Determining Whiplash Prognosis By: Morgan McMahill

Kinematics Typically, caused by rear-end collisions Pelvis accelerated forward; upper torso lags behind  initial flexion of neck Upper torso accelerates forward relative to the head  retraction, lower c-spine extension, upper c-spine flexion (reflexive SCM) Head is accelerated forward and backwards rotation of the head causes extension Head and torso rebound forward after contact with the seat and headrest (controlled by posterior neck muscles) http://www.completepaincare.com/patient-education/conditions-treated/neck-pain-cervicalgia/

Whiplash Injury Capsular ligament strain, bony impingement, intra- articular hemorrhage, cervical facet joints, facet capsular ligaments, vertebral arteries, dorsal root ganglia, craniovertebral junction, and cervical muscles Only the cervical facet joints have been explicitly linked to chronic whiplash pain.

Recovery 50% of individuals with whiplash-associated disorder (WAD) continue to have pain and disability at 6 months post injury Goals: Identify those at risk for chronic symptoms Develop more targeted treatments to aid in recovery

Journal of Orthopaedic & Sports Physical Therapy. Walton et al, 2013. Risk Factors for Persistent Problems Following Acute Whiplash Injury: Update of a Systematic Review and Meta-analysis Journal of Orthopaedic & Sports Physical Therapy. Walton et al, 2013.

Significant Predictors of Poor Outcome Walton et al, 2013) Number of Studies Fail-Safe N High pain intensity (> 5.5/10)* 11 405 Female* 14 109 Report of HA at inception* 5 64 Lower education (< postsecondary)* 7 48 High NDI (>14.5/50)* 3 39 WAD grade 2 or 3* 35 WAD grade 3 (versus 2) 4 18 Preinjury neck pain 8 16 Report of LBP at inception Fail-safe N is the number of studies with negative or non-significant results that would need to be included in the database to nullify the positive results found here. *Robust to publication bias…means the fail-safe N is greater than 5x the included study’s criterion ~NDI  recommended as a potential predictor variable of chronicity, esp. when predicting disability

Journal of Chiropractic Medicine. Croft et al, 2016 Classifying Whiplash Recovery Status Using the Neck Disability Index: Optimized Cutoff Points Derived From Receiver Operating Characteristic Journal of Chiropractic Medicine. Croft et al, 2016

Methods Croft et al, 2016 Subjects with whiplash injuries for at least 24 weeks prior to recruitment (n = 123) 18-68 yo Self-rated: recovered (n = 44) vs. nonrecovered (n = 79)  compared these state values with their NDI scores using the ROC ROC curve plots sensitivity vs. specificity Optimized cutoff points were computed based on sensitivity and specificity “Recovery” was not defined and could have been misinterpreted by the subjects.

Suggested NDI cut-off points between recovered vs. not recovered Men - 15 General demographic - 15 Women - 19 Older adults (>40 yo) - 21 The cut-off points optimized specificity and sensitivity Mean NDI for recovered group was 7.8 vs. nonrecovered was 27.1

Journal of Orthopaedic & Sports Physical Therapy. External Validation of a Clinical Prediction Rule to Predict Full Recovery and Ongoing Moderate/Severe Disability Following Acute Whiplash Injury Journal of Orthopaedic & Sports Physical Therapy. Ritchie et al, 2015

Dual-Pathway Whiplash CPR Ritchie et al, 2015 Full recovery NDI <32% Age <35 years Moderate/severe pain and disability NDI >40% Age >35 years Hyperarousal subscale (PDS) >6 Trouble sleeping, irritability, difficulties concentrating, being overly alert, and being easily startled

External Validation of CPR Ritchie et al, 2015 Confirmed the reproducibility and accuracy of the whiplash CPR 90.9% predictive probability for ongoing moderate/severe pain and disability 80% predictive probability of full recovery with younger age and lower initial levels of neck disability High specificities indicate a low false-positive rate and help rule in the condition If someone meets all of the criteria for either recovery status then they are likely to have that outcome Full recovery = 86 specificity Mod/severe p! & disability = 98.7% specificity

Summary of Evidence Walton et al, 2013 Croft et al, 2016 Use of NDI to predict chronicity, especially when determining disability NDI >14.5/50 Croft et al, 2016 Determined optimal NDI cut-off points between recovered vs. not recovered based off of sensitivity and specificity Men & General demographic - 15 Women – 19 Older adults (>40 yo) – 21 Ritchie et al, 2015 CPR developed and validated to predict full recovery or ongoing mod/severe pain and disability NDI, PDS subscale (if NDI > 40%) PDS subscale costs money to use the entire instrument It contains generic arousal questions that can be found in other free tools Impact of Event Scale-Revised Use the 5 hyperarousal symptom items independently of the entire PDS questionnaire

Questions?

References Siegmund, Gunter P., PhD, PEng. "The Biomechanics of Whiplash Injury." BC Medical Journal. Vol. 44, No. 5 (June 2002): 243-47. Web. 09 Aug. 2016. Abelson, Brian. "Resolving Whiplash Injuries." Kinetic Health. N.p., 2012. Web. <http://kinetichealth.ca/resolving-whiplash-injuries/>. Walton, DM, AA Giorgianni, JC Mascarenhas, S. West, and CA Zammit. "Risk Factors for Persistent Problems following Acute Whiplash Injury: Update of a Systematic Review and Meta-analysis." JOSPT 43.2 (2013): 31-43. Web. Croft et al. “Classifying Whiplash Recovery Status Using the Neck Disability Index: Optimized Cutoff Points Derived From Receiver Operating Characteristic.” Journal of Chiropractic Medicine 15 (2016): 95-101. Web. Ritchie et al. “External Validation of a Clinical Prediction Rule to Predict Full Recovery and Ongoing Moderate/Severe Disability Following Acute Whiplash Injury.” JOSPT 45.4 (2015): 242-250. Web.