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BACKGROUND: Neck pain is one of the leading causes of disability in most countries and it is likely to increase further. Numerous prognostic models for people with neck pain have been developed, few have been validated. In a recent systematic review, external validation of three promising models was advised before they can be used in clinical practice. OBJECTIVE: The purpose of this study was to externally validate three promising models that predict neck pain recovery in primary care. METHODS: This validation cohort consisted of 1311 patients with neck pain of any duration who were prospectively recruited and treated by 345 manual therapists in the Netherlands. Outcome measures were disability (Neck Disability Index) and recovery (Global Perceived Effect Scale) post-treatment and at 1-year follow-up. The assessed models were an Australian Whiplash-Associated Disorders (WAD) model (Amodel), a multicenter WAD model (Mmodel), and a Dutch non-specific neck pain model (Dmodel). Models' discrimination and calibration were evaluated. RESULTS: The Dmodel and Amodel discriminative performance (AUC < 0.70) and calibration measures (slope largely different from 1) were poor. The Mmodel could not be evaluated since several variables nor their proxies were available. CONCLUSIONS: External validation of promising prognostic models for neck pain recovery was not successful and their clinical use cannot be recommended. We advise clinicians to underpin their current clinical reasoning process with evidence-based individual prognostic factors for recovery. Further research on finding new prognostic factors and developing and validating models with up-to-date methodology is needed for recovery in patients with neck pain in primary care.

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BACKGROUND: Statistical analysis plans describe the processes of data handling and analysis in clinical trials; by doing so they increase the transparency of the analysis and reporting of studies. This paper reports the planned statistical analysis plan for the Whiplash ImPaCT study. For individuals with whiplash injury, Whiplash ImPaCT aims to assess the effectiveness of a guidelines-based clinical pathway of care compared with usual care. METHODS: We report the planned procedures, methods, and reporting for the primary and secondary analyses of the Whiplash ImPaCT study. The primary outcomes are Global Recovery and Neck Disability Index at 3 months post-randomisation. Outcomes will be analysed according to the intention to treat principle using linear mixed models. A cost-utility analysis will be conducted to compute the incremental cost-effectiveness of the intervention to usual care. We describe data handling, our analytical approach, assumptions about missing data, and our planned methods of reporting. DISCUSSION: This paper will provide a detailed description of the planned analyses for the Whiplash ImPaCT trial.

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BACKGROUND: To address the need for a better treatment of chronic whiplash associated disorders (WAD), a contemporary neuroscience approach can be proposed. OBJECTIVE: To examine the effectiveness of a contemporary neuroscience approach, comprising pain neuroscience education, stress management, and cognition-targeted exercise therapy versus conventional physical therapy for reducing disability (primary outcome measure) and improving quality of life and reducing pain, central sensitization, and psychological problems (secondary outcome measures) in people with chronic WAD. METHODS: The study is a multi-center, two-arm randomized, controlled trial with 1-year follow-up and will be performed in two university-based and one regional hospital. People with chronic WAD (n=120) will be recruited. The experimental group will receive pain neuroscience education followed by cognition-targeted exercise therapy, and stress management. The control group will receive biomedically focused education followed by graded and active exercise therapy focusing on muscle endurance, strength, and flexibility, and ergonomic principles. The treatment will have a duration of 16 weeks. Functional status (Neck Disability Index) is the primary outcome measure. Secondary outcome measures include quality of life, pain, central sensitization, and psychological and socio-economic factors. In addition, electroencephalography will measure brain activity at rest and during a conditioned pain modulation paradigm. Assessments will take place at baseline, immediately post-treatment and at 6 and 12 months follow-up. CONCLUSIONS: This study will examine whether a contemporary neuroscience approach is superior over conventional physical therapy for improving functioning, quality of life, and reducing pain, central sensitization, and psychological problems in people with chronic WAD.

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BACKGROUND: The aim of this study is to evaluate the physiological and psychological effect after an electromyographic biofeedback treatment in combination with progressive muscular relaxation training in patients with acute whiplash. METHODS: Twelve patients with acute whiplash volunteered to participate in a quasi-experimental design and a control group. INCLUSION CRITERIA: Two months maximum after car accident, severity levels II and I. EXCLUSION CRITERIA: previous history of persistent pain or serious previous injury. The groups were randomly divided in two (treatment and waiting list groups). We used electromyographic measures of the trapezius muscles with psychometric tests: Beck Anxiety and Depression Inventory; Oswestry Pain Disability Questionnaire; Visual Analog Scale of Pain; TAMPA Scale for Kinesiophobia. The treatment consisted in electromyographic biofeedback after progressive muscular relaxation training. RESULTS: There were significant intra-group differences before and after treatment in muscular symmetry and subjective pain perception in the treatment group. CONCLUSIONS: We achieved a significant change (clinical and statistical) in subjective pain perception and muscular symmetry. This study highlights the importance of multidisciplinary work in acute pain patients and the effectiveness of clinical psychophysiological strategies with acute whiplash patients.

Introducción: el objetivo de este trabajo consistió en evaluar el efecto fisiológico y psicológico de la retroalimentación biológica de electromiografía de superficie (RB de EMGs) en combinación con relajación muscular progresiva (RMP) en pacientes con esguince cervical (EC) agudo. Métodos: Un total de 12 pacientes con EC agudo participaron voluntariamente en el estudio, con diseño cuasiexperimental, y grupo control. Criterios de inclusión: máximo dos meses del accidente automovilístico; gravedad I y II. Se excluyeron: pacientes con historia previa de dolor persistente, o que hayan tenido lesión seria. Se dividió en dos grupos aleatoriamente (de intervención y en lista de espera). Se realizó un registro psicofisiológico de los músculos trapecios con EMGs, en conjunto con instrumentos psicométricos: inventario de ansiedad y depresión de Beck; índice de incapacidad de Oswestry; escala visual análoga y de miedo al movimiento. La intervención consistió aplicar RB de EMGs, posterior a un entrenamiento en RMP. Resultados: el grupo de intervención disminuyó significativamente su valor de simetría muscular (permaneciendo dentro de lo normal) así como su percepción subjetiva del dolor, intragrupo antes/después de la intervención. Conclusiones: se produjo un cambio significativo (tanto clínico como estadístico) en la percepción del dolor y la actividad conjunta de músculos pares. Igualmente, muestra la relevancia de atender un problema agudo multidisciplinariamente; así como la utilidad de las estrategias psicofisiológicas clínicas en pacientes agudos de EC.

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The same day as being involved in a traffic incident as a pedestrian hit by a car, a middle-aged woman accessed emergency medical care and was later discharged. After two days the patient returned to emergency with complaints of neck pain. X-rays were conducted was immobilized with a cervical collar. Since the pain persisted, she was examined a few days later by physiatry, where a limitation in the arc of motion of the neck was found and whiplash was considered a possibility. This type of cases related to chronic posttraumatic pain are relatively common in clinical consultation and represent a great challenge for physicians, mainly in the forensic field, since there are often many symptoms and very few signs to identify the damage. Therefore, a forensic doctor must recur to the clinical history and carefully examine the mechanism of injury and the evolution of the clinical presentation, in addition to calling on other disciplines such as orthopedics, physiatry, psychiatry and pain medicine to issue a definitive concept.

Una mujer de edad mediana sufrió un accidente de tránsito como peatón al ser arrollada por un automóvil, este mismo día recibió atención mediante el servicio médico de urgencias dándosele de alta posteriormente. A los dos días la mujer consultó nuevamente el servicio de urgencias por dolor cervical, le realizaron radiografías y le inmovilizaron con cuello ortopédico. Dada la persistencia de dolor cervical, días después fue valorada por fisiatría, donde encontraron limitación para arcos de movimiento del cuello y se consideró posible síndrome de latigazo cervical. Este tipo de casos relacionados con dolor crónico postraumático es relativamente frecuente en la consulta clínica y reviste un gran reto para los médicos, principalmente en el campo forense, ya que con frecuencia hay muchos síntomas y muy pocos signos que logren objetivar el daño. De esta manera, el médico forense debe recurrir a la historia clínica y escudriñar detalladamente el mecanismo de lesión y la evolución del cuadro clínico, además de pedir el concepto de varias disciplinas como ortopedia, fisiatría, psiquiatría y medicina del dolor, para emitir su concepto definitivo.

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Whiplash injury usually occurs in people who suffered an automobile accident, but also occurs as a result of physical assault and other mechanisms. Diagnosis and initial management of the patient by the emergency physician or orthopedist, and prescribing indications, are taken into account by two forensic intervention specialists. One of these is the medical officer, who, through analysis of the injury mechanism, establishes a cause-effect relationship and concludes whether the accident suffered by a worker it is related to work or not, determines how long the worker will remain disabled and if the injury caused permanent disability under Federal Labor Law. The medical examiner by injury classification assists the Public Ministry so that it can frame the crime of injury to the Criminal Code of Federal District. For these reasons a review of medical information about the mechanism of injury, diagnosis, treatment and healing time was performed to help both specialists to standardize their approach in their daily activities.

El esguince cervical es una lesión que se presenta en personas que sufrieron un accidente automovilístico, pero también como consecuencia de agresiones físicas y otros mecanismos. El diagnóstico y el manejo inicial del paciente por el médico de urgencias o el ortopedista, así como las indicaciones que prescriben, suelen tomarse en consideración por dos especialistas con intervención médico-legal. Uno de ellos es el médico del trabajo, el cual, mediante un análisis del mecanismo de lesión, establece la relación causa-efecto, califica si el accidente sufrido por un trabajador tiene o no relación con el trabajo, determina cuánto tiempo permanecerá incapacitado y señala si la lesión provocó alguna incapacidad permanente prevista en la Ley Federal del Trabajo. Mediante la clasificación de la lesión, el médico legista auxilia al Ministerio Público para que este pueda encuadrar el delito de lesiones en el Código Penal del Distrito Federal. Por estas razones, se realiza una revisión de la información médica acerca del mecanismo de la lesión, el diagnóstico, el tratamiento y el tiempo de curación, lo cual ayudará a ambos especialistas a establecer el criterio en su actividad cotidiana.

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BACKGROUND: cervical sprain or whiplash incidence has high costs in medical care, disabilities and work absences. The aim was to demonstrate that disability days caused by cervical sprain I and II are reduced without the use of neck immobilizer collar (NIC). METHODS: a transverse study in 100 patients with cervical sprain I and II at the emergency room was evaluated. The use of the collar and disability days was measured. Descriptive statistics were used. RESULTS: patients treated with NIC and anti-inflammatory medications (AI) were 68 % of patients and 32 % of patients were treated without NIC and only with AI. The mean work absence was 11.75 days in 86 % of patients, 74.4 % used NIC. Within the patients (14 %) that had no work absence, only 28.6 % used NIC with a χ(2) = 11.63 and a p < 0.001. CONCLUSIONS: the days of disability and recovery were lower in patients who did not use the collar.

Introducción: la incidencia del esguince cervical ocasiona altos costos en atención médica, incapacidades y ausencias laborales. El objetivo fue demostrar que los días de incapacidad por esguince cervical grados I y II son menores sin el uso de collarín. Métodos: estudio transversal en 100 pacientes que acudieron a la consulta de urgencias por esguince cervical grados I y II. Se evaluó el uso de collarín y los días de incapacidad laboral. Se utilizó estadística descriptiva para el análisis estadístico. Resultados: fueron tratados con collarín más antiinflamatorio 68 % de los pacientes y 32 %, solamente con antiinflamatorio; 86 % requirió incapacidad laboral, con 11.75 días en promedio. De los pacientes incapacitados, 74.4 % utilizó collarín; de los 14 pacientes que no requirieron incapacidad, 28.6 % utilizó collarín (χ2 = 11.63, p < 0.001). Conclusiones: los días de incapacidad y recuperación fueron menores en los pacientes que no utilizaron collarín.

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A prevalência de cervicalgia varia de 22% a 30%, indicando que 67% dos indivíduos vão sofrer de dor na cervical em alguma fase da vida. Foi realizada uma revisão de literatura sobre a estabilização cervical, comparando a eficácia do treino de flexão crâniocervical com outras técnicas. Foram pesquisados artigos científicos nas bases de dados SciELO, MEDLINE, LILACS, PubMed e Science Direct com os descritores: Cervicalgia, Atlas Cervical, Whiplash Injuries e Neck Pain no idioma inglês entre os anos 2000-2011. O treino de baixa carga de flexão crâniocervical promove uma melhor funcionalidade e redução da dor nos pacientes com disfunção na musculatura cervical.

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Traumatic posterior fossa epidural hematomas are uncommon lesions. Among these lesions, retroclival epidural hematomas (REDH) are particularly rare conditions that usually occur in the pediatric population due to predisposing anatomical features in this patient group. We describe a typical case of traumatic REDH from the mechanism of trauma to outcome. This 8-year-old girl was involved in a motor vehicle accident leading to whiplash cervical injury and cranial nerve palsy. Any children involved in a severe motor vehicle accident with such a sequence of events should raise suspicion for prompt diagnosis.

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Cervicogenic headache (CEH) is a well-recognized syndrome. Proposed diagnostic criteria differentiate CEH from migraine and tension-type headache (TTH) in most of the cases. The best differentiating factors include side-locked unilateral pain irradiating from the back and evidence of neck involvement--attacks may be precipitated by digital pressure over trigger spots in the cervical/nuchal areas or sustained awkward neck positions. Migrainous traits may be present in some cases. Cervical lesions are not necessarily seen, and most common cervical lesions do not produce CEH. Whiplash may occasionally induce headaches. This is suspected when the pain onset and the whiplash trauma are close in time. Whiplash-related headaches tend to be short-lasting, admitting mostly a TTH or a CEH-like phenotype. Neuroimaging abnormalities are not necessarily expected in CEH. Whiplash patients must undergo cervical imaging mostly in connection with the trauma, as no abnormalities are pathognomonic in chronic cases.

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The cervical sprain, also known as Whiplash Syndrome, is a frequent pathology that produces high economic losses by year in the big cities. The most common mechanism most for whiplash, is the automobile accident with collision in the backside of the car, although it can be caused by other mechanisms. The pathophysiology of the whiplash syndrome is poorly understood, therefore the treatment is controversial and poorly described in the literature. Many signs and symptoms are reported, some of which are related to poor prognosis and are rarely reported. While making the diagnosis work-up, plain X-rays have low sensibility compared to Magnetic Resonance Imaging (MRI) in the detection of changes. The electroneurophysiology studies should be considered for using them in a routine basis, and when alterations appear, it is recommended to use MRI. Unfortunatelly, the rehabilitation treatments for whiplash syndrome have not been scientifically evaluated, thus there is few supportive evidence of the benefits and effectiveness from said treatments. It is very important to mention the treatment could be surgical.

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Whiplash is a controversial concept. The real nature and prevalence of whiplash-related headaches are not known. To address this issue, the history of severe trauma was collected from occipital/nuchal headache-cervicogenic headache, migraine and tension-type headache patients attending a neurology office. The two last groups of patients had significantly less history of trauma in their medical records, with longer time span between the injury and the headache onset. Whiplash may induce preferably cervicogenic and tension-type headaches.

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Whiplash is a sprain of the ligament with strain of the paraspinal muscles due to acceleration or back acceleration of energy transmitted to the neck. The symptoms are neck pain, neck stiffness, muscular spasm and a multitude of discomforts that affect job-related and activities of daily living. In 2000, the Mexican Social Security System treated more than 15,000 cases of whiplash due to job-related activities. With this information, we organized an expert team in order to develop guidelines using methodology of evidence-based medicine and with a focus on early treatment prescribed by the general practitioner in order for the patient to obtain quick relief and to return the patient to his job and to his daily living activities as soon as possible.

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Objetivo: No presente estudo comparamos os resultados de 176 casos de perícias médicas otoneurológicas de pacientes com síndrome da chicotada tardia que recorreram a nós apenas com objetivos diagnósticos. Método: Todos os nossos pacientes foram submetidos a uma história sistemática (NOASC I) e a um exame otoneurológico funcional audiométrico e equilibriométrico. Desta forma, tentamos estabelecer a localização e natureza da degeneraçäo funcional subjacente aos sintomas residuais pós-traumáticos, como a vertigem. As investigaçöes da equilibriometria, incluíram a Electronistagmografia e a Craniocorpografia, assim obtendo um registro da postura por meio de uma imagem tipo radar de um marcador colocado na cabeça e nos ombros do doente, durante a marcha e a posiçäo estática de pé, assim como ao inclinar, estender e rodar o pescoço. Resultados: Ao analisarmos 176 perícias de doentes com síndrome da chicotada tardia descobrimos que em média cada caso já tinha sido submetido a 4,6 outras perícias médicas, inclusive com o recurso a 18 especialidades médicas diferentes. Num caso extremo verificamos, num único doente, 29 perícias anteriores à nossa. Conclusäo: Pudemos identificar alguns padröes de lesöes funcionais das vias neurotológicas, que objetiva e quantitativamente podem confirmar as queixas subjetivas.

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