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Clinical Prediction Models for Patients With Nontraumatic Knee Pain in Primary Care: A Systematic Review and Internal Validation Study.
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Clinical Prediction Models for Patients With Nontraumatic Knee Pain in Primary Care: A Systematic Review and Internal Validation Study.

J Orthop Sports Phys Ther. 2017 Jun 16;:1-29

Authors: Panken G, Verhagen AP, Terwee CB, Heymans MW

Abstract
Study Design A systematic review and validation study. Background Many prognostic models of knee pain outcomes have been developed for use in primary care. Variability among published studies with regard to patient population, outcome measures, and relevant prognostic factors hampers the generalizability and implementation of these models. Objectives To summarise existing prognostic models in patients with knee pain in a primary care setting and to develop and internally validate new summary prognostic model(s). Methods After a sensitive search strategy two reviewers independently selected prognostic models for patients with non-traumatic knee pain and assessed the methodological quality of the included studies. All predictors of the included studies were evaluated, summarized and classified. The predictors assessed in multiple studies of sufficient quality are presented in this review. We used predictors with a strong level of evidence to develop new prognostic models for each outcome measure and internally validated these models. Results Sixteen studies were eligible for inclusion. We considered eleven studies of sufficient quality. None of these studies validated their models. Five predictors with strong evidence were related to function and six to recovery and were used to compose two prognostic models for patients with knee pain at one year. Running these new models in another dataset showed explained variances (R(2)) of 0.36 (function) and 0.33 (recovery). The area under the curve (AUC) of the recovery model was 0.79. After internal validation, the adjusted R(2) of the models were 0.30 (function) and 0.20 (recovery) respectively, and the AUC 0.73. Conclusions We developed two valid prognostic models for function and recovery for patients with non-traumatic knee pain, based on predictors with strong evidence. A longer duration of complaints predicts poor function or less chance of recovery. Level of Evidence Prognosis, levels 1a and 1b. J Orthop Sports Phys Ther, Epub 16 Jun 2017. doi:10.2519/jospt.2017.7142.

PMID: 28622751 [PubMed - as supplied by publisher]




General Exercise Does Not Improve Long-Term Pain and Disability in Individuals With Whiplash-Associated Disorders: A Systematic Review.
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General Exercise Does Not Improve Long-Term Pain and Disability in Individuals With Whiplash-Associated Disorders: A Systematic Review.

J Orthop Sports Phys Ther. 2017 Jun 16;:1-29

Authors: Griffin A, Leaver A, Moloney N

Abstract
Study Design Systematic review of randomized controlled trials. Background General exercise, defined as purposeful physical activity involving repetitive exercises, and incorporating multiple muscle groups, is frequently used in the management of whiplash associated disorders (WAD). Evidence supporting its efficacy is not well established. Objectives To determine whether general exercise is effective in reducing pain and disability in people with WAD. Methods Studies published in English in peer-reviewed journals between January 1990 and May 2015 were eligible if they evaluated a general exercise intervention compared with a different intervention or control. Studies were required to evaluate pain and disability at medium- (6 to 14 weeks) and long-term (52 weeks) follow up. The mean (SD) and sample size were recorded for follow-up scores, or changes from baseline at follow-up. Results Three high quality studies were eligible for inclusion; none investigated general exercise alone. There were no clinically meaningful differences between comprehensive exercise programs, which included general exercise, and minimal intervention controls at medium- and long-term. No studies directly compared general exercise with a no-treatment control. All included studies used different control interventions preventing meta-analysis. Conclusion A lack of significant long-term improvements from general exercise interventions in individuals with WAD was identified. This finding differs from the positive benefits of general exercise for other musculoskeletal conditions. This may, in part, relate to the complexity of whiplash conditions. This may also reflect the challenge of exercise prescription in this population, where the need for sufficient intensity is balanced against the impact that exercise has on pain. Level of Evidence Therapy, Level 1a. J Orthop Sports Phys Ther, Epub 16 Jun 2017. doi:10.2519/jospt.2017.7081.

PMID: 28622749 [PubMed - as supplied by publisher]




The Role of Exercise and Patient Education in the Noninvasive Management of Whiplash: A Clinical Commentary.
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The Role of Exercise and Patient Education in the Noninvasive Management of Whiplash: A Clinical Commentary.

J Orthop Sports Phys Ther. 2017 Jun 16;:1-32

Authors: Rebbeck T

Abstract
Synopsis The majority of people with whiplash associated disorder (WAD) do not have neurological deficit or fracture and are therefore largely managed with non-surgical interventions such as exercise, patient education, and behavioral based-interventions. To date clinical guidelines, systematic reviews, and the results of high quality randomized controlled trials recommend exercise and patient education as the primary interventions for people in both acute and chronic stages after injury. However, the relatively weak evidence and small effect sizes in individual trials have led authors of some systematic reviews to reach equivocal recommendations for either exercise or patient education and for policy makers and funders to question whether the more expensive intervention (exercise) should be funded at all. Physical therapists are one of the most commonly consulted professionals treating individuals with WAD. As a profession therefore, we need to look beyond the evidence, for insights as to what role patient education and exercise should play in the future management of whiplash. This clinical commentary therefore will review the evidence for exercise, patient education, and behavioral-based interventions for whiplash and provide clinical insight as to the future role that exercise and patient education should play in the management of this complex condition. Possible sub-groups who may best respond to exercise will be explored, using stratification based on impairments, treatment response, and risk/prognostic factors. J Orthop Sports Phys Ther, Epub 16 Jun 2017. doi:10.2519/jospt.2017.7138.

PMID: 28622489 [PubMed - as supplied by publisher]




Dizziness, Unsteadiness, Visual Disturbances, and Sensorimotor Control in Traumatic Neck Pain.
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Dizziness, Unsteadiness, Visual Disturbances, and Sensorimotor Control in Traumatic Neck Pain.

J Orthop Sports Phys Ther. 2017 Jun 16;:1-25

Authors: Treleaven J

Abstract
Synopsis There is considerable evidence to support the importance of cervical afferent dysfunction in the development of dizziness, unsteadiness, visual disturbances and altered balance, eye, and head movement control following neck trauma, especially in those with persistent symptoms. However, there are other possible causes for these symptoms and secondary adaptive changes should also be considered in the process of differential diagnosis. Understanding the nature of these symptoms and the differential diagnosis of their potential origin is important for rehabilitation. In addition to symptoms and the evaluation of potential impairments (altered cervical joint position and movement sense, static and dynamic balance, and ocular mobility and co-ordination), should become an essential part of the routine assessment of those with traumatic neck pain, including those with concomitant injuries such as concussion and vestibular or visual pathology or deficits. Once adequately assessed, appropriate tailored management should be implemented. Research to further assist differential diagnosis and to understand the most important contributing factors associated with abnormal cervical afferent input and subsequent disturbances to the sensorimotor control system as well as the most efficacious management of such symptoms and impairments are important directions for the future. J Orthop Sports Phys Ther, Epub 16 Jun 2017. doi:10.2519/jospt.2017.7052.

PMID: 28622488 [PubMed - as supplied by publisher]




An Integrated Model of Chronic Whiplash-Associated Disorder.
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An Integrated Model of Chronic Whiplash-Associated Disorder.

J Orthop Sports Phys Ther. 2017 Jun 16;:1-26

Authors: Walton DM, Elliott JM

Abstract
Synopsis The development of persistent symptoms following whiplash injury from a motor vehicle collision (MVC) is common and contributes substantially to societal and personal costs. The popular Quebec Task Force (QTF) classification system of whiplash-associated disorders (WAD) was meant to function as a prognostic and intervention decision aid, but its usefulness has been questioned. Emerging evidence highlights the heterogeneity of WAD by demonstrating physical and psychological impairments that are unique to those who develop persistent symptoms. These impairments are not recognized in the QTF classification system. The purpose of this clinical commentary is to describe an integrated model focusing on how psychological and neurobiological factors interact and are influenced by existing personal and environmental factors to contribute to the development of chronic WAD. The model has been developed through more than 20 years of work in the field, consultation with experts, in depth synthesis of existing evidence, and new evidence from the authors' own research programs. A sub-theme is that a point of convergence currently exists between the psychological, physiological, and social determinants of health literature that can further explain the complex presentation of WAD. The new model is proposed to orient future research towards more interdisciplinary efforts across non-traditional fields including data scientists and consumers to clarify the mystery of WAD. J Orthop Sports Phys Ther, Epub 16 Jun 2017. doi:10.2519/jospt.2017.7455.

PMID: 28622487 [PubMed - as supplied by publisher]




The Physiological Basis of Cervical Facet-Mediated Persistent Pain: Basic Science and Clinical Challenges.
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The Physiological Basis of Cervical Facet-Mediated Persistent Pain: Basic Science and Clinical Challenges.

J Orthop Sports Phys Ther. 2017 Jun 16;:1-36

Authors: Ita ME, Zhang S, Holsgrove TP, Kartha S, Winkelstein BA

Abstract
Synopsis Chronic neck pain is common and a primary clinical symptom of whiplash and other spinal injuries. Loading-induced neck injuries produce abnormal kinematics between the vertebrae, with the potential to injure facet joints and the afferent fibers that innervate the specific joint tissues, including the capsular ligament. Mechanoreceptive and nociceptive afferents that innervate the facet have their peripheral terminals in the capsule, cell bodies in the dorsal root ganglia, and terminal processes in the spinal cord. As such, biomechanical loading of these afferents can initiate nociceptive signaling in the peripheral and central nervous systems. Their activation depends on the local mechanical environment of the joint and encodes the neural processes that initiate pain and lead to its persistence. This commentary reviews the complex anatomical, biomechanical, and physiological consequences of facet-mediated whiplash injury and pain. The clinical presentation of facet-mediated pain is complex in its sensory and emotional components. Yet, human studies are limited in their ability to elucidate the physiological mechanisms by which abnormal facet-loading leads to pain. Over the past decade, however, in vivo models of cervical facet injury have been developed that reproduce clinical pain symptoms, and have been used to define the complicated and multi-faceted electrophysiological, inflammatory, and nociceptive signaling cascades that are involved in the pathophysiology of whiplash facet pain. Integrating the whiplash-like mechanics in vivo and in vitro allows transmission of pathophysiological mechanisms across scales, with the hope of informing clinical management. Yet, despite these advances, many challenges remain. This commentary further describes and highlights such challenges. J Orthop Sports Phys Ther, Epub 16 Jun 2017. doi:10.2519/jospt.2017.7255.

PMID: 28622486 [PubMed - as supplied by publisher]




The Nature of Whiplash in a Compensable Environment: Injury, Disability, Rehabilitation, and Compensation Systems.
Related Articles

The Nature of Whiplash in a Compensable Environment: Injury, Disability, Rehabilitation, and Compensation Systems.

J Orthop Sports Phys Ther. 2017 Jun 16;:1-16

Authors: Connelly LB

Abstract
Synopsis Whiplash is a compensable injury in many jurisdictions, but there is considerable heterogeneity in the compensation arrangements that apply across jurisdictions, even within some countries. These schemes have, however, been subject to a common set of inter-related concerns, chiefly concerning the incentives, behaviours, and outcomes that may arise when financial compensation for injuries is available to injured parties. This article provides a non-technical overview of some of those concerns through the lens of economics: principally, insurance economics and health economics, including related subsets such as information economics and agency theory, as well as economics and the law. It notes that because it is generally infeasible to randomise the treatment (ie, compensation) via trials, analyses of observational data are necessary to discover more about the relationship between compensation and health outcomes. This poses the analytical challenge of discovering causal connections between phenomena from non-randomised datasets. This is possible, but challenging, to do: the article calls for further research that enables convincing, causal, interpretations of such relationships via the careful analysis of rich observational datasets with modern econometric methods. J Orthop Sports Phys Ther, Epub 16 Jun 2017. doi:10.2519/jospt.2017.7533.

PMID: 28622485 [PubMed - as supplied by publisher]