Prospective Study The Effect of Neck-specific Exercise With, or Without a Behavioral Approach, on Pain, Disability, and Self-Efficacy in Chronic Whiplash-associated Disorders Similar factors predict disability and posttraumatic stress disorder trajectories after whiplash injury Managing Injuries of the Neck Trial (MINT): a randomised controlled trial of treatments for whiplash injuries. Prolonged functional impairments after whiplash injury. Physical and psychological factors predict outcome following whiplash injury
Background Many patients suffer from chronic neck pain following a whiplash injury . A combination of cognitive , behavioural therapy with physiotherapy interventions has been indicated to be effective in the management of patients with chronic whiplash-associated disorders . The objective is to present the design of a r and omised controlled trial ( RCT ) aim ed at evaluating the effectiveness of a combined individual physical and cognitive behavioural- grade d activity program on self-reported general physical function , in addition to neck function , pain , disability and quality of life in patients with chronic neck pain following whiplash injury compared with a matched control group measured at baseline and 4 and 12 months after baseline . Methods / Design The design is a two-centre , RCT - study with a parallel group design . Included are whiplash patients with chronic neck pain for more than 6 months , recruited from physiotherapy clinics and an out-patient hospital department in Denmark . Patients will be r and omised to either a pain management ( control ) group or a combined pain management and training (intervention)group . The control group will receive four educational sessions on pain management , whereas the intervention group will receive the same educational sessions on pain management plus 8 individual training sessions for 4 months , including guidance in specific neck exercises and an aerobic training programme . Patients and physiotherapists are aware of the allocation and the treatment , while outcome assessors and data analysts are blinded . The primary outcome measures will be Medical Outcomes Study Short Form 36 ( SF36 ) , Physical Component Summary ( PCS ) . Secondary outcomes will be Global Perceived Effect ( -5 to + 5 ) , Neck Disability Index ( 0 - 50 ) , Patient Specific Functioning Scale ( 0 - 10 ) , numeric rating scale for pain bothersomeness ( 0 - 10 ) , SF-36 Mental Component Summary ( MCS ) , TAMPA scale of Kinesiophobia ( 17 - 68 ) , Impact of Event Scale ( 0 - 45 ) , EuroQol ( 0 - 1 ) , craniocervical flexion test ( 22 mmHg - 30 mmHg ) , joint position error test and cervical range of movement . The SF36 scales are scored using norm-based methods with PCS and MCS having a mean score of 50 with a st and ard deviation of 10 . Discussion The perspectives of this study are discussed , in addition to the strengths and weaknesses . Trial registration The study is registered in http://www . Clinical Trials.gov identifier NCT01431261 Study Design . R and omized , parallel-group trial . Objective . To compare the effect of 3 early intervention strategies following whiplash injury . Summary of Background Data . Long-lasting pain and disability , known as chronic whiplash-associated disorder ( WAD ) , may develop after a forced flexion-extension trauma to the cervical spine . It is unclear whether this , in some cases disabling , condition can be prevented by early intervention . Active interventions have been recommended but have not been compared with information only . Methods . Participants were recruited from emergency units and general practitioners within 10 days after a whiplash injury and r and omized to : 1 ) immobilization of the cervical spine in a rigid collar followed by active mobilization , 2 ) advice to “ act-as-usual , ” or 3 ) an active mobilization program ( Mechanical Diagnosis and Therapy ) . Follow-up was carried out after 3 , 6 , and 12 months postinjury . Treatment effect was measured in terms of headache and neck pain intensity ( 0–10 ) , disability , and work capability . Results . A total of 458 participants were included . At the 1-year follow-up , 48 % of participants reported considerable neck pain , 53 % disability , and 14 % were still sick listed at 1 year follow-up . No significant differences were observed between the 3 interventions group . Conclusion . Immobilization , “ act-as-usual , ” and mobilization had similar effects regarding prevention of pain , disability , and work capability 1 year after a whiplash injury We have conducted a prospect i ve trial of the management of 135 adult patients who had sustained soft-tissue injuries of the neck in vehicle accidents .  Early traction and physiotherapy was compared with rest in a collar and unsupervised mobilisation . No benefit from the active treatment could be identified ; moulded collars in slight flexion gave the best pain relief and are recommended Study Design . Prospect i ve cohort study . Objective . To investigate the consequences of neck pain after motor vehicle accidents in terms of disability for work and the relationship this has with symptom and work-related factors . Summary of Background Data . Previous studies on work disability related to whiplash are very heterogeneous , are often limited in sample size and show a wide variability in terms of results . A relationship has been suggested between poor recovery from or persistent work disability after whiplash and female gender , older age , marital status , heavy manual work , self-employment , prior psychological problems , subjective complaints of poor concentration , pain catastrophizing , and kinesiophobia . Methods . Individuals with neck complaints after involvement in traffic accidents , who initiated compensation cl aim procedures with a Dutch insurance company ( n = 879 ) , were sent question naires ( Q1 ) concerning the accident , the injuries that they had sustained , their complaints at that time , and questions regarding work and disability . The course of complaints and work disability was monitored at 6 ( Q2 ) and 12 months ( Q3 ) after the accident . Results . A total of 58.8 % of the population with neck complaints studied was work-disabled after the accident . Age and impaired concentration complaints after 1 month were found to be related to work disability at 1 year , independent of physical complaints and work characteristics . Conclusion . Age and concentration complaints were important independent predictors of long-lasting work disability , whereas no evidence emerged to indicate that the degree of manual labor ( blue or white collar work ) or educational level was involved in persistent work disability in postwhiplash syndrome . The current results suggest that work disability could benefit most from interventions related to recovery from cognitive complaints and less from physically related interventions The authors undertook a case-control study of chronic neck pain and whiplash injuries in nine states in the United States to determine whether whiplash injuries contributed significantly to the population of individuals with chronic neck and other spine pain . Four hundred nineteen patients and 246 controls were r and omly enrolled . Patients were defined as individuals with chronic neck pain , and controls as those with chronic back pain . The two groups were surveyed for cause of chronic pain as well as demographic information . The two groups were compared using an exposure-odds ratio . Forty-five per cent of the patients attributed their pain to a motor vehicle accident . An OR of 4.0 and 2.1 was calculated for men and women , respectively . Based on the results of the present study , it reasonable to infer that a significant proportion of individuals with chronic neck pain in the general population were originally injured in a motor vehicle accident Study Design . An experimental study of motor and sensory function and psychological distress in subjects with acute whiplash injury . Objectives . To characterize acute whiplash injury in terms of motor and sensory systems dysfunction and psychological distress and to compare subjects with higher and lesser levels of pain and disability . Summary of Background Data . Motor system dysfunction , sensory hypersensitivity , and psychological distress are present in chronic whiplash associated disorders ( WAD ) , but little is known of such factors in the acute stage of injury . As higher levels of pain and disability in acute WAD are accepted as signs of poor outcome , further characterization of this group from those with lesser symptoms is important . Material s and Methods .  Motor function ( cervical range of movement [ ROM ] , joint position error [ JPE ] ; activity of the superficial neck flexors [ EMG ] during a test of cranio-cervical flexion ) , quantitative sensory testing ( pressure , thermal pain thresholds , and responses to the brachial plexus provocation test ) , and psychological distress ( GHQ-28 , TAMPA , IES ) were measured in 80 whiplash subjects ( WAD II or III ) within 1 month of injury , as were 20 control subjects . Results . Three subgroups were identified in the cohort using cluster analysis based on the Neck Disability Index : those with mild , moderate , or severe pain and disability . All whiplash groups demonstrated decreased ROM and increased EMG compared with the controls ( all P < 0.01 ) . Only the moderate and severe groups demonstrated greater JPE and generalized hypersensitivity to all sensory tests ( all P < 0.01 ) . The three whiplash subgroups demonstrated evidence of psychological distress , although this was greater in the moderate and severe groups . Measures of psychological distress did not impact on between group differences in motor or sensory tests . Conclusions . Acute whiplash subjects with higher levels of pain and disability were distinguished by sensory hypersensitivity to a variety of stimuli , suggestive of central nervous system sensitization occurring soon after injury . These responses occurred independently of psychological distress . These findings may be important for the differential diagnosis of acute whiplash injury and could be one reason why those with higher initial pain and disability demonstrate a poorer outcome BACKGROUND AND PURPOSE Physical mechanisms are the possible factors involved in the development and maintenance of long-term h and icaps after acute whiplash injury . This study prospect ively examined the role of active neck mobility , cervical and extra-cervical pains , as well as non-painful complaints after a whiplash injury as predictors for subsequent h and icap . METHODS Consecutive acute whiplash patients ( n = 688 ) were interviewed and examined by a study nurse after the median of 5 days after injury , and divided into a high- or a low-risk group by an algorithm based on pain intensity , number of non-painful complaints and active neck mobility [ active cervical range of motion ( CROM ) ] . All 458 high-risk patients and 230 low-risk patients received mailed question naires after 3 , 6 and 12 months . Two examiners examined all high-risk patients ( n = 458 ) and 41 consecutive low-risk patients at median 11 , 109 , 380 days after injury . The main outcome measures were : h and icaps , severe headaches , neck pain and neck disability . RESULTS The relative risk for a 1-year disability increased by 3.5 with initial intense neck pain and headaches , by 4.6 times with reduced CROM and by four times with multiple non-painful complaints . CONCLUSION Reduced active neck mobility , immediate intense neck pain and headaches and the presence of multiple non-painful complaints are the important prognostic factors for a 1-year h and icap after acute whiplash Objective of the investigation : In a 6-month prospect i ve study of 141 consecutive acute whiplash-injured participants , and 40 acute , ankle-injured controls , pain and tenderness in the neck/head , and at a distant control site , were measured . Basic procedures : Muscle palpation and pressure algometry in five head/neck muscle-pairs were performed after 1 week and 1 , 3 and 6 months after injury . Algometry was performed at a distant control site . Main findings : Whiplash-injured patients had lowered pressure-pain-detection thresholds and higher palpation-score initially in the neck/head , but the groups were similar after 6 months , and the control site was not sensitized . Principal conclusion : Focal , but not generalized , sensitization to musculoskeletal structure is present until 3 months , but not 6 months , after whiplash injury , and probably does not play a major role in the development of late whiplash syndrome . Pressure algometry and palpation are useful clinical tools in the evaluation of neck and jaw pain in acute whiplash injury There has been little investigation into whether or not differences exist in the nature of physical impairment associated with neck pain of whiplash and insidious origin . This study examined the neck flexor synergy during performance of the cranio-cervical flexion test , a test targeting the action of the deep neck flexors . Seventy-five volunteer subjects participated in this study and were equally divided between Group 1 , asymptomatic control subjects , Group 2 , subjects with insidious onset neck pain and Group 3 , subjects with neck pain following a whiplash injury .  The cranio-cervical flexion test was performed in five progressive stages of increasing cranio-cervical flexion range . Subjects ' performance was guided by feedback from a pressure sensor inserted behind the neck which monitored the slight flattening of the cervical lordosis which occurs with the contraction of longus colli .  Myoelectric signals ( EMG ) were detected from the muscles during performance of the test . The results indicated that both the insidious onset neck pain and whiplash groups had higher measures of EMG signal amplitude ( normalized root mean square ) in the sternocleidomastoid during each stage of the test compared to the control subjects ( all P<0.05 ) and had significantly greater shortfalls from the pressure targets in the test stages ( P<0.05 ) . No significant differences were evident between the neck pain groups in either parameter indicating that this physical impairment in the neck flexor synergy is common to neck pain of both whiplash and insidious origin 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 This paper describes the development and implementation of a physiotherapy intervention for a large multicentred r and omised controlled trial of the early management of whiplash injuries in a National Health Service setting . Participants were eligible if they were classified as having whiplash-associated disorder grade s I to III and self-referred for treatment within 6 weeks of injury . The intervention development was informed through a variety of methods including the current evidence base , published guidelines , clinician opinion , a pilot study and expert opinion . The intervention was targeted at known , potentially modifiable risk factors for poor recovery , and utilised manual therapy , exercises and psychological strategies . The treatment was individually tailored , with a maximum of six treatments allowed within the trial protocol over an 8-week period . The intervention was delivered to 300 participants . The amount and types of treatments delivered are described Study Design . A prospect i ve study of 135 patients with whiplash injury . Objectives . To identify factors predictive of prolonged disability following whiplash injury . Summary of Background Data . Although patients with whiplash associated disorders lack demonstrable physical injury , many exhibit prolonged disability . Disability appears unrelated to the severity of the collision . Methods . A total of 147 patients with recent whiplash injury were interviewed for putative risk factors for disability , and 135 were reinterviewed 12 months later to assess degree and duration of disability . Bivariate and multivariate analyses were undertaken to measure the association between putative risk factors and measures of outcome ( change in Neck Pain Outcome Score [ NPOS ] and visual analogue pain score [ VAPS ] , return to work , still requiring treatment , settlement of cl aim ) . Results . The bodily pain score and role emotional scores of the Short Form-36 health question naire showed a consistent significant positive association with better outcomes . After adjustment for bodily pain score and role emotional scores , consulting a lawyer was associated with less improvement in NPOS ( P < 0.05 ) , but there was no association with change in VAPS . Consulting a lawyer was associated with a lesser chance of cl aim settlement ( P < 0.01 ) and a greater chance of still having treatment ( P < 0.01 ) after 1 year , but there was no significant association with a return to work . The degree of damage to the vehicle was not a predictor of outcome . Conclusions . Short Form-36 scores for bodily pain and role emotional are useful means of identifying patients at risk of prolonged disability . The findings support the implementation of an insurance system design ed to minimize litigation Objectives : The aim of this study was to compare the effect on self-rated pain , disability , and self-efficacy of 3 interventions for the management of chronic whiplash-associated disorders :  physiotherapist-led neck-specific exercise ( NSE ) , physiotherapist-led NSE with the addition of a behavioral approach , or Prescription of Physical Activity ( PPA ) . Material s and Methods : A total of 216 volunteers with chronic whiplash-associated disorders participated in this r and omized , assessor blinded , clinical trial of 3 exercise interventions .  Self-rated pain/pain bothersomeness ( Visual Analogue Scale ) , disability ( Neck Disability Index ) , and self-efficacy ( Self-Efficacy Scale ) were evaluated at baseline and at 3 and 6 months . Results : The proportion of patients reaching substantial reduction in pain bothersomness ( at least 50 % reduction ) was more evident ( P<0.01 ) in the 2 NSE groups ( 29 % to 48 % ) compared with the PPA group ( 5 % ) at 3 months . At 6 months 39 % to 44 % of the patients in the 2 neck-specific groups and 28 % in the PPA group reported substantial pain reduction . Reduction of disability was also larger in the 2 neck-specific exercise groups at both 3 and 6 months ( P<0.02 ) . Self-efficacy was only improved in the NSE group without a behavioral approach ( P=0.02 ) . However , there were no significant differences in any outcomes between the 2 physiotherapist-led NSE groups . Discussion : NSE result ed in superior outcomes compared with PPA in this study , but the observed benefits of adding a behavioral approach to the implementation of exercise in this study were inconclusive & NA ; Distinct developmental trajectories for neck disability and posttraumatic stress disorder ( PTSD ) symptoms after whiplash injury have recently been identified . This study aim ed to identify baseline predictors of membership to these trajectories and to explore their dual development . In a prospect i ve study , 155 individuals with whiplash were assessed at < 1 month , 3 , 6 , and 12 months postinjury . Outcomes at each time point were assessed according to the Neck Disability Index and the Posttraumatic Stress Diagnostic Scale . Baseline predictor variables were age , gender , initial pain ( based on a visual analogue scale [ VAS ] ) , pressure pain thresholds ( PPT ) , cold pain thresholds ( CPT ) , and sympathetic vasoconstrictor responses . Group‐based trajectory analytical techniques were used to parameterise the optimal trajectories and to identify baseline predictors . A dual trajectory analysis was used to explore probabilities of conditional and joint trajectory group membership . CPT ⩾ 13 ° C ( OR = 26.320 , 95 % CI = 4.981–139.09 ) , initial pain level ( VAS ) ( OR = 4.3 , 95 % CI = 4.98–139.1 ) , and age ( OR = 1.109 , 95 % CI = 1.043–1.180 ) predicted a chronic/severe disability trajectory . The same baseline factors also predicted chronic moderate/severe PTSD ( CPT ⩾ 13 ° C , OR = 9.7 , 95%CI = 2.22–42.44 ; initial pain level [ VAS ] : OR = 2.13 , 95 % CI = 1.43–3.17 ; age : OR = 1.07 , 95 % CI = 1.01–1.14 ) . There was good correspondence of trajectory group for both disability and PTSD . These findings support the proposal of links between the development of chronic neck related disability and PTSD after whiplash injury . Developmental trajectories of disability and posttraumatic stress disorder ( PTSD ) after whiplash injury are mostly in synchrony , and similar factors predict their membership . This suggests links between the development of chronic neck pain‐related disability and PTSD 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 Thirty patients with whiplash injuries were examined 1 to 55 months after the accidents .  Pain had appeared on the day of the accident in 24 ( 80 % ) of the patients and with different delays in the remainder . The mean pain intensity was 43 mm ( SD 26 ) on a visual analogue scale ( VAS ) . All patients had pain in the neck , 17 - 33 % had headache  and 6 - 17 % had pain in various regions of the arms . Thirteen patients ( 43 % ) suffered from constant pain , while 17 ( 57 % ) had pain-free periods . Muscle tenderness was higher at all tested sites compared with controls . The tolerance level to pressure pain in the index finger as well as grip strength and neck mobility was reduced compared with controls . The whiplash patients showed poorer mental well-being compared with a reference group representing the general population and compared with a group of tension-type headache patients & NA ; Predictors of outcome following whiplash injury are limited to socio‐demographic and symptomatic factors , which are not readily amenable to secondary and tertiary intervention . This prospect i ve study investigated the predictive capacity of early measures of physical and psychological impairment on pain and disability 6 months following whiplash injury . Motor function ( ROM ; kinaesthetic sense ; activity of the superficial neck flexors ( EMG ) during cranio‐cervical flexion ) , quantitative sensory testing ( pressure , thermal pain thresholds , brachial plexus provocation test ) , sympathetic vasoconstrictor responses and psychological distress ( GHQ‐28 , TSK , IES ) were measured in 76 acute whiplash participants . The outcome measure was Neck Disability Index scores at 6 months . Stepwise regression analysis was used to predict the final NDI score . Logistic regression analyses predicted membership to one of the three groups based on final NDI scores ( < 8 recovered , 10–28 mild pain and disability , > 30 moderate/severe pain and disability ) . Higher initial NDI score ( 1.007–1.12 ) , older age ( 1.03–1.23 ) , cold hyperalgesia ( 1.05–1.58 ) , and acute post‐traumatic stress ( 1.03–1.2 ) predicted membership to the moderate/severe group . Additional variables associated with higher NDI scores at 6 months on stepwise regression analysis were : ROM loss and diminished sympathetic reactivity . Higher initial NDI score ( 1.03–1.28 ) , greater psychological distress ( GHQ‐28 ) ( 1.04–1.28 ) and decreased ROM ( 1.03–1.25 ) predicted subjects with persistent milder symptoms from those who fully recovered . These results demonstrate that both physical and psychological factors play a role in recovery or non‐recovery from whiplash injury . This may assist in the development of more relevant treatment methods for acute whiplash
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 .
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 .