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 Physiotherapist-delivered stress inoculation training integrated with exercise versus physiotherapy exercise alone for acute whiplash-associated disorder (StressModex): a randomised controlled trial of a combined psychological/physical intervention Are Work Disability Prevention Interventions Effective for the Management of Neck Pain or Upper Extremity Disorders? A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration Implementation of a guideline-based clinical pathway of care to improve health outcomes following whiplash injury (Whiplash ImPaCT): protocol of a randomised, controlled trial. Coping and Recovery in Whiplash-associated Disorders: Early use of Passive Coping Strategies is Associated With Slower Recovery of Neck Pain and Pain-related Disability Are People With Whiplash-Associated Neck Pain Different From People With Nonspecific Neck Pain? Dysfunctional pain inhibition in patients with chronic whiplash-associated disorders: an experimental study Protocol for an economic evaluation alongside the University Health Network Whiplash Intervention Trial: cost-effectiveness of education and activation, a rehabilitation program, and the legislated standard of care for acute whiplash injury in Ontario Prospective Ten-Year Follow-up Study Comparing Patients With Whiplash-Associated Disorders and Asymptomatic Subjects Using Magnetic Resonance Imaging A Randomized Controlled Trial of Cognitive-behavioral Therapy for the Treatment of PTSD in the Context of Chronic Whiplash Does acupuncture activate endogenous analgesia in chronic whiplash-associated disorders? A randomized crossover trial. The role of fear of movement in subacute whiplash-associated disorders grades I and II Acute whiplash-associated disorders (WAD): the effects of early mobilization and prognostic factors in long-term symptomatology Is there a relationship between whiplash-associated disorders and concussion in hockey? A preliminary study A Randomized Controlled Trial of an Educational Intervention to Prevent the Chronic Pain of Whiplash Associated Disorders Following Rear-End Motor Vehicle Collisions Characterization of Acute Whiplash-Associated Disorders The Development of Sensory Hypoesthesia After Whiplash Injury A new clinical test for cervicocephalic kinesthetic sensibility: "the fly". Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: A pilot randomised controlled trial. A Combination of Gestalt Therapy, Rosen Body Work, and Cranio Sacral Therapy did not help in Chronic Whiplash-Associated Disorders (WAD) - Results of a Randomized Clinical Trial Multidimensional associative factors for improvement in pain, function, and working capacity after rehabilitation of whiplash associated disorder: a prognostic, prospective outcome study Changes in Pain, Disability, and Muscle Activation Patterns in Chronic Whiplash Patients After Ambulant Myofeedback Training A three-group study, internet-based, face-to-face based and standard- management after acute whiplash associated disorders (WAD) – choosing the most efficient and cost-effective treatment: study protocol of a randomized controlled trial Pain neurophysiology education improves cognitions, pain thresholds, and movement performance in people with chronic whiplash: a pilot study. Reduced reactivity and enhanced negative feedback sensitivity of the hypothalamus–pituitary–adrenal axis in chronic whiplash-associated disorder Neither the WAD-classification nor the Quebec Task Force follow-up regimen seems to be important for the outcome after a whiplash injury. A prospective study on 186 consecutive patients Cervical Facet Joint Injections in the Neck and Shoulder Pain Upper trapezius muscle activation patterns in neck–shoulder pain patients and healthy controls Head position and impact direction in whiplash injuries: associations with MRI-verified lesions of ligaments and membranes in the upper cervical spine. Chemokines and Their Receptors in Whiplash Injury: Elevated RANTES and CCR-5 Dry-needling and exercise for chronic whiplash-associated disorders: a randomized single-blind placebo-controlled trial Testing the feasibility of a knowledge translation intervention designed to improve chiropractic care for adults with neck pain disorders: study protocol for a pilot cluster-randomized controlled trial Neck Collar, “Act-as-Usual” or Active Mobilization for Whiplash Injury?: A Randomized Parallel-Group Trial The perception of pain and pain-related cognitions in subacute whiplash-associated disorders: Its influence on prolonged disability Risk factors for chronic disability in a cohort of patients with acute whiplash associated disorders seeking physiotherapy treatment for persisting symptoms. Short-term effects of cervical kinesio taping on pain and cervical range of motion in patients with acute whiplash injury: a randomized clinical trial. Whiplash-associated disorders – predicting disability from a process-oriented perspective of coping Expectations for Recovery Important in the Prognosis of Whiplash Injuries Psychological determinants of quality of life in patients with whiplash associated disorders-a prospective study. Head Repositioning Accuracy in Patients With Whiplash-Associated Disorders Long-term functioning following whiplash injury: the role of social support and personality traits Development and delivery of a physiotherapy intervention for the early management of whiplash injuries: the Managing Injuries of Neck Trial (MINT) Intervention. The Risk Assessment Score in Acute Whiplash Injury Predicts Outcome and Reflects Biopsychosocial Factors Can Exposure and Acceptance Strategies Improve Functioning and Life Satisfaction in People with Chronic Pain and Whiplash‐Associated Disorders (WAD)? A Randomized Controlled Trial Deep muscle pain, tender points and recovery in acute whiplash patients: A 1-year follow-up study Sensory hypersensitivity occurs soon after whiplash injury and is associated with poor recovery Are anxiety and depression addressed in primary care patients with chronic obstructive pulmonary disease? A chart review. Psychological flexibility as a mediator of improvement in Acceptance and Commitment Therapy for patients with chronic pain following whiplash. A prospective randomized controlled study of the role of botulinum toxin in whiplash-associated disorder Guidelines for the pharmacological treatment of anxiety disorders, obsessive–compulsive disorder and posttraumatic stress disorder in primary care World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 1: Update 2013 on the acute and continuation treatment of unipolar depressive disorders Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology Widespread Sensory Hypersensitivity Is a Feature of Chronic Whiplash-Associated Disorder but not Chronic Idiopathic Neck Pain Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. The Effect of Neck-specific Exercise With, or Without a Behavioral Approach, on Pain, Disability, and Self-Efficacy in Chronic Whiplash-associated Disorders Elusive search for effective provider interventions: a systematic review of provider interventions to increase adherence to evidence-based treatment for depression Evaluating two implementation strategies for whiplash guidelines in physiotherapy: a cluster randomised trial. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the prevention and treatment of postmenopausal osteoporosis: 2001 edition, with selected updates for 2003. British Dietetic Association evidence-based guidelines for the dietary management of irritable bowel syndrome in adults. Influence of vestibular rehabilitation on neck pain and cervical range of motion among patients with whiplash-associated disorder: a randomized controlled trial. Efficacy of postural and neck-stabilization exercises for persons with acute whiplash-associated disorders: a systematic review. Are altered smooth pursuit eye movements related to chronic pain and disability following whiplash injuries? A prospective trial with one-year follow-up Impact of the ICD-10 Primary Health Care (PHC) diagnostic and management guidelines for mental disorders on detection and outcome in primary care. Cluster randomised controlled trial. More Informative Abstracts of Articles Describing Clinical Practice Guidelines Psychological Factors and the Development of Chronic Whiplash–associated Disorder(s): A Systematic Review The study design and rationale of the randomized controlled trial: translating COPD guidelines into primary care practice Testing the effectiveness of an innovative information package on practitioner reported behaviour and beliefs: The UK Chiropractors, Osteopaths and Musculoskeletal Physiotherapists Low back pain ManagemENT (COMPLeMENT) trial [ISRCTN77245761] Reduced cold pressor pain tolerance in non-recovered whiplash patients: a 1-year prospective study. Are benzodiazepines still the medication of choice for patients with panic disorder with or without agoraphobia? Computerised patient-specific guidelines for management of common mental disorders in primary care: a randomised controlled trial. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: executive summary. A randomized study of new sling exercise treatment vs traditional physiotherapy for patients with chronic whiplash-associated disorders with unsettled compensation claims. Protocol of a randomized controlled trial of the effectiveness of physician education and activation versus two rehabilitation programs for the treatment of Whiplash-associated Disorders: The University Health Network Whiplash Intervention Trial A comparison of the effects of computer and manual reminders on compliance with a mental health clinical practice guideline. A Randomized Trial Comparing Acupuncture and Simulated Acupuncture for Subacute and Chronic Whiplash 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 Results of a naturalistic longitudinal study of benzodiazepine and SSRI use in the treatment of generalized anxiety disorder and social phobia. Pragmatic randomised controlled trial to evaluate guidelines for the management of infertility across the primary care-secondary care interface Randomized controlled trial of education and feedback for implementation of guidelines for acute low back pain Implementing guidelines for cancer pain management: results of a randomized controlled clinical trial. Effectiveness of manual therapies: the UK evidence report Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. IMPLEmenting a clinical practice guideline for acute low back pain evidence-based manageMENT in general practice (IMPLEMENT): Cluster randomised controlled trial study protocol The effectiveness of a supervised physical training model tailored to the individual needs of patients with whiplash-associated disorders - a randomized controlled trial Improving the care for people with acute low-back pain by allied health professionals (the ALIGN trial): A cluster randomised trial protocol Randomised controlled trial of tailored interventions to improve the management of anxiety and depressive disorders in primary care Effect of therapeutic jaw exercise on temporomandibular disorders in individuals with chronic whiplash-associated disorders External validation of a clinical prediction rule to predict full recovery and ongoing moderate/severe disability following acute whiplash injury. Randomized clinical trial of conservative treatment for patients with whiplash-associated disorders: considerations for the design and dynamic treatment protocol. Similar factors predict disability and posttraumatic stress disorder trajectories after whiplash injury Knowledge transfer in family physicians managing patients with acute low back pain: a prospective randomized control trial. Controlled trials of CQI and academic detailing to implement a clinical practice guideline for depression. Congruence between Decisions To Initiate Chiropractic Spinal Manipulation for Low Back Pain and Appropriateness Criteria in North America Effectiveness of a clinical practice guideline implementation strategy for patients with anxiety disorders in primary care: cluster randomized trial The Incidence of Whiplash Trauma and the Effects of Different Factors on Recovery Treatment of anxiety disorders in primary care practice: a randomised controlled trial. Evaluation of an instructional program for improving medication compliance for chronically mentally ill outpatients. The effectiveness of a clinical practice guideline for the management of presumed uncomplicated urinary tract infection in women. Assessment of Decision Support for Blood Test Ordering in Primary Care Do clinical guidelines introduced with practice based education improve care of asthmatic and diabetic patients? A randomised controlled trial in general practices in east London Promoting research use in speech and language therapy: a cluster randomized controlled trial to compare the clinical effectiveness and costs of two training strategies Dry needling and exercise for chronic whiplash - a randomised controlled trial Implementation of the Dutch Low Back Pain Guideline for General Practitioners: A Cluster Randomized Controlled Trial Diagnosis and treatment of acromegaly complications Does the presence of sensory hypersensitivity influence outcomes of physical rehabilitation for chronic whiplash? – A preliminary RCT Pharmacological management of chronic neuropathic pain - consensus statement and guidelines from the Canadian Pain Society. Cervical radiofrequency neurotomy reduces central hyperexcitability and improves neck movement in individuals with chronic whiplash. Implementation of a Guideline for Low Back Pain Management in Primary Care: A Cost-Effectiveness Analysis
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 Objective There are few effective treatments for acute whiplash-associated disorders ( WAD ) . Early symptoms of postinjury stress predict poor recovery . This r and omised controlled trial ( StressModex ) investigated whether physiotherapist-led stress inoculation training integrated with exercise is more effective than exercise alone for people with acute WAD . Methods 108 participants ( < 4 weeks ) at risk of poor recovery ( moderate pain-related disability and hyperarousal symptoms ) were r and omly assigned by concealed allocation to either physiotherapist-led stress inoculation training and guideline -based exercise ( n=53 ) or guideline -based exercise alone ( n=55 ) . Both interventions comprised 10 sessions over 6 weeks . Participants were assessed at 6 weeks and at 6 and 12 months postr and omisation . Analysis was by intention to treat using linear mixed models . Results The combined stress inoculation training and exercise intervention was more effective than exercise alone for the primary outcome of pain-related disability at all follow-up points . At 6 weeks , the treatment effect on the 0–100 Neck Disability Index was ( mean difference ) −10 ( 95 % CI −15.5 to −4.48 ) , at 6 months was −7.8 ( 95 % CI −13.8 to −1.8 ) and at 12 months was −10.1 ( 95 % CI −16.3 to −4.0 ) . A significant benefit of the stress inoculation and exercise intervention over exercise alone was also found for some secondary outcomes . Conclusion A physiotherapist-led intervention of stress inoculation training and exercise result ed in clinical ly relevant improvements in disability compared with exercise alone — the most commonly recommended treatment for acute WAD . This contributes to the case for physiotherapists to deliver an early psychological intervention to patients with acute WAD who are otherwise at high risk of a poor outcome . Trial registration number ACTRN12614001036606 Abstract Purpose We conducted a systematic review to critically appraise and synthesize literature on the effectiveness of work disability prevention ( WDP ) interventions in workers with neck pain , whiplash-associated disorders ( WAD ) , or upper extremity disorders . Methods We search ed electronic data bases from 1990 to 2012 . R and om pairs of independent review ers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria . Scientifically admissible studies were summarized and synthesized following best- evidence synthesis methodology . Results Of the 6,359 articles retrieved , 16 r and omized controlled trials were eligible for critical appraisal and five were admissible . We found that a return-to-work coordination program ( including workplace-based work hardening ) was superior to clinic-based work hardening for persistent rotator cuff tendinitis . Workplace high-intensity strength training and workplace advice had similar outcomes for neck and shoulder pain . Mensendieck/Cesar postural exercises and strength and fitness exercises had similar outcomes for non-specific work-related upper limb complaints . Adding a brief job stress education program to a workplace ergonomic intervention was not beneficial for persistent upper extremity symptoms . Adding computer-prompted work breaks to ergonomic adjustments and workplace education benefited workers ’ recovery from recent work-related neck and upper extremity complaints . Conclusions At present , no firm conclusions can be drawn regarding the effectiveness of WDP interventions for managing neck pain , WAD , and upper extremity disorders . Our review suggests a return-to-work coordination program is more effective than clinic-based work hardening . Also , adding computer-prompted breaks to ergonomic and workplace interventions benefits workers ’ recovery . The current quality of evidence does not allow for a definitive evaluation of the effectiveness of ergonomic interventions INTRODUCTION Whiplash-associated disorders ( WAD ) are a huge worldwide health and economic burden . The propensity towards developing into chronic , disabling conditions drives the rise in health and economic costs associated with treatment , productivity loss and compulsory third party insurance cl aims . Current treatments fail to address the well-documented heterogeneity of WAD and often result in poor outcomes . A novel approach is to evaluate whether the care provided according to the estimated risk of poor prognosis improves health outcomes while remaining cost-effective . RESEARCH QUESTIONS ( 1 ) Does a guideline -based clinical pathway of care improve health outcomes after whiplash injury compared to usual care ? ( 2 ) Does risk of recovery have a differential effect on health outcomes for the clinical pathway of care ? ( 3 ) Is the clinical pathway of care intervention cost-effective ? ( 4 ) What are the variations in professional practice between usual care and the clinical pathway of care ? DESIGN Multi-centre , r and omised , controlled trial conducted over two Australian states : Queensl and and New South Wales . PARTICIPANTS AND SETTING 236 people with WAD ( grade I-III , within 6 weeks of injury ) and their primary healthcare providers . INTERVENTION A clinical pathway of care , with care matched to the predicted risk of poor recovery . Participants at low risk of ongoing pain and disability ( hence , predicted to fully recover ) will receive up to three sessions of guideline -based advice and exercise with their primary healthcare provider . Participants at medium/high risk of developing ongoing pain and disability will be referred to a specialist ( defined as a practitioner with expertise in whiplash ) who will conduct a more in-depth physical and psychological assessment . As a result , the specialist will liaise with the original primary healthcare provider and determine one of three further pathways of care . CONTROL Usual care provided by the primary healthcare provider that is based on clinical judgment . MEASUREMENTS Primary ( global rating of change and neck-related disability ) and secondary ( self-efficacy , pain intensity , general health and disability and psychological health ) outcomes will be collected using vali date d scales . Direct ( eg , professional care , transportation costs , time spent for care , co-payments ) and indirect ( eg , lost economic productivity ) costs will be obtained through an electronic cost diary . Health and cost outcomes will be assessed at baseline , 3 , 6 and 12 months after r and omisation . Professional practice outcomes will be evaluated through question naires completed by healthcare providers and their patients at 3 months . PROCEDURE Potential participants ( patients ) will be identified through emergency departments , primary health clinics and advertisements . Eligible participants will complete baseline assessment s and will be categorised into low or medium/high risk of poor recovery using a clinical prediction rule . After this assessment , participants will be r and omly allocated to either a  control group ( n=118 ) or intervention group ( n=118 ) , stratified by risk subgroup and treatment site . The participants ' nominated primary healthcare providers will be informed of their involvement in the trial . Consent will be obtained from the primary healthcare providers to participate and to obtain information about professional practice . Participants in the intervention group will additionally have access to an interactive website that provides information about whiplash and recovery relative to their risk category . ANALYSIS Analysis will be conducted on an intention-to-treat basis . Outcomes will be analysed independently through cross-sectional analyses using generalised linear models methods , with an appropriate link function , to test for an intervention effect , adjusted for the baseline values . The risk category will be tested for its association with treatment effect by adding risk group to the regression equation . Cost-effectiveness will be calculated using utility weights and the result ing measure will be cost per quality -adjusted life year ( QALY ) saved . Professional practice outcomes will be analysed using descriptive statistics . DISCUSSION This research is significant as it will be the first study to address the heterogeneity of whiplash by implementing a clinical pathway of care that matches evidence -based interventions to projected risk of poor recovery . The results of this trial have the potential to change clinical practice for WAD , thereby maximising treatment effects , improving patient outcomes , reducing costs and maintaining the compulsory third party system Objective : Coping is shown to affect outcomes in chronic pain patients ; however , few studies have examined the role of coping in the course of recovery in whiplash-associated disorders ( WAD ) . The purpose of this study was to determine the predictive value of coping style for 2 key aspects of WAD recovery , reductions in neck pain , and in disability . Methods : A population -based prospect i ve cohort study design was used to study 2986 adults with traffic-related WAD . Participants were assessed at baseline , 6 weeks , and 4 , 8 , and 12 months postinjury .  Coping  was measured at 6 weeks using the Pain Management Inventory  , and neck pain recovery was assessed at each subsequent follow-up , using a 100 mm  visual analogue scale ( VAS ) . Disability was assessed at each follow-up using the Pain Disability Index ( PDI ) . Pain recovery was defined as a VAS score of 0 to 10 ; disability recovery was defined as a PDI score of 0 to 4 . Data analysis used multivariable Cox proportional hazards models . Results : Those using high versus low levels of passive coping at 6 weeks postinjury experienced 28 % slower pain recovery and 43 % slower disability recovery . Adjusted hazard rate ratios for pain recovery and disability recovery were 0.72 ( 95 % CI , 0.59 - 0.88 ) and 0.57 ( 95 % CI , 0.41 - 0.78 ) , respectively . Active coping was not associated with recovery of neck pain or disability . Conclusions : Passive coping style predicts neck pain and self-assessed disability recovery . It may be beneficial to assess and improve coping style early in WAD Study Design Secondary analysis of a prospect i ve cohort study with cross-sectional and longitudinal analyses . Background The clinical importance of a history of whiplash-associated disorder ( WAD ) in people with neck pain remains uncertain . Objective To compare people with WAD to people with nonspecific neck pain , in terms of their baseline characteristics and pain and disability outcomes over 1 year . Methods Consecutive patients with neck pain who presented to a secondary -care spine center answered a comprehensive self-report question naire and underwent a physical examination . Patients were classified into a group of either those with WAD or those with nonspecific neck pain . We compared the outcomes of baseline characteristics of the 2 groups , as well as pain intensity and activity limitation at follow-ups of 6 and 12 months . Results A total of 2578 participants were included in the study . Of these , 488 ( 19 % ) were classified as having WAD . At presentation , patients with WAD were statistically different from patients without WAD for almost all characteristics investigated . While most differences were small ( 1.1 points on an 11-point pain-rating scale and 11 percentage points on the Neck Disability Index ) , others , including the presence of dizziness and memory difficulties , were substantial . The between-group differences in pain and disability increased significantly ( P<.001 ) over 12 months . At 12-month follow-up , the patients with WAD had on average approximately 2 points more pain and 17 percentage points more disability than those with nonspecific neck pain . Conclusion People referred to secondary care with WAD typically had more self-reported pain and disability and experienced worse outcomes than those with nonspecific neck pain . Caution is required when interpreting the longitudinal outcomes due to lower-than-optimal follow-up rates . Level of Evidence Prognosis , level 2 . J Orthop Sports Phys Ther 2016;46(10):894 - 901 . Epub 3 Sep 2016 . doi:10.2519/jospt.2016.6588 Inefficient endogenous pain inhibition , in particular impaired conditioned pain modulation ( CPM ) , may disturb central pain processing in patients with chronic whiplash-associated disorders ( WAD ) . Previous studies revealed that abnormal central pain processing is responsible for a wide range of symptoms in patients with chronic WAD . Hence , the present study aim ed at examining the functioning of descending pain inhibitory pathways , and in particular CPM , in patients with chronic WAD . Thirty-five patients with chronic WAD and 31 healthy controls were subjected to an experiment evaluating CPM . CPM was induced by an inflated occlusion cuff and evaluated by comparing temporal summation ( TS ) of  pressure pain prior to and during cuff inflation . Temporal summation was provoked by means of 10 consecutive pressure pulses at upper and lower limb location . Pain intensity of first , fifth , and 10th pressure pulse was rated . During heterotopic noxious conditioning stimulation , TS of pressure pain was significantly depleted among healthy controls . In contrast , TS was quite similar prior to and during cuff inflation in chronic WAD , providing evidence for dysfunctional CPM in patients with chronic WAD . The present study demonstrates a lack of endogenous pain inhibitory pathways , and in particularly CPM , in patients with chronic WAD , and hence provides additional evidence for the presence of central sensitization in chronic WAD Background Whiplash injury affects 83 % of persons in a traffic collision and leads to whiplash-associated disorders ( WAD ) . A major challenge facing health care decision makers is identifying cost-effective interventions due to lack of economic evidence . Our objective is to compare the cost-effectiveness of : 1 ) physician-based education and activation , 2 ) a rehabilitation program developed by Aviva Canada ( a group of property and casualty insurance providers ) , and 3 ) the legislated st and ard of care in the Canadian province of Ontario  : the Pre-approved Framework Guideline for Whiplash developed by the Financial Services Commission of Ontario . Methods / Design The economic evaluation will use participant-level data from the University Health Network Whiplash Intervention Trial and will be conducted from the societal perspective over the trial 's one-year follow-up . Re source use ( costs ) will include all health care goods and services , and benefits provided during the trial 's 1-year follow-up . The primary health effect will be the quality -adjusted life year . We will identify the most cost-effective intervention using the incremental cost-effectiveness ratio and incremental net-benefit . Confidence ellipses and cost-effectiveness acceptability curves will represent uncertainty around these statistics , respectively . A budget impact analysis will assess the total annual impact of replacing the current legislated st and ard of care with each of the other interventions . An expected value of perfect information will determine the maximum research expenditure Canadian society should be willing to pay for , and inform priority setting in , research of WAD management . Discussion Results will provide health care decision makers with much needed economic evidence on common interventions for acute whiplash management . Trial Registration http:// Clinical Trials.govidentifierNCT00546806[Trial registry date : October 18 , 2007 ; Date first patient was r and omized : February 27 , 2008 Study Design . A prospect i ve 10-year follow-up study of patients with whiplash-associated disorders ( WAD ) and asymptomatic volunteers . Objective . To clarify long-term impact of whiplash injury on patient 's symptoms and on magnetic resonance imaging ( MRI ) findings of the cervical spine . Summary of Background Data . Long-term prognosis of WAD has not been fully eluci date d. Methods . Between 1993 and 1996 , we conducted cross-sectional comparative study of 508 acute WAD patients and 497 asymptomatic volunteers , all of whom underwent MRI of the cervical spine .  For this follow-up study , 133 WAD patients and 223 control subjects were recruited again . All participants underwent follow-up MRI and physical examination , and answered to question naires regarding neck symptoms . Evaluation of MRI included decrease in signal intensity of discs , posterior disc protrusion , disc space narrowing , and foraminal stenosis using 2 to 4 numerical grade s. Increase in the numerical grade s by one or more was considered to be progression of degenerative changes . Results . Progression of decrease in signal intensity was observed in 109 WAD patients ( 82.0 % ) , and 132 control subjects ( 59.2 % ) , ( age , sex adjusted odds ratio [ OR ] : 3.06 ) , posterior disc protrusion in 101 ( 75.9 % ) and in 155 ( 69.5 % ) ( OR = 1.46 ) , disc space narrowing in 33 ( 24.8 % ) and in 59 ( 26.5 % ) ( OR = 0.98 ) , and foraminal stenosis in 6 ( 4.5 % ) , and in 20 ( 9.0 % ) ( OR = 0.52 ) , respectively . Neck pain was observed in 34 WAD patients ( 25.6 % ) and 22 control subjects ( 9.9 % ) ( P < 0.0001 ) . There was no statistically significant correlation between neck pain and progression in each MR finding in either group . Conclusion . The results of this study suggest that , although some WAD patients are more likely to suffer from long-lasting neck pain , MRI findings can not explain the symptoms Objectives : Whiplash-associated disorders ( WAD ) are common and involve both physical and psychological impairments . Research has shown that persistent posttraumatic stress symptoms are associated with poorer functional recovery and physical therapy outcomes .  Trauma-focused cognitive-behavioral therapy ( TF-CBT ) has shown moderate effectiveness in chronic pain sample s. However , to date , there have been no clinical trials within WAD . Thus , this study will report on the effectiveness of TF-CBT in individuals meeting the criteria for current chronic WAD and posttraumatic stress disorder ( PTSD ) . Method : Twenty-six participants were r and omly assigned to either TF-CBT or a waitlist control , and treatment effects were evaluated at posttreatment and 6-month follow-up using a structured clinical interview , self-report question naires , and measures of physiological arousal and sensory pain thresholds . Results : Clinical ly significant reductions in PTSD symptoms were found in the TF-CBT group compared with the waitlist at post assessment , with further gains noted at the follow-up . The treatment of PTSD was also associated with clinical ly significant improvements in neck disability , physical , emotional , and social functioning and physiological reactivity to trauma cues , whereas limited changes were found in sensory pain thresholds . Discussion : This study provides support for the effectiveness of TF-CBT to target PTSD symptoms within chronic WAD . The finding that treatment of PTSD result ed in improvements in neck disability and quality of life and changes in cold pain thresholds highlights the complex and interrelating mechanisms that underlie both WAD and PTSD . Clinical implication s of the findings and future research directions are discussed BACKGROUND Many patients with chronic pain , including those with chronic whiplash-associated disorders ( WAD ) , show features of central sensitization . R and omized trials examining whether treatments are able to influence the process of central sensitization in patients with chronic WAD are emerging . Therefore , the present study aim ed at examining whether acupuncture results in activation of endogenous analgesia and relief in symptoms in patients with chronic WAD . METHODS In this r and omized crossover pilot trial with blinded assessors , each patient ( n = 39 ) received two treatment sessions of identical duration , with acupuncture and relaxation therapy r and omly crossed over in visit 2 . Primary outcome measurement included immediate activation of endogenous analgesia i.e. , pressure pain sensitivity and conditioned pain modulation . Secondary outcome measurements included pain relief and reduced disability level . RESULTS Local pressure pain sensitivity at baseline and during conditioned pain modulation decreased significantly more following acupuncture compared with relaxation ( time × group interactions : p < 0.001 ) , both in the neck and at a site distinct from the painful region . When comparing the effects of acupuncture versus relaxation , no differences were observed on conditioned pain modulation , temporal summation of pressure pain , neck disability or symptom severity ( all p-values > 0.05 ) . CONCLUSION It was shown that one session of acupuncture treatment results in acute improvements in pressure pain sensitivity in the neck and calf of patients with chronic WAD .  Acupuncture had no effect on conditioned pain modulation or temporal summation of pressure pain . Both acupuncture and relaxation appear to be well-tolerated treatments for people with chronic WAD . These findings suggest that acupuncture treatment activates endogenous analgesia in patients with chronic WAD Summary Fear of movement plays and important role in individuals with subacute whiplash‐associated disorders and it should be directly targeted in treatment . ABSTRACT Fear and avoidance of activity may play a role in fostering disability in  whiplash‐associated disorders ( WAD ) . This study examined the role of fear after WAD and assessed the effectiveness of 3 treatments targeting fear . People still symptomatic from WAD grade I‐II injuries approximately 3 months previously ( n = 191 ) completed question naires ( eg , Neck Disability Index [ NDI ] ) and were r and omized to 1 of the treatments : ( 1 ) informational booklet ( IB ) describing WAD and the importance of resuming activities , ( 2 ) IB + didactic discussion s ( DD ) with clinicians reinforcing the booklet , and ( 3 ) IB + imaginal and direct exposure desensitization ( ET ) to feared activities . DD and ET participants received three 2‐hour treatment sessions . Absolute improvements in NDI were in predicted direction ( ET = 14.7 , DD = 11.9 , IB = 9.9 ) . ETs reported significantly less posttreatment pain severity compared with the IB ( Mean = 1.5 vs 2.3 , P < .001 , d = 0.6 ) and DD ( M = 1.5 vs 2.0 , P = .039 , d = 0.6 ) groups . Reduction in fear was the most important predictor of improvement in NDI ( β = 0.30 , P < .001 ) , followed by reductions in pain ( β = 0.20 , P = .003 ) and depression ( β = 0.18 , P = .004 ) . The mediational analysis confirmed that fear reduction significantly mediated the effect of treatment group on outcome . Results highlight the importance of fear in individuals with subacute WAD and suggest the importance of addressing fear via exposure therapy and /or educational interventions to improve function Objective : To compare two different home exercise programmes for patients with acute whiplash-associated disorders ( WAD ) . A further aim was to describe the initial prognostic variables related to self-reported pain at six months follow-up . Design : A r and omized treatment study with a follow-up period of six months . Setting s : The study was undertaken in an orthopaedic clinic at a university hospital . Subjects : A total of 59 symptomatic ( neck pain , stiffness , etc . ) patients with acute whiplash injury . Interventions : Patients were r and omized to a regular treatment group ( RT group ) and an additional-exercise treatment group ( AT group ) . Main outcome measures : Pain Disability Index ( PDI ) , Self-Efficacy Scale ( SES ) , Coping Strategies Question naire ( CSQ ) , neck range of motion ( ROM ) , head posture , kinaesthetic sensibility , visual analogue scale ( VAS ) . Results : Patients given an additional exercise did not improve more than patients with regular treatment . Only one CSQ item , ‘ Ability to decrease pain ' , showed a significant difference between the groups in its pattern of change over time : the AT group had a significant increase between three and six months whilst values in the RT group decreased . Nonsymptomatic patients at six months follow-up were characterized by initially better self-efficacy , lower disability and significantly different patterns in the use of ‘ behavioural coping strategies ' when compared with symptomatic patients . The nonsymptomatic patients also reported more frequent training than symptomatic patients , i.e. they complied better with the treatment regime . Conclusion : This home exercise programme , including training of neck and shoulder ROM , relaxation and general advice seems to be sufficient treatment for acute WAD patients when used on a daily basis . Additionally , patients reporting low self-efficacy and high disability levels may profit from more attention initially , as these psychological factors are significant predictors of pain at long-term follow-up Primary objective : To examine the relationship between the occurrence of  whiplash-associated disorders and concussion symptoms in hockey players . Research design : Prospect i ve cohort observational study to examine the relationship between whiplash associated disorders and concussion in actual hockey play . Methods and procedures : Twenty hockey teams were followed prospect ively for one season . Team therapists completed acute and 7–10 day follow-up evaluation question naires for all of the players who received either a whiplash mechanism or a concussion . Main outcomes and results : 183 players were registered for this study ; 13 received either a whiplash mechanistic injury or a concussion injury . Initial injuries ranged from WAD I to WAD III and all subjects reported concussion symptoms . Only three subjects reported full resolution of bothWAD and concussion symptoms at the 7–10 day follow-up evaluation . Conclusions : There is a strong association between whiplash induced neck injuries and the symptoms of concussion in hockey injuries . Both should be evaluated when dealing with athletes/ patients suffering from either injury Study Design . Concealed allocation , multicenter , single-blind , r and omized controlled clinical trial . Objective . To assess the efficacy of an educational video in the tertiary prevention of persistent WAD symptoms following rear-end motor vehicle collisions ( MVCs ) . Summary of Background Data . Whiplash-associated disorders ( WAD ) are an important and costly health problem . There is a lack of high quality evidence surrounding efficacy of treatments for WAD . Existing research supports active interventions and early return to regular activities . Methods . Consecutive patients presenting to four tertiary care emergency departments following rear-end MVCs were eligible . Following informed consent , patients were allocated , using central r and omization , to receive an educational video plus usual care or usual care alone . The video provided reassurance , and advice about posture , return to regular activities , exercises , and pain-relief methods . Data were collected by telephone using st and ardized question naires . The primary outcome was presence of Persistent WAD Symptoms at 24 weeks postinjury , based on the frequency and severity of neck , shoulder , or upper back pain . The absolute difference in proportion of patients with persistent WAD symptoms and rate ratios were calculated . Changes in pain scores were compared using the Mann-Whitney U test . Results . The  intervention ( n = 206 ) and control ( n = 199 ) groups were similar at baseline ( mean age 38.4 years ; 64 % female ) . Overall , the proportion of subjects with Persistent WAD Symptoms decreased from 89.1 % at baseline to 33.6 % at 24 weeks after injury . At 24 weeks , the proportion of subjects with persistent WAD symptoms in the intervention group was 7.9 % ( 95 % CI , −2.0 , 17.8 ) lower than the control group . The median improvement in pain score at 24 weeks was 3 for the intervention group and 2 for the control group ( P = 0.016 ) . Conclusion . The presence of persistent WAD symptoms following simple rear-end MVCs was high in this sample . The video group demonstrated a trend toward less severe WAD symptoms . We recommend evaluating other educational interventions that could reduce WAD symptoms 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 Objectives ( 1 ) To investigate the development of hypoesthesia from soon after the whiplash injury to 6 months postinjury and ( 2 ) to determine differences in detection thresholds between those with initial features of poor recovery and those without these signs . Methods Fifty-two participants with acute whiplash-associated disorders ( WAD ) ( < 1 mo ) were classified as either “ high-risk ” ( n=17 ; Neck Disability Index > 30 ; sensory hypersensitivity ) or “ low risk ” ( n=35 ; without these signs ) .  Detection thresholds to electrical , thermal , and vibration stimuli and psychological distress were prospect ively measured within 1 month of injury and then 3 and 6 months postinjury . Detection thresholds were also measured in the 38 controls . Results Both WAD groups showed hypoesthesia ( vibration , electrical , and cold ) at 1 month postinjury . Vibration and electrocutaneous hypoesthesia persisted to 3 and 6 months only in the high-risk WAD group . Heat detection thresholds were not different between the groups at 1 month postinjury but were elevated in the high-risk group at 3 and 6 months . Both WAD groups were distressed at 1 month but this decreased by 3 months in the low-risk group . The differences in the Impact of Event Scale did not impact on any of the sensory measures . Discussion Sensory hypoesthesia is a feature of acute WAD but persists only in those at higher risk of poor recovery . These findings suggest the involvement of the central inhibitory mechanisms that may be sustained by ongoing nociception OBJECTIVE To investigate the reliability and discriminative ability of a new test design ed to detect accuracy of neck movements . DESIGN Repeated- measures . Case-control . SETTING University musculoskeletal research clinic in Icel and . PARTICIPANTS Twenty women ( mean age + /- st and ard deviation [ SD ] , 30.8+/-9.1 y ; range , 18 - 49 y ) with chronic whiplash-associated disorders ( WAD ) grade s I and II ( duration , 6 mo-6 y ) , with current pain score on a visual analog scale of 46.8+/-21.8 , and a disability score on the Northwick Park Neck Pain Disability Index of 45%+/-14 % . Twenty asymptomatic women ( mean age + /- SD , 29.3+/-8.6 y ; range , 18 - 48 y ) with no history of whiplash or insidious onset neck pain served as controls . INTERVENTION A slowly moving object appeared on a computer screen and traced an unpredictable movement path that the subjects were required to follow by moving their heads . Three r and omly ordered movement patterns were tested . MAIN OUTCOME MEASURE A new software program connected to a 3Space Fastrak system  was used to measure the mean absolute error ( in millimeters ) of 3 trials in each movement pattern . RESULTS The mean differences ( + /-2 SD ) between days 1 and 2 were.01+/-.64 mm for the asymptomatic group and .33+/-1.80 mm for the WAD group . The between-day intraclass correlation coefficients were between.60 and .77 for the asymptomatic group and .79 and .86 for the WAD group . Repeated- measures analysis of variance revealed a significant difference between groups ( P=.02 ) . The Tukey post hoc test showed significant between-group differences for each movement pattern ( P</=.05 ) . In each successive trial , a slight improvement for the asymptomatic group and a slight worsening for the WAD group were detected . CONCLUSIONS Better reliability was detected for the asymptomatic group than for the WAD group . The test could discriminate between the asymptomatic group versus the chronic WAD group Sensory hypersensitivity indicative of augmented central pain processing is a feature of chronic whiplash associated disorders ( WAD ) . This study investigated the immediate effects of a cervical spine manual therapy ( SMT ) technique on measures of central hyperexcitability . In a r and omised , single blind , clinical trial , 39 participants with chronic WAD were r and omly assigned to a cervical SMT ( lateral glide ) or manual contact intervention . The Neck Disability Index ( NDI ) and GHQ-28 were administered at baseline . Pressure pain thresholds ( PPTs ) , thermal pain thresholds ( TPTs ) and Nociceptive Flexion Reflex ( NFR ) responses ( threshold and VAS of pain ) were measured pre and post intervention . There was a significantly greater increase in NFR threshold following SMT compared to the manual contact intervention ( p = 0.04 ) . PPTs at the cervical spine increased following both SMT ( mean + /- SE : 24.1 + /- 7.3 % ) and manual contact ( 21 + /- 8.4 % ) with no difference between interventions . There was no difference between interventions for pain ratings with the NFR test , PPTs at the Median Nerve or Tibialis Anterior , heat or cold TPT . SMT may be effective in reducing spinal hyperexcitability in chronic WAD The chronic state of whiplash-associated disorder ( WAD ) might be understood as a somatization of existential pain . Intervention aim ed to improve quality of life ( QOL )  seemed to be a solution for such situations . The basic idea behind the intervention was holistic , restoring quality of life and relationship with self , in order to diminish tension in the locomotion system , especially the neck . A psychosomatic theory for WAD is proposed . Our treatment was a short 2-day course with teachings in philosophy of life , followed by 6 to 10 individual sessions in gestalt psychotherapy and body therapy ( Rosen therapy and Cranio Sacral therapy ) , followed by a 1-day course approximately 2 months later , closing the intervention . Two independent institutions did the intervention and the assessment s. In a r and omized , clinical ly controlled setting , 87 chronic WAD patients were included with a median duration of 37 months from their whiplash accidents . One patient never started . Forty-three had the above intervention ( female/male = 36/7 , ages 22—49 , median 37 years ) and another 43 were assigned to a nontreated control group ( female/male = 35/8 , ages 1848 , median 38 ) . Six had disability pension and 27 had pending medicolegal issues in each group . Effect variables were pain in neck , arm , and /or head ; measures of quality of life and daily activities ; as well as general physical or mental health . Wilcoxon test for between-groups comparisons with intention-to-treat analyses was conducted ; the square curve paradigm testing for immediate improvements of health and quality of life was also used . The groups were comparable at baseline . From the intervention group , 11 dropped out during the intervention ( 4 of those later joined the follow-up investigation ) , 22 of the remaining 32 graduated the course , and 35 of the 43 controls did as well . Approximately 3 months later , we found no clinical ly relevant or significant increase in any effect measure . The above version of a quality of life intervention based on alternative therapy had no effect on patients with chronic WAD Background Whiplash associated disorders ( WAD ) have dramatic consequences for individual and public health . Risk factors for better and worse outcomes are important to optimize management . This study aim ed to determine short- and mid-term associative co-factors of neck pain relief , improved physical functioning , and improved working capacity ( dependent variables ) in patients suffering from whiplash associated disorder who participated in a st and ardized , inpatient pain management program .  Methods Naturalistic , observational , prospect i ve cohort study . Outcome was measured by st and ardized assessment instruments . Co-factors covered sociodemographics , comorbidities , social participation , affective health , and coping abilities . Stepwise , multivariate linear regression analysis was performed at discharge and at the 6-month follow-up . Results All regression models explained high proportions of variance ( 53.3 % – 72.1 % ) . The corresponding baseline level was significantly associated with a change in every dependent variable ( explained variances : 11.4%-56.7 % ) . Pain relief significantly depended on improved function and vice-versa ( 3.4%-14.8 % ) . Improved ability to decrease pain was associated with pain relief at discharge ( 9.6 % ) . Functional improvement was associated with decreased catastrophizing ( 19.4 % ) at discharge and decreased depression ( 20.5 % ) at the 6 month follow-up . Conclusions Pain relief , improved physical function and working capacity were associated with each other . Improved coping ( catastrophizing and ability to decrease pain ) and reduced depression may act as important predictors for pain relief and improved function . These findings offer toe-holds for optimized therapy of chronic WAD Objective The aim of this exploratory study was to investigate changes in pain , disability , and muscle activation patterns in patients with chronic whiplash-associated disorder ( WAD ) after 4 weeks of myofeedback training . Methods Eleven WAD patients received ambulatory myofeedback training  , during which upper trapezius muscle activation and relaxation were continuously recorded and processed for 4 weeks . Feedback was provided when muscle relaxation was insufficient . Pain in neck , shoulders , and upper back ( Visual Analogue Scale ) , disability ( Neck Disability Index ) , and muscle activation patterns during rest , typing , and stress tasks ( surface electromyography ) were assessed before and after the 4 weeks of training . Results Pain intensity decreased after 4 weeks of training . Clinical ly relevant changes were found with regard to pain in the neck and upper back region ( 55 % of the patients ) , right shoulder ( 64 % ) , and left shoulder ( 18 % ) . A trend for decreased disability was found which was clinical ly relevant in 36 % of the patients . A remarkable reduction was found in the Neck Disability Index items concerning headache and lifting weights . Overall , muscle activation was lower and muscle relaxation was higher after the training period with the largest differences during rest . Clinical ly relevant changes in surface electromyography parameters were found in a minority of patients . Conclusion Four weeks of ambulant training may be beneficial in reducing pain and disability levels and normalizing muscle activation patterns in chronic WAD patients . A r and omized-controlled study is recommended to further explore the effects of myofeedback training Background The management of Whiplash Associated Disorders is one of the most complicated challenges with high expenses for the health care system and society . There are still no general guidelines or scientific documentation to unequivocally support any single treatment for acute care following whiplash injury . The main purpose of this study is to try a new behavioural medicine intervention strategy at acute phase aim ed to reduce the number of patients who have persistent problems after the whiplash injury . The goal is also to identify which of three different interventions that is most cost-effective for patients with Whiplash Associated Disorders . In this study we are controlling for two factors . First , the effect of behavioural medicine approach is compared with st and ard care . Second , the manner in which the behavioural medicine treatment is administered , Internet or face-to-face , is evaluated in it 's effectiveness and cost-effectiveness . Methods / Design The study is a r and omized , prospect i ve , experimental three-group study with analyses of cost-effectiveness up to two-years follow-up . Internet – based programme and face-to-face group treatment programme are compared to st and ard-treatment only . Patient follow-ups take place three , six , twelve and 24 months , that is , short-term as well as long-term effects are evaluated . Patients will be enrolled via the emergency ward during the first week after the accident . Discussion This new self-help management will concentrate to those psychosocial factors that are shown to be predictive in long-term problems in Whiplash Associated Disorders , i.e. the importance of self-efficacy , fear of movement , and the significance of catastrophizing as a coping strategy for restoring and sustaining activities of daily life . Within the framework of this project , we will develop , broaden and evaluate current physical therapy treatment methods for acute Whiplash Associated Disorders . The project will contribute to the creation of a cost-effective  behavioural medicine approach to management of acute Whiplash Associated Disorders . The results of this study will answer an important question ; on what extent and how should these patients be treated at acute stage and how much does the best management cost . Trial registration numberCurrent Controlled Trials IS RCT Chronic whiplash is a debilitating condition characterized by increased sensitivity to painful stimuli , maladaptive illness beliefs , inappropriate attitudes , and movement dysfunctions . Previous work in people with chronic low back pain and chronic fatigue syndrome indicates that pain neurophysiology education is able to improve illness beliefs and attitudes as well as movement performance . This single-case study ( A-B-C design ) with six patients with chronic whiplash associated disorders ( WAD ) was aim ed at examining whether education about the neurophysiology of pain is accompanied by changes in symptoms , daily functioning , pain beliefs , and behavior . Periods A and C represented assessment periods , while period B consisted of the intervention ( pain neurophysiology education ) . Results showed a significant decrease in kinesiophobia ( Tampa Scale for Kinesiophobia ) , the passive coping strategy of resting ( Pain Coping Inventory ) , self-rated disability ( Neck Disability Index ) , and photophobia ( WAD Symptom List ) . At the same time , significantly increased pain pressure thresholds and improved pain-free movement performance ( visual analog scale on Neck Extension Test and Brachial Plexus Provocation Test ) were established . Although the current results need to be verified in a r and omized , controlled trial , they suggest that education about the physiology of pain is able to increase pain thresholds and improve pain behavior and pain-free movement performance in patients with chronic WAD Abstract Dysregulations of the hypothalamus – pituitary – adrenal ( HPA ) axis have been discussed as a physiological substrate of chronic pain and fatigue . The aim of the study was to investigate possible dysregulations of the HPA axis in chronic whiplash‐associated disorder ( WAD ) . In 20 patients with chronic WAD and 20 healthy controls  , awakening cortisol responses as well as a short circadian free cortisol profile were assessed before and after administration of 0.5 mg dexamethasone . In comparison to the controls , chronic WAD patients had attenuated cortisol responses to awakening , normal cortisol levels during the day , and showed enhanced and prolonged suppression of cortisol after the administration of 0.5 mg dexamethasone . Dysregulations of the HPA axis in terms of reduced reactivity and enhanced negative feedback suppression exist in chronic WAD . The observed endocrine abnormalities could serve as a systemic mechanism of symptoms experienced by chronic WAD patients A classification of injury and a follow-up schedule were proposed by the Quebec Task Force ( QTF ) in 1995 . No general agreement about the clinical usefulness of the WAD-classification or of the suggested follow-up regimen exists . A series of 186 consecutive cases seen in the emergency room during the acute phase after a whiplash injury was prospect ively studied for 1 year . All findings including history and physical findings were recorded using st and ardized QTF protocol s. In one group follow-up visits were done according to the QTF regimen : at 1 , 3 , 6 , 12 weeks and 1 year after the accident ; in a control group no visit was scheduled . The outcome variable was neck pain at 1 year after the accident . After 1 year , 18 % of the total number of patients had significant neck pain . Risk factors for chronic neck pain at 1 year after whiplash injury were : neck pain before the accident and a high degree of emotional distress at the time of the accident ; both factors independently associated with a tenfold increased risk of developing chronic neck pain . Neither the WAD classification nor the QTF follow-up regimen could be linked to a better outcome . In this study the outcome was associated with patient-specific characteristics and not with physical signs of injury , the depth of the initial evaluation or the follow-up regimen The effects from cervical facet joint injections in those patients who have been complaining cervical zygapophyseal joint pain were compared . The patients were diagnosed originally as myofascial pain syndrome ( MPS ) , cervical herniated nucleus pulposus ( HNP ) , and whiplash-associated disorders ( WAD ) . Patients with the zygapophyseal joints pain of C5 - 6 and C6 - 7 were classified by their pain origin as MPS , HNP , and WAD . All patients had been undergone cervical zygapophyseal joints injections with the mixture of lidocaine and triamcinolone unilaterally or bilaterally through the posterior approach under C-arm imaging guide . The therapeutic effects were compared with reduction of numeric rating scale ( NRS ) of pain before and immediately after blockade and symptom-free periods in each group after 12 months . Symptom duration s before injections were 16.1±9.6 , 4.6±1.9 and 4.1±1.1 months in each MPS , HNP , and WAD groups . The reductions of NRS immediately after the blockade among the three groups were not different . However , the symptom-free duration after blockade lasted longer in the HNP group than the other two groups . In patients with cervical zygapophyseal pain syndromes , the analgesic effect from cervical facet joint blocks lasted longer in cervical HNP than MPS or WAD This study aim ed at investigating whether patients with neck – shoulder complaints from different aetiologies ( work-related musculo-skeletal disorders , WMSD ; whiplash associated disorders , WAD ) show comparable muscle activation patterns , characterised by higher activation and lower relaxation levels of the trapezius muscles compared to healthy controls . Twenty healthy controls , 21 WMSD and 20 WAD patients with non-acute neck-shoulder pain were recruited for this cross-sectional study .  Surface electromyography ( sEMG ) recordings were performed at the upper trapezius muscles during reference contractions , st and ardised computer tasks ( typing and unilateral stress task ) , and rest measurements . sEMG was continuously recorded during these measurements .  Outcome measures were root mean square ( RMS ) to study muscle activity , and relative rest time ( RRT ) to study muscle relaxation . Statistical analysis comprised the bootstrap technique and Kruskall – Wallis tests . Results showed no clear evidence for abnormal muscle activation patterns in WMSD and WAD patients compared to healthy controls . However , a tendency was observed for higher RMS levels during the reference contractions and computer tasks in both patient groups compared to healthy controls , and lower RRT levels at the non-dominant side during stress . Both patient groups also showed larger variability in RMS and RRT values . This variability has more often been reported in literature and may suggest the existence of subgroups of pain patients with corresponding different muscle activation patterns not related to aetiology . Future research may focus on identifying these subgroups of patients with neck-shoulder pain In the present study , we compared magnetic resonance imaging ( MRI ) findings of soft tissue structures in the upper cervical spine between whiplash-associated disorder ( WAD ) patients and population -based control persons , and examined whether MRI-verified abnormalities in WAD patients were related to accident-related factors hypothesized to be of importance for severity of injury . A total of 92 whiplash patients and 30 control persons , r and omly drawn , were included . Information on the accident-related factors ( i.e. , head position and impact direction ) was obtained by a question naire that was answered within 1 week after the accident . The MRI examination was performed 2 - 9 ( mean 6 ) years after the accident . Focus was on MRI abnormalities of the alar and the transverse ligaments , and the tectorial and posterior atlanto-occipital membranes , grade d 0 - 3 . For all neck structures , the whiplash patients had more high- grade lesions ( grade 2 or 3 ) than the control persons ( Chi-square test , p < 0.055 ) . An abnormal alar ligament was most common ( 66.3 % grade d 2 or 3 ) . Whiplash patients who had been sitting with their head/neck turned to one side at the moment of collision more often had high- grade lesions of the alar and transverse ligaments ( p < 0.001 , p = 0.040 , respectively ) . Severe injuries to the transverse ligament and the posterior atlanto-occipital membrane were more common in front than in rear end collisions ( p < 0.001 , p = 0.001 , respectively ) . In conclusion , the difference in MRI-verified lesions between WAD patients and control persons , and in particular the association with head position and impact direction at time of accident , indicate that these lesions are caused by the whiplash trauma The human sufferings and socioeconomic burden due to whiplash-associated disorders ( WAD ) are obvious but the pathogenesis of WAD is obscure . The possible involvement of the immune system during the disease process in WAD is not known . Effector molecules including chemokines and their receptors could play a role in WAD . In a prospect i ve study using flow cytometry , we examined percentages of blood mononuclear cells ( MNC ) expressing the chemokines RANTES , MCP-1 , MIP-1α , MIP-1β , and IL-8 , the chemokine receptor CCR-5 , the T cell activation marker CD25 , and the T cell chemoattractant IL-16 in patients with WAD and , for reference , in healthy controls . Higher percentages of RANTES-expressing blood MNC and T cells were observed in patients with WAD examined within 3 days compared to 14 days after the whiplash injury and , likewise , compared with healthy controls . The patients with WAD examined within 3 days after the accident also had higher percentages of CCR-5-expressing blood MNC , T cells , and CD45RO+ T cells compared to healthy controls . In contrast , there were no differences for any of these variables between patients with WAD examined 14 days after injury and healthy controls . In conclusion , WAD is associated with a systemic but transient dysregulation in percentages of RANTES and CCR-5 expressing MNC and T cells Abstract This r and omized controlled trial investigated the effectiveness and cost-effectiveness of dry-needling and exercise compared with sham dry-needling and exercise for chronic whiplash-associated disorders ( WAD ) . The setting was a single university centre and 4 physiotherapy practice s in Queensl and , Australia . Eighty patients with chronic WAD ( > 3 months ) were enrolled between June 2009 and August 2012 with 1-year follow-up completed in August 2013 . The interventions were 6 weeks of dry-needling to posterior neck muscles ( n = 40 ) and exercise or sham dry-needling and exercise ( n = 40 ) . The primary outcomes of the Neck Disability Index ( NDI ) and self-rated recovery were measured at baseline , 6 and 12 weeks , 6 and 12 months by a blinded assessor . Analysis was intention to treat . An economic evaluation was planned but missing data deemed further analysis unwarranted . Seventy-nine patients ( 99 % ) were followed up at 6 weeks , 78 ( 98 % ) at 12 weeks , 74 ( 93 % ) at 6 months , and 73 ( 91 % ) at 12 months . The dry-needling and exercise intervention was more effective than sham dry-needling and exercise  in reducing disability at 6 and 12 months but not at 6 and 12 weeks . The treatment effects were small and not clinical ly worthwhile . At 6 weeks , the treatment effect on the 0 - 100 NDI was −0.3 ( 95 % confidence interval −5.4 to 4.7 ) , 12 weeks −0.3 ( −5.2 to 4.9 ) , 6 months −4.4 ( −9.6 to −0.74 ) , and 12 months −3.8 ( −9.1 to −0.5 ) . There was no effect for self-rated recovery . In patients with chronic WAD  , dry-needling and exercise has no clinical ly worthwhile effects over sham dry-needling and exercise Background Neck pain in adults is common and a leading cause of physical disability . Recently , a guideline was developed for the management of non-specific neck pain ( NSNP ) with an aim to improve the quality of the delivery of chiropractic care . One key guideline recommendation is to undertake multimodal care for patients with NSNP . The aim of this pilot study is to determine the feasibility of implementing a multifaceted knowledge translation intervention by promoting the use of multimodal care by chiropractors managing patients with NSNP . Methods / design The design is a cluster-r and omized controlled pilot and feasibility trial . Chiropractors in private practice in Canada will be approached to participate in the study . Thirty consenting chiropractors will be r and omized to receive either a theory-based educational intervention in the experimental group or simply a printed copy of the guideline in the control group .  Each chiropractor will recruit five neck pain patients ( a total of 150 patients ) into the study . Development of the multifaceted intervention was informed by the results of a related qualitative study based on the Theoretical Domains Framework and consists of a series of three webinars , two online case scenarios , a self-management video on Brief Action Planning , and a printed copy of the practice guideline . Primary feasibility outcomes for both chiropractors and patients include rates of ( 1 ) recruitment , ( 2 ) retention , and ( 3 ) adherence to the intervention . A checklist of proxy measures embedded within patient encounter forms will be used to assess chiropractors ’ compliance with guideline recommendations ( e.g. exercise and self-care prescriptions ) at study onset and at 3 months . Secondary outcomes include scores of behavioural constructs ( level of knowledge and self-efficacy ) for recommended multimodal care . Clinical outcomes include pain intensity and neck pain-specific disability . Analyses from this study will focus on generating point estimates and corresponding 95 % confidence intervals for parameters of a priori interest ( recruitment , retention , adherence , pain intensity , Neck Disability Index ) . Discussion Results of this study will inform the design of a larger cluster-r and omized controlled trial aim ed at evaluating the effectiveness of the theory-based tailored intervention and increasing the use of multimodal care by chiropractors managing patients with NSNP.Trial registration https:// clinical trials.gov/ , 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 Purpose . To clarify the relations between the sensory , affective and cognitive dimensions of pain and to analyse what influence these components have on  persistent disability in patients with subacute whiplash-associated disorders ( WAD ) . Method . The data was obtained from an on-going r and omised controlled trial ( RCT ) on 47 patients . The sensory dimension of pain was evaluated with a  visual analogue scale ( VAS ) diary and a Painometer ® . The affective dimension was assessed using the Painometer ® . The Tampa Scale for Kinesiophobia ( TSK ) and the Self-Efficacy Scale ( SES ) were used as measures of pain-related cognitions . The Pain Disability Index ( PDI ) was used as the outcome measure . Results . Forty patients ( 85 % ) completed the trial . The correlations between the sensory and affective dimensions of pain were non-significant , which indicates that they are two independent constructs that describe various dimensions of whiplash-related pain . High pain intensity and pain affect , more widespread pain , and high fear of movement/(re)injury corresponded to low self-efficacy . Multiple regression analyses showed that self-efficacy was the most important predictor of persistent disability contributing to 42 % of the variation in the PDI score . Conclusion . The treatment approach for patients with subacute WAD should incorporate the multidimensional nature of pain and to prevent disability special effort should be made to enhance the patient 's self-efficacy beliefs OBJECTIVES ( 1 ) To identify risk factors for chronic disability in people with acute whiplash associated disorders ( WAD ) . ( 2 ) To estimate the impact of the numbers of risk factors present . DESIGN Prospect i ve cohort study . Data were collected , on average , 32 days after injury ( SD=10.9 ) and 12 months later . Baseline measures of pain , disability , neck movement , psychological and behavioural factors were independent variables and chronic disability at 12 months was the dependent variable in a multivariable logistic regression analysis . SETTING National Health Service physiotherapy departments . PARTICIPANTS Participants ( n=599 ) with symptoms 3 weeks after injury , self-referred to physiotherapy as part of a r and omised controlled trial . 430 ( 72 % ) participants provided complete data for this analysis . MAIN OUTCOME MEASURES Chronic disability based on Neck Disability Index scores . RESULTS 136 ( 30 % ) participants developed chronic disability . High baseline disability ( OR 3.3 , 95 % CI 1.97 to 5.55 ) , longer predicted recovery time ( OR 2.4 , 95 % CI 1.45 to 3.87 ) , psychological distress ( OR 1.9 , 95%CI 1.05 to 3.51 ) , passive coping ( OR 1.8 , 95 % CI 1.07 to 2.97 ) and greater number of symptoms ( OR 1.7 , 95 % CI 1.07 to 2.78 ) were associated with chronic disability . One risk factor result ed in 3.5 times the risk ( 95 % CI 1.04 to 11.45 ) of chronic disability but this risk increased to 16 times ( 95%CI 5.36 to 49.27 ) in those with four or five risk factors . CONCLUSION Baseline disability had the strongest association with chronic disability but psychological and behavioural factors were also important . Treatment strategies should reflect this which may require a change to current physiotherapy approaches for acute WAD . The number of risk factors present should be considered when evaluating potential for poor outcome DESIGN R and omized clinical trial . OBJECTIVES To determine the short-term effects of Kinesio Taping , applied to the cervical spine , on neck pain and cervical range of motion in individuals with acute whiplash-associated disorders ( WADs ) . BACKGROUND Research ers have begun to investigate the effects of Kinesio Taping on different musculoskeletal conditions ( eg , shoulder and trunk pain ) . Considering the demonstrated short-term effectiveness of Kinesio Tape for the management of shoulder pain , it is suggested that Kinesio Tape may also be beneficial in reducing pain associated with WAD . METHODS AND MEASURES Forty-one patients ( 21 females ) were r and omly assigned to 1 of 2 groups : the experimental group received Kinesio Taping to the cervical spine ( applied with tension ) and the placebo group received a sham Kinesio Taping application ( applied without tension ) . Both neck pain ( 11-point numerical pain rating scale ) and cervical range-of-motion data were collected at baseline , immediately after the Kinesio Tape application , and at a 24-hour follow-up by an assessor blinded to the treatment allocation of the patients . Mixed-model analyses of variance ( ANOVAs ) were used to examine the effects of the treatment on each outcome variable , with group as the between-subjects variable and time as the within-subjects variable . The primary analysis was the group-by-time interaction . RESULTS The group-by-time interaction for the 2-by-3 mixed-model ANOVA was statistically significant for pain as the dependent variable ( F = 64.8 ; P<.001 ) , indicating that patients receiving Kinesio Taping experienced a greater decrease in pain immediately postapplication and at the 24-hour follow-up ( both , P<.001 ) . The group-by-time interaction was also significant for all directions of cervical range of motion : flexion ( F = 50.8 ; P<.001 ) , extension ( F = 50.7 ; P<.001 ) , right ( F = 39.5 ; P<.001 ) and left ( F = 3.8 , P<.05 ) lateral flexion , and right ( F = 33.9 , P<.001 ) and left ( F = 39.5 , P<.001 ) rotation . Patients in the experimental group obtained a greater improvement in range of motion than thosein the control group ( all , P<.001 ) . CONCLUSIONS Patients with acute WAD receiving an application of Kinesio Taping , applied with proper tension , exhibited statistically significant improvements immediately following application of the Kinesio Tape and at a 24-hour follow-up . However , the improvements in pain and cervical range of motion were small and may not be clinical ly meaningful . Future studies should investigate if Kinesio Taping provides enhanced outcomes when added to physical therapy interventions with proven efficacy or when applied over a longer period . LEVEL OF EVIDENCE Therapy , level 1b . J Orthop Sports Phys Ther 2009;39(7):515 - 521 , Epub 24 February 2009 . doi:10.2519/jospt.2009.3072 Objective : To describe the coping process over time for patients with whiplash-associated disorders ( WAD ) . Design : The study was conducted by following patients prospect ively for 12 months . Setting s : The orthopaedic clinic at a university hospital . Subjects : Fifty-three patients out of 59 had complete data -sets . Main outcome measures : Two measures were used : the Pain Disability Index ( PDI ) and the Coping Strategies Question naire ( CSQ ) .  Results : The results showed that the proportion of variance in disability shared with coping increased over time . Conclusion : The importance of coping as an explanatory factor for disability increased during the one year follow-up . Thus , coping has a crucial role for disability . The possibility of a positive long-term outcome could therefore be improved by teaching patients to use active and adaptive coping strategies shortly after an accident Background Individuals ' expectations on returning to work after an injury have been shown to predict the duration of time that a person with work-related low back pain will remain on benefits ; individuals with lower recovery expectations received benefits for a longer time than those with higher expectations . The role of expectations in recovery from traumatic neck pain , in particular whiplash-associated disorders ( WAD ) , has not been assessed to date to our knowledge . The aim of this study was to investigate if expectations for recovery are a prognostic factor after experiencing a WAD . Methods and Findings We used a prospect i ve cohort study composed of insurance cl aim ants in Sweden . The participants were car occupants who filed a neck injury cl aim ( i.e. , for WAD ) to one of two insurance companies between 15 January 2004 and 12 January 2005 ( n = 1,032 ) .  Postal question naires were completed shortly ( average 23 d ) after the collision and then again 6 mo later . Expectations for recovery were measured with a numerical rating scale ( NRS ) at baseline , where 0 corresponds to “ unlikely to make a full recovery ” and 10 to “ very likely to make a full recovery . ” The scale was reverse coded and trichotomised into NRS 0 , 1–4 , and 5–10 . The main outcome measure was self-perceived disability at 6 mo postinjury , measured with the Pain Disability Index , and categorised into no/low , moderate , and high disability . Multivariable polytomous logistic regression was used for the analysis . There was a dose response relationship between recovery expectations and disability . After controlling for severity of physical and mental symptoms , individuals who stated that they were less likely to make a full recovery ( NRS 5–10 ) , were more likely to have a high disability compared to individuals who stated that they were very likely to make a full recovery ( odds ratio [ OR ] 4.2 [ 95 % confidence interval ( CI ) 2.1 to 8.5 ] . For the intermediate category ( NRS 1–4 ) , the OR was 2.1 ( 95 % CI 1.2 to 3.2 ) . Associations between expectations and disability were also found among individuals with moderate disability . Conclusions Individuals ' expectations for recovery are important in prognosis , even after controlling for symptom severity . Interventions design ed to increase patients ' expectations may be beneficial and should be examined further in controlled studies PURPOSE To evaluate whether psychological factors and personality traits influence recovery in terms of quality of life in patients with subacute whiplash associated disorders ( WAD ) . METHOD The data was obtained from a r and omized controlled trial ( RCT ) on 47 patients . The patients completed measures of pain intensity , affective dimension of pain , pain location , psychological stress , heightened somatic awareness , depression , catastrophizing , self-efficacy , fear of movement (re)injury , and physical disability . After three months of physiotherapy interventions , the outcome of quality of life was measured with the Short Form Health survey ( SF-12 ) . All variables were entered in a multiple regression analysis , after controlling for age and sex . RESULTS Forty patients ( 85 % ) completed the trial . The self-efficacy scale ( SES ) was the only variable in the model that significantly explained the fraction of the SF12-score . The correlation between the SES and SF-12 was B = 0.64 ( p < 0.01 ) , and the adjusted R(2 ) was 0.40 ( p < 0.05 ) , which means that 40 % of the variation in the SF12 outcomes was explained by the SES . CONCLUSION In order to improve health-related quality of life in patients with WAD , the present study stresses the importance of targeting self-efficacy . A special effort should be made to enhance these beliefs in the rehabilitation process Study Design . Controlled study , measuring head repositioning error ( HRE ) using an electrogoniometric device . Objective . To compare HRE in neutral position , axial rotation and complex postures of patients with whiplash-associated disorders ( WAD ) to that of control subjects . Summary of Background Data . The presence of kinesthetic alterations in patients with WAD is controversial . Methods . In 26 control subjects and 29 patients with WAD ( aged 22–74 years ) , head kinematics was sample d using a 3-dimensional electrogoniometer mounted using a harness and a helmet . All tasks were realized in seated position . The repositioning tasks included neutral repositioning after maximal flexion-extension , eyes open and blindfolded , repositioning at 50 ° of axial rotation , and repositioning at 50 ° of axial rotation combined to 20 ° of ipsilateral bending . The flexion-extension , ipsilateral bending , and axial rotation components of HRE were considered . A multiple-way repeated- measures analysis of variance was used to compare tasks and groups . Results . The WAD group displayed a reduced flexion-extension range ( P = 1.9 × 10−4 ) , and larger HRE during flexion-extension and repositioning tasks ( P = 0.009 ) than controls . Neither group nor task affected maximal motion velocity . Neutral HRE of the flexion-extension component was larger in blindfolded condition ( P = 0.03 ) . Ipsilateral bending and axial rotation HRE components were smaller than the flexion-extension component ( P = 7.1 × 10−23 ) . For pure rotation repositioning , axial rotation HRE was significantly larger than flexion-extension and ipsilateral bending repositioning error ( P = 3.0 × 10−23 ) . Ipsilateral bending component of HRE was significantly larger combined tasks than for pure rotation tasks ( P = 0.004 ) . Conclusions . In patients with WAD  , range of motion and head repositioning accuracy were reduced . However , the differences were small . Vision suppression and task type influenced HRE Transition from acute whiplash injury to either recovery or chronicity and the development of chronic whiplash-associated disorders ( WAD ) remains a challenging issue for research ers and clinicians . The roles of social support and personality traits in long-term functioning following whiplash have not been studied concomitantly . The present study aim ed to examine whether social support and personality traits are related to long-term functioning following whiplash . One hundred forty-three subjects , who had experienced a whiplash injury in a traffic accident 10–26 months before the study took place , participated . The initial diagnoses were a ‘ sprain of the neck ’ ( ICD-9 code 847.0 ) ; only the outcome of grade s I – III acute WAD was studied . Long-term functioning was considered within the biopsychosocial model : it was expressed in terms of disability , functional status , quality of life and psychological well-being . Participants filled out a set of question naires to measure the long-term functioning parameters ( i.e. the Neck Disability Index , Medical Outcome Study Short-Form General Health Survey , Anamnestic Comparative Self- Assessment measure of overall well-being and the Symptom Checklist-90 ) and potential determinants of long-term functioning ( the Dutch Personality Question naire and the Social Support List ) . The results suggest that social support ( especially the discrepancies dimension of social support ) and personality traits ( i.e. inadequacy , self-satisfaction and resentment ) are related to long-term functioning following whiplash injury ( Spearman rho varied between 0.32 and 0.57 ; p < 0.01 ) . Within the discrepancy dimension , everyday emotional support , emotional support during problems , appreciative support and informative support were identified as important correlates of long-term functioning . Future prospect i ve studies are required to confirm the role of social support and personality traits in relation to long-term functioning following whiplash . For such studies , a broad view of long-term functioning within the biopsychological model should be applied 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 . One-year prospect i ve study of 141 acute whiplash patients ( WLP ) and 40 acute ankle-injured controls . Objective . This study investigates a priori determined potential risk factors to develop a risk assessment tool , for which the expediency was examined . Summary of Background Data . The whiplash-associated disorders ( WAD ) grading system that emerged from The Quebec Task-Force-on-Whiplash has been of limited value for predicting work-related recovery and for explaining biopsychosocial disability after whiplash and new predictive factors , for example , risk criteria that comprehensively differentiate acute WLP in a biopsychosocial manner are needed . Methods . Consecutively , 141 acute WLP and 40 ankle-injured recruited from emergency units were examined after 1 week , 1 , 3 , 6 , and 12 months obtaining neck/head visual analog scale score , number of nonpainful complaints , epidemiological , social , psychological data and neurological examination , active neck mobility , and furthermore muscle tenderness and pain response , and strength and duration of neck muscles . Risk factors derived ( reduced cervical range of motion , intense neck pain/headache , multiple nonpain complaints ) were applied in a risk assessment score and divided into seven risk strata . Results . A receiver operating characteristics curve for the Risk Assessment Score and 1-year work disability showed an area of 0.90 . Risk strata and number of sick days showed a log-linear relationship . In stratum 1 full recovery was encountered , but for high-risk patients in stratum 6 only 50 % and 7 only 20 % had returned to work after 1 year ( P < 5.4 × 10−5 ) . Strength measures , psychophysical pain measurements , and psychological and social data ( reported elsewhere ) showed significant relation to risk strata . Conclusion . The Risk Assessment score is suggested as a valuable tool for grading WLP early after injury . It has reasonable screening power for encountering work disability and reflects the biopsychosocial nature of whiplash injuries Although 14 % to 42 % of people with whiplash injuries end up with chronic debilitating pain , there is still a paucity of empirically supported treatments for this group of patients . In chronic pain management , there is increasing consensus regarding the importance of a behavioural medicine approach to symptoms and disability . Cognitive behaviour therapy has proven to be beneficial in the treatment of chronic pain . An approach that promotes acceptance of , or willingness to experience , pain and other associated negative private events ( e.g. fear , anxiety , and fatigue ) instead of reducing or controlling symptoms has received increasing attention . Although the empirical support for treatments emphasizing exposure and acceptance ( such as acceptance and commitment therapy ) is growing , there is clearly a need for more outcome studies , especially r and omized controlled trials . In this study , participants ( N = 21 ) with chronic pain and whiplash‐associated disorders were recruited from a patient organization and r and omized to either a treatment or a wait‐list control condition . Both groups continued to receive treatment as usual . In the experimental condition , a learning theory framework was applied to the analysis and treatment . The intervention consisted of a 10‐session protocol emphasizing values‐based exposure and acceptance strategies to improve functioning and life satisfaction by increasing the participants ' abilities to behave in accordance with values in the presence of interfering pain and distress ( psychological flexibility ) . After treatment , significant differences in favor of the treatment group were seen in pain disability , life satisfaction , fear of movements , depression , and psychological inflexibility . No change for any of the groups was seen in pain intensity . Improvements in the treatment group were maintained at 7‐month follow‐up . The authors discuss implication s of these findings and offer suggestions for further research in this area Abstract Local sensitization to noxious stimuli has been previously described in acute whiplash injury and has been suggested to be a risk factor for chronic sequelae following acute whiplash injury . In this study , we prospect ively examined the development of tender points and mechano‐sensitivity in 157 acute whiplash injured patients , who fulfilled criteria for WAD grade 2 ( n = 153 ) or grade 3 ( n = 4 ) seen about 5 days after injury ( 4.8 ± 2.3 ) and who subsequently had or had not recovered 1 year after a cervical sprain .  Tender point scores and stimulus – response function for mechanical pressure were determined in injured and non‐injured body regions at specific time‐points after injury . Thirty‐six of 157 WAD grade 2 patients ( 22.9 % ) had not recovered , defined as reduced work capacity after 1 year . Non‐recovered patients had higher total tender point scores after 12 ( p < 0.05 ) , 107 ( p < 0.05 ) and 384 days ( p < 0.05 ) relative to those who recovered . Tenderness was found in the neck region and in remote areas in non‐recovered patients . The stimulus – response curves for recovered and non‐recovered patients were similar after 12 days and 107 days after the injury , but non‐recovered patients had steeper stimulus – response curves for the masseter ( p < 0.02 ) and trapezius muscles ( p < 0.04 ) after 384 days . This study shows early mechano‐sensitization after an acute whiplash injury and the development of further sensitization in patients with long‐term disability Hypersensitivity to a variety of sensory stimuli is a feature of persistent whiplash associated disorders ( WAD ) . However , little is known about sensory disturbances from the time of injury until transition to either recovery or symptom persistence . Quantitative sensory testing  ( pressure and thermal pain thresholds , the brachial plexus provocation test ) , the  sympathetic vasoconstrictor reflex and psychological distress ( GHQ‐28 ) were prospect ively measured in 76 whiplash subjects within 1 month of injury and then 2 , 3 and 6 months post‐injury . Subjects were classified at 6 months post‐injury using scores on the Neck Disability Index : recovered ( < 8 ) , mild pain and disability ( 10–28 ) or moderate/severe pain and disability ( > 30 ) . Sensory and sympathetic nervous system tests were also measured in 20 control subjects . All whiplash groups demonstrated local mechanical hyperalgesia in the cervical spine at 1 month post‐injury . This hyperalgesia persisted in those with moderate/severe symptoms at 6 months but resolved by 2 months in those who had recovered or reported persistent mild symptoms . Only those with persistent moderate/severe symptoms at 6 months demonstrated generalised hypersensitivity to all sensory tests . These changes occurred within 1 month of injury and remained unchanged throughout the study period . Whilst no significant group differences were evident for the sympathetic vasoconstrictor response , the moderate/severe group showed a tendency for diminished sympathetic reactivity . GHQ‐28 scores of the moderate/severe group were higher than those of the other two groups . The differences in GHQ‐28 did not impact on any of the sensory measures . These findings suggest that those with persistent moderate/severe symptoms at 6 months display , soon after injury , generalised hypersensitivity suggestive of changes in central pain processing mechanisms . This phenomenon did not occur in those who recover or those with persistent mild symptoms OBJECTIVE Screening for mental illness in primary care is widely recommended , but little is known about the evaluation , treatment , and long-term management processes that follow screening . The aim of this study was to examine and describe the quality of mental health care for persons with chronic obstructive pulmonary disease ( COPD ) and anxiety/depressive disorders , as measured by adherence to practice guidelines . METHOD This retrospective chart review examined data for 102 primary care and mental health care patients with COPD who were diagnosed , using Structured Clinical Interview for DSM-IV criteria , with major depressive disorder , dysthymia , depression not otherwise specified , generalized anxiety disorder , or anxiety not otherwise specified . Data were gathered from primary care progress notes from the year prior to enrollment in a r and omized controlled trial ( enrollment was from July 2002 to April 2004 ) . We compared the care received by these patients over 1 year with that recommended by practice guidelines . Charts were abstract ed using a checklist of recommended practice guidelines for diagnostic evaluation , acute treatment , and long-term management of anxiety and depressive disorders . RESULTS Fifty ( 49 % ) of the 102 patients were recognized during the review year as having an anxiety or depressive disorder .  Eighteen patients were newly assessed for depressive or anxiety disorders  during the chart review year . Patients followed in primary care alone , compared with those who were comanaged by mental health care providers , were less likely to have guideline -adherent care . CONCLUSION Depressive and anxiety disorders are recognized in about half of patients ; however , guideline -supported diagnostic evaluation , acute treatment ( except for medications ) , and long-term management rarely occur in the primary care setting . To improve the treatment of depressive and anxiety disorders in primary care , the process of care delivery must be understood and changed Cognitive behavior therapy ( CBT ) has made important contributions to chronic pain management , but the process by which it is effective is not clear . Recently , strong arguments have been raised concerning the need for theory driven research to e.g. identify mechanisms of change in CBT and enhance the effectiveness of this type of treatment . However , the number of studies addressing these issues is still relatively scarce . Furthermore , the arrival of varieties of CBT with seemingly different process targets increases the need for such information . The present study explored the processes of change in a previously reported successful r and omized controlled trial evaluating the effectiveness of an exposure-based form of behavioral and cognitive therapy , Acceptance and Commitment Therapy ( ACT ) , on improvement in pain-related disability and  life satisfaction for patients suffering from whiplash-associated disorder ( WAD ) . Several process variables relevant to theories underlying traditional CBT were included : pain , distress , kinesiophobia , self-efficacy , and the process primarily targeted by ACT : psychological inflexibility . Mediation analyses were performed using a non-parametric cross-product of the coefficients approach . Results illustrated that pain intensity , anxiety , depression , kinesiophobia , and self-efficacy did not have significant mediating effects on the dependent variables . In contrast , significant indirect effects were seen for psychological inflexibility on pain-related disability ( pre- to post-change scores ) and life satisfaction ( pre- to post ; pre- to 4-month follow-up change scores ) . Although tentative , these results support the mediating role of psychological inflexibility in ACT-oriented interventions aim ed at improving functioning and life satisfaction in people with chronic pain Objectives : To investigate the effectiveness of botulinum toxin in preventing the development of chronic whiplash-associated disorder . Design : Prospect i ve , r and omized , placebo-controlled double-blind study . Setting : Regional Neurological Rehabilitation Centre with participants being at home . Subjects : Thirty-seven patients with whiplash-associated disorder who remained symptomatic two months after injury . Interventions : Patients were r and omized to receive either 250 units botulinum toxin type A ( Dysport ) or placebo ( normal saline ) . Four trigger points were injected with 0.625 mL of injectant . Outcome measures : Tenderness to palpation scores , visual analogue pain scale , Vernon — Mior Neck Pain and Disability Index and cervical range of motion . Follow-up assessment s were carried out at four weeks and three months after treatment . Results : Twenty participants received botulinum toxin and 17 received placebo . Both groups showed a tendency towards improvement in pain scores , Vernon — Mior Index and range of motion at four weeks and three months , with the changes being more pronounced in the toxin group . The change in Vernon — Mior Index in the toxin group was both statistically and clinical ly significant ( i.e. a change of score of ≥5 from baseline to follow-up ) . Group comparisons did not meet statistical significance . Conclusion : The improvements in outcome measures suggest that botulinum toxin type A may have a role to play in the management of whiplash-associated disorder but larger studies are required to clarify the situation Abstract Objective . Anxiety disorders are frequently under-diagnosed conditions in primary care , although they can be managed effectively by general practitioners . Methods . This paper is a short and practical summary of the World Federation of Biological Psychiatry ( WFSBP ) guidelines for the pharmacological treatment of anxiety disorders , obsessive – compulsive disorder ( OCD ) and posttraumatic stress disorder ( PTSD ) for the treatment in primary care . The recommendations were developed by a task force of 30 international experts in the field and are based on r and omized controlled studies . Results . First-line pharmacological treatments for these disorders are  selective serotonin reuptake inhibitors  ( for all disorders ) ,  serotonin-norepinephrine reuptake inhibitors  ( for some ) and  pregabalin  ( for generalized anxiety disorder only ) . A combination of  medication and cognitive behavior/exposure therapy  was shown to be a clinical ly desired treatment strategy . Conclusions . This short version of an evidence -based guideline may improve treatment of anxiety disorders , OCD , and PTSD in primary care Abstract Objectives . This 2013 up date of the practice guidelines for the biological treatment of unipolar depressive disorders was developed by an international Task Force of the World Federation of Societies of Biological Psychiatry ( WFSBP ) . The goal has been to systematic ally review all available evidence pertaining to the treatment of unipolar depressive disorders , and to produce a series of practice recommendations that are clinical ly and scientifically meaningful based on the available evidence . The guidelines are intended for use by all physicians seeing and treating patients with these conditions . Methods . The 2013 up date was conducted by a systematic up date literature search and appraisal . All recommendations were approved by the Guidelines Task Force . Results . This first part of the guidelines ( Part 1 ) covers disease definition , classification , epidemiology , and course of unipolar depressive disorders , as well as the management of the acute and continuation phase treatment . It is primarily concerned with the biological treatment ( including antidepressants , other psychopharmacological medications , electroconvulsive therapy , light therapy , adjunctive and novel therapeutic strategies ) of adults . Conclusions . To date , there is a variety of evidence -based antidepressant treatment options available . Nevertheless there is still a substantial proportion of patients not achieving full remission . In addition , somatic and psychiatric comorbidities and other special circumstances need to be more thoroughly investigated . Therefore , further high- quality informative r and omized controlled trials are urgently needed The British Association for Psychopharmacology guidelines specify the scope and targets of treatment for bipolar disorder . The third version is based explicitly on the available evidence and presented , like previous Clinical Practice Guidelines , as recommendations to aid clinical decision making for practitioners : it may also serve as a source of information for patients and carers , and assist audit . The recommendations are presented together with a more detailed review of the corresponding evidence . A consensus meeting , involving experts in bipolar disorder and its treatment , review ed key areas and considered the strength of evidence and clinical implication s. The guidelines were drawn up after extensive feedback from these participants . The best evidence from r and omized controlled trials and , where available , observational studies employing quasi-experimental design s was used to evaluate treatment options . The strength of recommendations has been described using the GRADE approach . The guidelines cover the diagnosis of bipolar disorder , clinical management , and strategies for the use of medicines in short-term treatment of episodes , relapse prevention and stopping treatment . The use of medication is integrated with a coherent approach to psychoeducation and behaviour change Objectives : To investigate sensory changes present in patients with chronic whiplash-associated disorders and chronic idiopathic neck pain using a variety of quantitative sensory tests to better underst and the pain processing mechanisms underlying persistent symptoms . Methods : A case control study was used with 29 subjects with chronic whiplash-associated disorders , 20 subjects with chronic idiopathic neck pain , and 20 pain-free volunteers .  Pressure pain thresholds  were measured over the articular pillars of C2-C3 , C5-C6 , the median , radial , and ulnar nerve trunks in the arm and over a remote site , the muscle belly of tibialis anterior . Heat pain thresholds , cold pain thresholds , and von Frey hair sensibility were measured over the cervical spine , tibialis anterior , and deltoid insertion . Anxiety was measured with the Short-Form of the Spielberger State Anxiety Inventory . Results : Pressure pain thresholds were decreased over cervical spine sites in both subject groups when compared with controls ( P < 0.05 ) . In the chronic whiplash-associated disorders group , pressure pain thresholds were also decreased over the tibialis anterior , median , and radial nerve trunks ( P < 0.001 ) . Heat pain thresholds were decreased and cold pain thresholds increased at all sites ( P < 0.03 ) . No differencesin heat pain thresholds or cold pain thresholds were evident in the idiopathic neck pain group at any site compared with the control group ( P > 0.27 ) . No abnormalities in von Frey hair sensibility were evident in either neck pain group ( P > 0.28 ) . Discussion : Both chronic whiplash-associated disorders and idiopathic neck pain groups were characterized by mechanical hyperalgesia over the cervical spine . Whiplash subjects showed additional widespread hypersensitivity to mechanical pressure and thermal stimuli , which was independent of state anxiety and may represent changes in central pain processing mechanisms . This may have implication s for future treatment approaches DESCRIPTION The American College of Physicians ( ACP ) developed this guideline to present the evidence and provide clinical recommendations on the management of chronic insomnia disorder in adults . METHODS This guideline is based on a systematic review of r and omized , controlled trials published in English from 2004 through September 2015 . Evaluated outcomes included global outcomes assessed by question naires , patient-reported sleep outcomes , and harms . The target audience for this guideline includes all clinicians , and the target patient population includes adults with chronic insomnia disorder . This guideline grade s the evidence and recommendations by using the ACP grading system , which is based on the GRADE ( Grading of Recommendations Assessment , Development and Evaluation ) approach . RECOMMENDATION 1 ACP recommends that all adult patients receive cognitive behavioral therapy for insomnia ( CBT-I ) as the initial treatment for chronic insomnia disorder . ( Grade : strong recommendation , moderate- quality evidence ) . RECOMMENDATION 2 ACP recommends that clinicians use a shared decision-making approach , including a discussion of the benefits , harms , and costs of short-term use of medications , to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom cognitive behavioral therapy for insomnia ( CBT-I ) alone was unsuccessful . ( Grade : weak recommendation , low- quality evidence ) 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 Background Depression is a common mental health disorder for which clinical practice guidelines have been developed . Prior systematic review s have identified complex organizational interventions , such as collaborative care , as effective for guideline implementation ; yet , many healthcare delivery organizations are interested in less re source -intensive methods to increase provider adherence to guidelines and guideline -concordant practice s. The objective of this systematic review was to assess the effectiveness of  healthcare provider  interventions that aim to increase adherence to evidence -based treatment of depression in routine clinical practice . Methods We search ed five data bases through August 2017 using a comprehensive search strategy to identify English- language r and omized controlled trials ( RCTs ) in the quality improvement , implementation science , and behavior change literature that evaluated outpatient provider interventions , in the absence of practice re design efforts , to increase adherence to treatment guidelines or guideline -concordant practice s for depression . We used meta- analysis to summarize odds ratios , st and ardized mean differences , and incidence rate ratios , and assessed quality of evidence ( QoE ) using the GRADE approach . Results Twenty-two RCTs promoting adherence to clinical practice guidelines or guideline -concordant practice s met inclusion criteria . Studies evaluated diverse provider interventions , including distributing guidelines to providers , education/training such as academic detailing , and combinations of education with other components such as targeting implementation barriers . Results were heterogeneous and analyses comparing provider interventions with usual clinical practice did not indicate a statistically significant difference in guideline adherence across studies . There was some evidence that provider interventions improved individual outcomes such as medication prescribing and indirect comparisons indicated more complex provider interventions may be associated with more favorable outcomes . We did not identify types of provider interventions that were consistently associated with improvements across indicators of adherence and across studies . Effects on patients ’ health in these RCTs were inconsistent across studies and outcomes . Conclusions Existing RCTs describe a range of provider interventions to increase adherence to depression guidelines . Low QoE and lack of replication of specific intervention strategies across studies limited conclusions that can be drawn from the existing research . Continued efforts are needed to identify successful strategies to maximize the impact of provider interventions on increasing adherence to evidence -based treatment for depression . Trial registration PROSPERO record CRD42017060460 on QUESTION Are implementation strategies involving education any more effective than mere dissemination of clinical practice guidelines in changing physiotherapy practice and reducing patient disability after acute whiplash ? DESIGN Cluster-r and omised trial . PARTICIPANTS Twenty-seven physiotherapists from different private physiotherapy clinics and the 103 patients ( 4 dropouts ) who presented to them with acute whiplash . INTERVENTION The implementation group of physiotherapists underwent education by opinion leaders about whiplash guidelines and the dissemination group had the guidelines mailed to them . OUTCOME MEASURES The primary outcome was patient disability , measured using the Functional Rating Index , collected on admission to the trial and at 1.5 , 3 , 6 and 12 months . Physiotherapist knowledge about the guidelines was measured using a custom-made question naire . Physiotherapist practice and cost of care were measured by audit of patient notes . RESULTS There were no significant differences between groups for any of the patient outcomes at any time . The implementation patients had 0.6 points ( 95 % CI -7.8 to 6.6 ) less disability than the dissemination patients at 12 months ; 44 % more physiotherapists in the implementation group reported that they prescribed two out of the five guideline -recommended treatments ; and 32 % more physiotherapists actually prescribed them . The cost of care for patients in the implementation group was $ 255 ( 95 % CI -1505 to 996 ) less than for patients in the dissemination group . CONCLUSION Although the active implementation program increased guideline -consistent practice , patient outcomes and cost of care were not affected * The up date s are underlined for quick reference . INTRODUCTION A critical need exists for efficient , measurable systems of disease management that reconcile conflicts between socioeconomic responsibility and patient welfare . Clinical guidelines have become an important component of these systems because they address elements of care that are effective and that reduce the variability in our approach to patient management . The American Association of Clinical Endo-crinologists ( AACE ) 2001 Medical Guidelines for Clinical Practice for the Prevention and Management of Postmenopausal Osteoporosis address the prevention , diagnosis , and management of postmenopausal osteoporo-sis , a disorder that is recognized as a major public health problem because of its physical and socioeconomic consequences . They are intended to simplify medical decision making and to help physicians and their patients make good decisions about skeletal health and postmenopausal osteoporosis . The specific goals of these guidelines are to reduce the incidence of fractures related to osteoporosis and to achieve the highest quality of life for individual patients by using the most effective and efficient methods of diagnosis and management . In the preparation of this 2001 edition , reports in the peer- review ed literature dealing with prevention , diagnosis , and treatment of postmenopausal osteoporosis , which were published and indexed between 1996 ( the publication date of the previous edition of these guidelines ) and January 2001 , were identified by computer search , review ed , and grade d for clinical relevance and scientific merit . Although cost-effectiveness was carefully considered , variabilities in actual costs could not be accurately determined . Therefore , cost-effectiveness modeling was not undertaken . Whenever possible , recommendations were based on r and omized , prospect i ve , double-blind studies of well-defined patient population s. Studies that used the most relevant clinical endpoint , fracturing , were considered " level 1 " evidence . When level 1 evidence was not available , recommendations were based on cross-sectional studies , investigations that tested smaller or nonr and omized patient population s , or studies that tested secondary or surrogate clinical endpoints for fracture , such as bone mineral density ( BMD ) or bone turnover markers , in treated population s ( level 2 evidence ) . When stronger evidence was not available , review s , editorials , and expert opinions were used ( level 3 evidence ) . We recognize that the process of developing clinical guidelines necessarily results in a narrowing and codifica-tion of clinical choices , which can be inappropriate in some clinical situations . Because the application of objective information to the specific needs of patients is the ultimate responsibility of the practicing physician , clinical practice guidelines are not intended to be rigid or restrictive , nor BACKGROUND Irritable bowel syndrome ( IBS ) is a chronic debilitating functional gastrointestinal disorder . Diet and lifestyle changes are important management strategies . The aim of these guidelines is to systematic ally review key aspects of the dietary management of IBS , with the aim of providing evidence -based guidelines for use by registered dietitians . METHODS Questions relating to diet and IBS symptom management were developed by a guideline development group . These included the role of milk and lactose , nonstarch polysaccharides ( NSP ) , fermentable carbohydrates in abdominal bloating , probiotics and empirical or elimination diets . A comprehensive literature search was conducted and relevant studies from January 1985 to November 2009 were identified using the electronic data base search engines : Cinahl , Cochrane Library , Embase , Medline , Scopus and Web of Science . Evidence statements , recommendations , good practice points and research recommendations were developed . RESULTS Thirty studies were critically appraised . A dietetic care pathway was produced following a logical sequence of treatment and formed the basis of these guidelines . Three lines of dietary management were identified . first line :  Clinical and dietary assessment , healthy eating and lifestyle management  with some general advice on lactose and NSP . Second line : Advanced dietary interventions to improve symptoms based on NSP , fermentable carbohydrates and probiotics . Third line : Elimination and empirical diets . Research recommendations were also identified relating to the need for adequately powered and well design ed r and omised controlled trials . CONCLUSIONS These guidelines provide evidence -based details of how to achieve the successful dietary management of IBS OBJECTIVE To describe how vestibular rehabilitation influences pain and range of motion among patients with whiplash-associated disorder and dizziness , and to describe whether pain or range of motion correlated with balance performance or self-perceived dizziness h and icap . SUBJECTS A total of 29 patients , 20 women and 9 men , age range 22 - 76 years . METHODS Patients with whiplash-associated disorder and dizziness were r and omized to either intervention ( vestibular rehabilitation ) or control .  Neck pain intensity , cervical range of motion ( CROM ) , balance and self-perceived dizziness h and icap were measured at baseline , 6 weeks and 3 months . RESULTS There were no differences in neck pain intensity or CROM between the 2 groups either at baseline , 6 weeks or 3 months ( p = 0.10 - 0.89 ) . At baseline , neck pain intensity correlated with CROM ( -0.406 ) and self-perceived dizziness h and icap ( 0.492 ) . CROM correlated with self-perceived dizziness h and icap and with 1 balance measure ( -0.432 ) . Neck pain intensity did not correlate with balance performance ( -0.188 - 0.049 ) . CONCLUSION Neck pain intensity and CROM was not influenced by vestibular rehabilitation . Importantly , the programme did not appear to increase pain or decrease neck motion , as initially thought . Neck pain intensity and CROM correlated with self-perceived dizziness h and icap . CROM also correlated with 1 balance measure 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 Objective : To evaluate the ability of early smooth pursuit testing to predict chronic whiplash-associated disorders , and to study whether the presence of abnormal smooth pursuit eye movements at one-year follow-up is associated with symptoms at that time . Design : Prospect i ve cohort study with one-year follow-up . Setting : The study was carried out at a university research centre and participants were recruited from emergency units and general practitioners . Subjects : In all , 262 participants were recruited within 10 days from a whiplash injury . Main measures :  Smooth pursuit eye movements were tested with electrooculography ( EOG )  an average of 12 days after a whiplash trauma and again after one year . Analyses of EOG recordings were computerized . Associations between test results both from baseline and one-year tests and self-reported neck pain , headache , neck disability and working ability one year after the car collision were determined . Results : Results of early eye movement tests were not associated with the prognosis . Reduced smooth pursuit performance when tested in static cervical rotation at the one-year follow-up was significantly associated with higher neck pain intensity at that time ( regression coefficient 0.8 , 95 % confidence interval ( CI ) 0.04—1.5 ) , but the association was too weak for the test to discriminate between recovered participants and those with lasting symptoms . Conclusions : Although reduced smooth pursuit performance at one-year follow-up was associated with persistent neck pain , smooth pursuit eye movement tests are not useful as predictive or diagnostic tests in whiplash-associated disorders BACKGROUND The World Health Organization ( WHO ) ICD-10 Primary Health Care ( PHC ) Guidelines for Diagnosis and Management of Mental Disorders ( 1996 ) have not been evaluated in a pragmatic r and omised controlled trial ( RCT ) . AIMS To evaluate the effect of local adaptation and dissemination of the guidelines . METHOD Pragmatic , pair-matched , cluster RCT involving 30 practice s. RESULTS Guideline practice s were less sensitive but more specific in identifying morbidity , but these differences were not significant .  Guideline patients did not differ from  usual-care patients on 12-item General Health Question naire scores at 3-month follow-up or in the proportion who were still cases . There were no significant differences in secondary outcomes . CONCLUSIONS Attempts to influence clinician behaviour through a process of adaptation and extension of guidelines are unlikely to change detection rates or outcomes Patients hope that their doctors will correctly identify health problems , clearly articulate sensible options for managing each problem , wisely interpret the best available evidence about probable outcomes associated with each option , sensitively solicit patient preferences for each outcome , and thereby implement practice s that are likely to achieve the results patients care about . Groups of patients hope that doctors will work to prevent , detect , and treat health problems in a way that maximizes the public good achieved with available health care re sources . To meet these dual expectations , doctors face forbidding tasks of clinical decision making . Improved methods for preparing , appraising , and abstract ing overviews of available evidence about a clinical topic can bring a broader range of high- quality information within the busy practitioner 's grasp [ 1 - 4 ] . However , even well- design ed overviews often do not synthesize information about benefits , harms , and costs of medical practice s in a way that facilitates clinical decision making . Clinical practice guidelines have been defined as systematic ally developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances [ 5 ] . Guidelines that are based on sound scientific evidence , and a trustworthy process for judging the value of alternative practice s , could help physicians deal with the information overload they face . Existing practice guidelines , however , vary widely in their quality , and clinicians should carefully consider the validity and applicability of each guideline they read . We propose a structured format for abstract s of articles describing practice guidelines that is based on emerging principles of guideline development and evaluation [ 6 - 13 ] . The proposal is design ed to help readers obtain the key information needed to assess the applicability , importance , and validity of any guideline . The proposed structure for more informative abstract s of articles describing clinical practice guidelines has been review ed and pilot-tested by guideline developers , evaluators , and implementors and by groups of practicing clinicians . Early versions of the proposal were sent to consultants at the National Library of Medicine , the Institute of Medicine , the American College of Physicians ( ACP ) , and the Agency for Health Care Policy and Research . Subsequent versions of the proposal were pilot tested on various published guidelines and were assessed by selected health care organizations for applicability to guidelines under development . An improved proposal was sent to 82 persons active in guideline development , evaluation , and implementation . The Internal Medicine Center to Advance Research and Education circulated the proposal to volunteer practitioners , and the authors solicited feedback from physician and health administrator participants at three national workshops about practice guidelines . The proposal that follows represents an integration of the collective wisdom of our external review ers . ( A glossary of terms used in articles on clinical practice guidelines is supplied in the Appendix . ) Proposed Structure and Content for Abstract s of Articles Describing Clinical Practice Guidelines The proposed structure for abstract s of papers describing clinical practice guidelines is summarized in Table 1 . Key elements of the guideline development process are captured with statements about the principal objective and target of the guideline , the main practice options and outcomes that were considered , the nature of the evidence and values that were analyzed , the main benefits and harms expected from guideline implementation , the key recommendations , and a statement of whether the recommendations have been tested and by whom they have been endorsed . If details about guideline development methods or supporting evidence are published separately , then the abstract should indicate the existence of supporting documents and the most relevant parts of those should be summarized in the abstract . To be included in their entirety in the online bibliographic data bases of the National Library of Medicine , structured abstract s of clinical practice guidelines should not exceed 4096 characters ( approximately 500 words ) in length . Individual journals may have different requirements . Table 1 . Proposed Format for Structured Abstract s of Clinical Practice Guidelines Objective The abstract should state the objective of the guideline by identifying the targeted health problem , the targeted patients and physicians , and the main reason or reasons for developing new recommendations concerning this problem for this population . For guidelines primarily concerned with the management of health conditions , the stage of illness and intent to prevent , diagnose , treat , or palliate the disorder should be specified . For guidelines primarily concerned with health procedures , an intervention and its role in patient management should be defined . Targeted providers , setting s , and patients should be specified so that readers can tell who should do what , where it should be done , and to whom . A statement of objective also may specify why a new guideline is needed and how it should be used . Practice guidelines may be written to clarify or resolve clinical controversies , to communicate important new findings from clinical studies , or to promote more effective , efficient , or consistent physician practice s at less cost or risk to patients . Guidelines may be used concurrently to help physicians and patients make choices ( for example , clinical algorithms ) , retrospectively to compare physician choices to pre-established criteria ( for example , utilization review ) , or prospect ively to set limits on physician choices ( for example , preprocedure approval ) . Options Clinical practice guidelines pertain to clinical decisions . The nature of those decisions should be made explicit by disclosing the main management options considered . The abstract should list principal alternative preventive , diagnostic , or therapeutic strategies available to targeted clinicians and patients . Outcomes The abstract also should specify which health outcomes , such as death , morbidity , quality of life , economic costs , or changes in the process of health care were considered . Evidence To estimate the probable effect of a health intervention on an outcome , relevant data must be defined , gathered , and appraised . Readers need to know what kind of evidence was considered and what methods were used to select and combine evidence from different sources . Potential sources of evidence about clinical outcomes include the results of clinical studies ( published or unpublished ) , expert opinion , information contained in public or private health data bases , and direct input from patients or providers . Potential sources of evidence about economic outcomes include the results of cost-effectiveness studies , various fee schedules , and information contained in public or private health cl aims data bases . Potential methods of gathering evidence include computerized search es for articles that satisfy predetermined criteria , review s of bibliographies of relevant articles , and surveys of relevant persons or organizations [ 1 ] . The abstract should state whether explicit methods were used to combine results from scientific studies ( for example , meta- analysis ) or opinions of experts ( for example , Delphi technique ) [ 14 , 15 ] . The abstract may also indicate whether specific criteria were used to gauge the quality of information from different sources [ 16 , 17 ] . Scientific evidence regarding the likelihood of certain outcomes is often missing or conflicting . It is desirable for the strength of evidence supporting a guideline to be gauged in some way [ 16 ] . If gaps in the evidence were bridged formally ( for example , through use of decision- analysis models ) or informally ( for example , best guess of clinical experts ) , then major assumptions or areas of uncertainty should be acknowledged [ 11 ] . Because of the extraordinary time required to properly assemble and review evidence and then to achieve consensus about practice recommendations , the abstract of a practice guideline should specify the publication date s of the most recent evidence considered . If a sensitivity analysis was performed , then any major vulnerability of the guideline to weaknesses in the evidence should be acknowledged . These considerations may be summarized by qualifying a guideline as provisional by specifying date s for expiration or review , by listing studies in progress that could affect the guideline , or by identifying key research priorities . Values The declaration of a recommended practice presumes an implicit or explicit process for judging the relative desirability of the health , economic , and process outcomes associated with alternative practice s. These are matters of opinion and value . For example , in developing guidelines for breast cancer screening , it is necessary to weigh the value of preventing a death from breast cancer against the value of avoiding unnecessary harm or anxiety in women who do not have breast cancer . A high value placed on maximizing detection of asymptomatic malignancy may motivate an organization to recommend teaching self-examination of breasts to young women [ 18 ] . A relatively greater value placed on avoiding false-positive results may motivate others to not promote such programs [ 19 ] . Consequently , the principal sources of such values and the method by which judgments were made should be reported in guideline abstract s. At a minimum , the abstract should identify the major groups that participated in the process of assigning values to outcomes ( for example , generalist or specialist physicians , other health care providers , insurers , representatives of health organizations , and special-interest groups ) and whether patient preferences were represented . The abstract may also indicate the method used to synthesize opinions from Objectives : To assess which psychological factors are important in the development of chronic whiplash symptoms . Methods : Search es were conducted across PubMed , CINAHL , Scopus , and PsychINFO up until March 2017 . Studies were included if they investigated psychological prognostic factors in association with recovery from a whiplash injury . Studies also had to be prospect i ve , cohort , follow-up or observational studies , have a 6 month follow-up and published in English . Quality assessment s were conducted by 2 independent review ers . Thirty-one articles were included investigating 34 psychological factors . Results : Poor expectations of recovery , posttraumatic stress symptoms and passive coping emerged as the most consistent prognostic factors of chronic neck pain and /or disability after a whiplash injury . Anxiety , travel anxiety , depression , personality , precollision distress , general psychological distress , and avoidance behavior were not associated with chronic whiplash problems Background Chronic obstructive pulmonary disease ( COPD ) is a progressive , debilitating disease associated with significant clinical burden and is estimated to affect 15 million individuals in the US . Although a large number of individuals are diagnosed with COPD , many individuals still remain undiagnosed due to the slow progression of the disorder and lack of recognition of early symptoms . Not only is there under-diagnosis but there is also evidence of sub-optimal evidence -based treatment of those who have COPD . Despite the development of international COPD guidelines , many primary care physicians who care for the majority of patients with COPD are not translating this evidence into effective clinical practice . Method / Design This paper describes the design and rationale for a r and omized , cluster design trial ( RCT ) aim ed at translating the COPD evidence -based guidelines into clinical care in primary care practice s. During Phase 1 , a needs assessment evaluated barriers and facilitators to implementation of COPD guidelines into clinical practice through focus groups of primary care patients and providers . Using formative evaluation and feedback from focus groups , three tools were developed . These include a computerized patient activation tool ( an interactive iPad with wireless data transfer to the spirometer ) ; a web-based COPD guideline tool to be used by primary care providers as a decision support tool ; and a COPD patient education toolkit to be used by the practice team . During phase II , an RCT will be performed with one year of intervention within 30 primary care practice s. The effectiveness of the material s developed in Phase I are being tested in Phase II regarding physician performance of COPD guideline implementation and the improvement in the clinical ly relevant outcomes ( appropriate diagnosis and management of COPD ) compared to usual care . We will also examine the use of a patient activation tool - ‘ MyLungAge ’ - to prompt patients at risk for or who have COPD to request spirometry confirmation and to request support for smoking cessation if a smoker . Discussion Using a multi-modal intervention of patient activation and a technology-supported health care provider team , we are testing the effectiveness of this intervention in activating patients and improving physician performance around COPD guideline implementation . Trial registration Clinical Trials.gov , Background Low back pain ( LBP ) is a common and costly problem . Initiatives design ed to assist practitioner and patient decisions about appropriate healthcare for LBP include printed evidence -based clinical guidelines . The three professional groups of chiropractic , osteopathy and musculoskeletal physiotherapy in the UK share common ground with their approaches to managing LBP and are amongst those targeted by LBP guidelines . Even so , many seem unaware that such guidelines exist . Furthermore , the behaviour of at least some of these practitioners differs from that recommended in these guidelines .Few r and omised controlled trials evaluating printed information as an intervention to change practitioner behaviour have utilised a no-intervention control . All these trials have used a cluster design and most have method ological flaws . None specifically focus upon practitioner behaviour towards LBP patients . Studies that have investigated other strategies to change practitioner behaviour with LBP patients have produced conflicting results . Although numerous LBP guidelines have been developed worldwide , there is a paucity of data on whether their dissemination actually changes practitioner behaviour . Primarily because of its low unit cost , sending printed information to large numbers of practitioners is an attractive dissemination and implementation strategy . The effect size of such a strategy , at an individual practitioner level , is likely to be small . However , if large numbers of practitioners are targeted , this strategy might achieve meaningful changes at a population level . Methods The primary aim of this prospect i ve , pragmatic r and omised controlled trial is to test the short-term effectiveness ( six-months following intervention ) of a directly-posted information package on the reported clinical behaviour ( primary outcome ) , attitudes and beliefs of UK chiropractors , osteopaths and musculoskeletal physiotherapists . We sought to r and omly allocate a combined sample of 1,800 consenting practitioners to receive either the information package ( intervention arm ) or no information above that gained during normal practice ( control arm ) . We collected question naire data at baseline and six-months post-intervention . The analysis of the primary outcome will assess between-arm differences of proportions of responses to questions on recommendations about activity , work and bed-rest , that fall within categories previously defined by an expert consensus exercise as either ' guideline -consistent ' and ' guideline -inconsistent ' UNLABELLED Whiplash injury and chronic whiplash syndrome represent major health problems in certain western communities , pain being the main symptom . Sensitization of the nociceptive system may play a role for non-recovery after whiplash injury . AIMS This study examined if tolerance to endure pain stimuli may predict outcome in whiplash injury . In a prospect i ve fashion , 141 acute whiplash patients exposed to rear-end car collision ( WAD grade 1 - 3 ) and 40 ankle-injured controls were followed and exposed to a cold pressor test , respectively , 1 week , 1 , 3 , 6 and 12 months after the injury . VAS score of pain and discomfort was obtained before , during and after immersion of the dominant h and into cold water for 2 min . The McGill Pain Question naire showed that ankle-injured controls had higher initial pain scores than the corresponding whiplash group , while whiplash-injured subjects had higher scores at 6 months ; pain scores being similar at other time points . No difference was found in cold pressor pain between recovered whiplash patients and ankle-injured subjects . Non-recovery was only encountered in whiplash injury . Eleven non-recovered whiplash patients ( defined as : h and icap after 1 year ) showed reduced time to peak pain from 1 week to 3 months ( P<0.001 ) , 6 months ( P<0.01 ) , but not 12 months after the injury . A larger pain area was seen in non-recovered vs. recovered whiplash-injured subjects during the entire observation period ( P<0.001 ) . Non-recovery after whiplash was associated with initially reduced cold pressor pain endurance and increased peak pain , suggesting that dysfunction of central pain modulating control systems plays a role in chronic pain after acute whiplash injury OBJECTIVE Recently , pharmacological treatment guidelines for panic disorder have changed as newer treatment options have become available . The authors examined how the use of psychotropic drugs has shifted over the course of 10 years to determine if prescribing patterns have changed to reflect these revised treatment guidelines . METHOD A total of 443 patients with panic disorder were enrolled in the Harvard/Brown Anxiety Research Project , a prospect i ve longitudinal study of anxiety disorders . These patients were interviewed over the course of 10 years to examine their use of psychotropic medications . RESULTS Despite efforts aim ed at increasing the use of selective serotonin reuptake inhibitors ( SSRIs ) in patients with panic disorder ( e.g. , APA 's practice guideline for panic disorder , Food and Drug Administration approval of particular SSRIs for the treatment of panic disorder ) , only a modest increase in their use was found . Treatment patterns for psychotropic drugs  appear to have remained stable over the past decade , with benzodiazepines being the most commonly used medication for panic disorder . In comparison , SSRI use throughout the follow-up period has remained low . Patients using an SSRI did not have a more favorable clinical course than those using a benzodiazepine , nor were there significantly better rates of remission in patients using SSRIs and benzodiazepines concomitantly . CONCLUSIONS These results highlight a gap between pharmacological treatment guidelines and actual delivery of care in that recommendations to use SSRIs to treat panic disorder are not being followed . Factors potentially associated with promoting and ignoring treatment recommendations are discussed BACKGROUND A large proportion of people with depression and anxiety go unrecognised by their general practitioner ( GP ) . Case-finding does not appear to be effective on its own . AIM To compare the effectiveness of case-finding followed by computer-generated patient-specific guidelines with usual care for the management of common mental disorders in primary care . DESIGN OF STUDY Individual patient r and omised controlled trial . SETTING Five general practice s in Bristol and Cardiff . METHOD 762 individuals aged > /= 16 years scoring > /= 12 on the Clinical Interview Schedule Revised were r and omised . The experimental intervention required participants to complete a  computerised psychosocial assessment that generated a report for the GP including patient-specific treatment recommendations . The control patients were treated as usual with access to locally agreed guidelines . RESULTS Participants ' 12-item General Health Question naire ( GHQ ) score dropped irrespective of treatment allocation . The experimental group had a significantly lower GHQ score at 6 weeks , but not at 6 months . Recovery at 6 months was 3 % greater among those receiving the experimental intervention ( 95 % confidence interval [ CI ] = -4 to 10 ) . Treatment was not significantly associated with quality of life or patient satisfaction . CONCLUSION Only small benefits are likely from using case-finding followed by patient-specific guidelines to improve clinical management of common mental disorders in primary care . However , depression and anxiety are important public health problems so the utility of such systems should be further investigated OBJECTIVE This executive summary presents in brief the current evidence assessed in the clinical practice guideline prepared by the Canadian Hypertensive Disorders of Pregnancy Working Group and published by Pregnancy Hypertension ( http://www.pregnancyhypertension.org/article/S2210-7789(14)00004-X/fulltext ) to provide a reasonable approach to the diagnosis , evaluation , and treatment of the hypertensive disorders of pregnancy . EVIDENCE Published literature was retrieved through search es of Medline , CINAHL , and The Cochrane Library in March 2012 using appropriate controlled vocabulary ( e.g. , pregnancy , hypertension , pre-eclampsia , pregnancy toxemias ) and key words ( e.g. , diagnosis , evaluation , classification , prediction , prevention , prognosis , treatment , postpartum follow-up ) . Results were restricted to systematic review s , r and omized control trials , controlled clinical trials , and observational studies published in French or English between January 2006 and February 2012 . Search es were up date d on a regular basis and incorporated in the guideline to September 2013 . Grey ( unpublished ) literature was identified through search ing the websites of health technology assessment and health technology-related agencies , clinical practice guideline collection s , clinical trial registries , and national and international medical specialty societies . VALUES The quality of evidence in the guideline summarized here was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care ( Table 1 ) BACKGROUND Many patients with chronic whiplash-associated disorders have reduced neuromuscular control of the neck and head . It has been proposed that a new sling exercise therapy may promote neuromuscular control of the neck . OBJECTIVES To compare the effects of traditional physiotherapy vs traditional physiotherapy combined with a new sling exercise therapy on discomfort and function in patients with chronic whiplash-associated disorders who have unsettled compensation cl aims ; and to investigate possible additional effects of guided , long-term home training . DESIGN A r and omized multi-centre trial with 4 parallel groups . METHODS A total of 214 patients were assigned r and omly to 4 treatment groups , and received either traditional physiotherapy with or without home training , or new sling exercise therapy with or without home training . Outcome measures were pain , disability , psychological distress , sick leave and physical tests . RESULTS A total of 171 patients ( 80 % ) completed the study . There were no important statistical or clinical differences between the groups after 4 months of treatment . There was a small statistically significant effect at 12-month follow-up in both groups with home training regarding pain during rest ( p = 0.05 ) and reported fatigue in the final week ( p = 0.02 ) . CONCLUSION No statistically significant differences were found between the traditional physiotherapy group and the new sling exercise group , with or without home training . Since the groups were not compared with a control group without treatment , we can not conclude that the studied treatments are effective for patients with whiplash-associated disorder , only that they did not differ in our study Background Whiplash injuries are an important public health problem that is associated with significant disability and high health care utilization . Recent cohort studies suggest that physician care may be the most effective treatment for patients with whiplash-associated disorders . However , these findings have not been tested in a r and omized controlled trial . The purpose of this study is to determine which of physician care or two rehabilitation programs of care is most effective in improving recovery of patients with recent whiplash associated disorders . Methods and Design We design ed a pragmatic r and omized clinical trial . A total of 444 participants ( 148 in each of three arms ) who reside in Southern Ontario , Canada will be recruited from a large insurer . We will include individuals who are 18 years of age or older and who are diagnosed with Grade I or II Whiplash-associated Disorders . Participants will be r and omized to  physician-based education and activation or one of two rehabilitation programs of care currently in use in Ontario . Our primary outcome , self-rated global recovery and all secondary outcomes ( neck pain intensity , whiplash disability , health-related quality of life , depressive symptomatology and satisfaction with care ) will be measured at baseline by a trial coordinator and at 6 weeks , 3 , 6 , 9 and 12 months follow-up by an interviewer who is blind to the participants ' baseline characteristics and treatment allocation . We will also collect information on general health status , other injuries , comorbidities , expectation of recovery , work status , pain coping , legal representation , and co- interventions . The primary intention-to-treat analysis will compare time to recovery between the three interventions . This trial will have 90 % power at an alpha of 0.05 to detect a 20 % difference in the rate of perceived recovery at one year . Secondary analyses will compare the health outcomes , rate of recurrence and the rate of adverse events between intervention groups . Conclusion The results of this study will provide the public , clinicians and policy makers much needed evidence on the effectiveness of common approaches used to manage whiplash-associated disorders . Trial registration Clinical Trials.gov identifier OBJECTIVE To evaluate the relative effectiveness of computer and manual reminder systems on the implementation of a clinical practice guideline . DESIGN Seventy-eight out patients in a mental health clinic were r and omly assigned within clinician to one of the two reminder systems . The computer system , called CaseWalker , reminded clinicians when guideline -recommended screening for mood disorder was due , ensured the fidelity of the diagnosis of major depressive disorder to criteria of the Diagnostic and Statistical Manual of Mental Disorders , 4th edition ( DSM-IV ) , and generated a progress note . The manual system was a checklist inserted in the paper medical record . MEASURES Screening rates for mood disorder and the completeness of the documentation of which DSM-IV criteria were met by patients who were said to have major depressive disorder were compared . RESULTS The CaseWalker , compared with the paper checklist , result ed in a higher screening rate for mood disorder ( 86.5 vs. 61 percent , P = 0.008 ) and a higher rate of complete documentation of DSM-IV criteria ( 100 vs. 5.6 percent , P < 0.001 ) . CONCLUSIONS In an outpatient mental health clinic , computer reminders were shown to be superior to manual reminders in improving adherence to a clinical practice guideline for depression Study Design . A r and omized controlled trial with 3 and 6 months follow-up . Objective . To compare the effectiveness of acupuncture with simulated acupuncture in patients with subacute and chronic whiplash-associated disorders . Summary of Background Data . Acupuncture is widely used for the treatment of neck and other musculoskeletal pain , and there is some evidence supporting its effectiveness for short-term pain relief . The effectiveness of acupuncture in the treatment of whiplash-associated disorders is not clear . Methods . A total of 124 patients between 18 and 65 years with chronic ( 85 % ) or subacute whiplash-associated disorders ( Grade I or II ) were r and omly allocated to real or simulated electroacupuncture treatment for 12 sessions during a 6-week period . Both treatments involved skin penetration with acupuncture needles and were provided by a single university-trained acupuncturist in a University Clinic in Sydney , Australia . Primary outcome measures were pain intensity ( 10-cm visual analog scale ) , disability ( Neck Disability Index ) , and health-related quality of life ( SF-36 ) . Secondary outcomes were patient-specific activity scales , and the McGill Pain Rating Index . Results . Mean initial pain intensity for all participants was 5.6 cm . Participants receiving the real electroacupuncture treatment had significantly greater reduction in pain intensity at 3 and 6 months , 0.9 cm ( P = 0.05 ) and 1.3 cm ( P = 0.007 ) , respectively , in comparison to the sham electro-acupuncture group . After adjustment for baseline status , there was no significant reduction in disability , or improvement in health-related quality of life . There was an improvement in the activity scales of a similar size to the reduction in pain , but no difference in the McGill Index . Conclusion . Real electroacupuncture was associated with a significant reduction in pain intensity over at least 6 months . This reduction was probably not clinical ly significant . There was no improvement in disability or quality of life 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 The past decade has brought major new developments in the psychopharmacologic management of generalized anxiety disorder and social phobia . We examined medication-prescribing patterns for the treatment of these anxiety disorders for 12 years to assess changes in patients ' anti-anxiety psychotropic medication usage during that period of evolving practice guidelines . We examined psychotropic medication use in 305 patients with generalized anxiety disorder and 232 with social phobia enrolled in the Harvard/Brown Anxiety Disorders Research Project ( HARP ) , a prospect i ve , longitudinal study of anxiety disorders .  Psychotropic treatment patterns seem to have remained relatively stable over 12 years with benzodiazepines the medications most commonly used for both generalized anxiety disorder and social phobia . Comparatively , selective serotonin reuptake inhibitor ( SSRI ) and venlafaxine usage as st and -alone medications for these disorders remained low throughout the follow-up period . At the 12-year follow-up , 24 % of patients with generalized anxiety disorder and 30 % of patients with social phobia were utilizing neither an  SSRI/selective norepinephrine reuptake inhibitor ( SNRI ) nor a benzodiazepine . Treatment recommendations for use of SSRIs and venlafaxine in the management of generalized anxiety disorder and social phobia initially promulgated in 1998 had a modest impact on changes in psychopharmacologic practice 4 - 5 years later . Difficulties in the implementation of treatment guidelines are discussed Abstract Objective : To investigate the effect of clinical guidelines on the management of  infertility  across the primary care- secondary care interface . Design : Cluster r and omised controlled trial . Setting : General practice s and NHS hospitals accepting referrals for infertility in the Greater Glasgow Health Board area . Participants : All 221 general practice s in Glasgow ; 214 completed the trial . Intervention : General practice s in the intervention arm received clinical guidelines developed locally . Control practice s received them one year later . Dissemination of the guidelines included educational meetings . Main outcome measures : The time from presentation to referral , investigations completed in general practice , the number and content of visits as a hospital outpatient , the time to reach a management plan , and costs for referrals from the two groups . Results : Data on 689 referrals were collected . No significant difference was found in referral rates for infertility . Fewer than 1 % of couples were referred inappropriately early . Referrals from intervention practice s were significantly more likely to have all relevant investigations carried out ( odds ratio 1.32 , 95 % confidence interval 1.00 to 1.75 , P=0.025 ) . 70 % of measurements of serum progesterone concentrations during the midluteal phase and 34 % of semen analyses were repeated at least once in hospital , despite having been recorded as normal when checked in general practice . No difference was found in the proportion of referrals in which a management plan was reached within one year or in the mean duration between first appointment and date of management plan . NHS costs were not significantly affected . Conclusions : Dissemination of infertility guidelines by commonly used methods results in a modest increase in referrals having recommended investigations completed in general practice , but there are no detectable differences in outcome for patients or reduction in costs . Clinicians in secondary care tended to fail to respond to changes in referral practice by doctors . Guidelines that aim to improve the referral process need to be disseminated and implemented so as to lead to changes in both primary care and secondary care . What is already known on this topic Most previous research into clinical guidelines has focused on their development and implementation Evidence is lacking about the outcomes and costs associated with the use of clinical guidelines What this study adds Clinical guidelines that may alter the balance of care between general practice and hospital setting s require more intensive implementation than guidelines aim ed at either setting on its own The cost effectiveness of clinical guidelines should not be OBJECTIVE : The effect of clinical guidelines on re source utilization for complex conditions with substantial barriers to clinician behavior change has not been well studied . We report the impact of a multifaceted guideline implementation intervention on primary care clinician utilization of radiologic and specialty services for the care of acute low back pain . DESIGN : Physician groups were r and omized to receive guideline education and individual feedback , supporting patient education material s , both , or neither . The impact on guideline adherence and re source utilization was evaluated during the 12-month period before and after implementation . PARTICIPANTS : Fourteen physician groups with 120 primary care physician and associate practitioners from 2 group model HMO practice s. INTERVENTIONS : Guideline implementation utilized an education/audit/feedback model with local peer opinion leaders . The patient education component included written and videotaped material s on the care of low back pain . MAIN RESULTS : The clinician intervention was associated with an absolute increase in guideline -consistent behavior of 5.4 % in the intervention group versus a decline of 2.7 % in the control group ( P=.04 ) . The patient education intervention produced no significant change in guideline -consistent behavior , but was poorly adopted . Patient characteristics including duration of pain , prior history of low back pain , and number of visits during the illness episode were strong predictors of service utilization and guideline -consistent behavior . CONCLUSIONS : Implementation of an education and feedback-supported acute low back pain care guideline for primary care clinicians was associated with an increase in guideline -consistent behavior . Patient education material s did not enhance guideline effectiveness . Implementation barriers could limit the utility of this approach in usual care setting PURPOSE  Pain and symptom management  is an integral part of the clinical practice of oncology . A number of guidelines have been developed to assist the clinician in optimizing comfort care . We implemented clinical guidelines for cancer pain management in the community setting and evaluated whether these guidelines improved care . PATIENTS AND METHODS Eighty-one cancer patients , aged 37 to 76 years , were enrolled onto a prospect i ve , longitudinal , r and omized controlled study from the outpatient clinic setting s of 26 western Washington-area medical oncologists . A multilevel treatment algorithm based on the Agency for Health Care Policy and Research Guidelines for Cancer Pain Management was compared with st and ard- practice ( control ) pain and symptom management therapies used by community oncologists . The primary outcome of interest was pain ( Brief Pain Inventory ) ; secondary outcomes of interest were all other symptoms ( Memorial Symptom Assessment Scale ) and quality of life ( Functional Assessment of Cancer Therapy Scale ) . RESULTS Patients r and omized to the pain algorithm group achieved a statistically significant reduction in usual pain intensity , measured as slope scores , when compared with st and ard community practice ( P < .02 ) . Concurrent chemotherapy and patient adherence to treatment were significant mediators of worst pain . There were no significant differences in other symptoms or quality of life between the two treatment groups . CONCLUSION This guideline implementation study supports the use of algorithmic decision making in the management of cancer pain . These findings suggest that comprehensive pain assessment and evidence -based analgesic decision-making processes do enhance usual pain outcomes Background The purpose of this report is to provide a succinct but comprehensive summary of the scientific evidence regarding the effectiveness of manual treatment for the management of a variety of musculoskeletal and non-musculoskeletal conditions . Methods The conclusions are based on the results of systematic review s of r and omized clinical trials ( RCTs ) , widely accepted and primarily UK and United States evidence -based clinical guidelines , plus the results of all RCTs not yet included in the first three categories . The strength/ quality of the evidence regarding effectiveness was based on an adapted version of the grading system developed by the US Preventive Services Task Force and a study risk of bias assessment tool for the recent RCTs . Results By September 2009 , 26 categories of conditions were located containing RCT evidence for the use of manual therapy :  13 musculoskeletal conditions , four types of chronic headache and nine non-musculoskeletal conditions . We identified 49 recent relevant systematic review s and 16 evidence -based clinical guidelines plus an additional 46 RCTs not yet included in systematic review s and guidelines .Additionally , brief references are made to other effective non-pharmacological , non-invasive physical treatments . Conclusions Spinal manipulation/mobilization is effective in adults for : acute , subacute , and chronic low back pain ; migraine and cervicogenic headache ; cervicogenic dizziness ;  manipulation/mobilization is effective for several extremity joint conditions ; and thoracic manipulation/mobilization is effective for acute/subacute neck pain . The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration , and for manipulation/mobilization for mid back pain , sciatica , tension-type headache , coccydynia , temporom and ibular joint disorders , fibromyalgia , premenstrual syndrome , and pneumonia in older adults . Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation , or for Stage 1 hypertension when added to an antihypertensive diet . In children , the evidence is inconclusive regarding the effectiveness for otitis media and enuresis , and it is not effective for infantile colic and asthma when compared to sham manipulation . Massage is effective in adults for  chronic low back pain and chronic neck pain . The evidence is inconclusive for knee osteoarthritis , fibromyalgia , myofascial pain syndrome , migraine headache , and premenstrual syndrome . In children , the evidence is inconclusive for asthma and infantile colic OBJECTIVE The aim was to formulate practice guidelines on the management of  hyperglycemia in hospitalized patients in the non-critical care setting . PARTICIPANTS The Task Force was composed of a chair , selected by the Clinical Guidelines Subcommittee of The Endocrine Society , six additional experts , and a method ologist . EVIDENCE This evidence -based guideline was developed using the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) system to describe both the strength of recommendations and the quality of evidence . CONSENSUS PROCESS One group meeting , several conference calls , and e-mail communications enabled consensus . Endocrine Society members , American Diabetes Association , American Heart Association , American Association of Diabetes Educators , European Society of Endocrinology , and the Society of Hospital Medicine review ed and commented on preliminary drafts of this guideline . CONCLUSIONS Hyperglycemia is a common , serious , and costly health care problem in hospitalized patients . Observational and r and omized controlled studies indicate that improvement in glycemic control results in lower rates of hospital complications in general medicine and surgery patients . Implementing a st and ardized sc insulin order set promoting the use of scheduled basal and nutritional insulin therapy is a key intervention in the inpatient management of diabetes . We provide recommendations for practical , achievable , and safe glycemic targets and describe protocol s , procedures , and system improvements required to facilitate the achievement of glycemic goals in patients with hyperglycemia and diabetes admitted in non-critical care setting Background Evidence generated from reliable research is not frequently implemented into clinical practice . Evidence -based clinical practice guidelines are a potential vehicle to achieve this . A recent systematic review of implementation strategies of guideline dissemination concluded that there was a lack of evidence regarding effective strategies to promote the uptake of guidelines . Recommendations from this review , and other studies , have suggested the use of interventions that are theoretically based because these may be more effective than those that are not . An evidence -based clinical practice guideline for the management of acute low back pain was recently developed in Australia . This provides an opportunity to develop and test a theory-based implementation intervention for a condition which is common , has a high burden , and for which there is an evidence - practice gap in the primary care setting . Aim This study aims to test the effectiveness of a theory-based intervention for implementing a clinical practice guideline for acute low back pain in general practice in Victoria , Australia . Specifically , our primary objectives are to establish if the intervention is effective in reducing the percentage of patients who are referred for a plain x-ray  , and improving mean level of disability for patients three months post-consultation . Methods / Design This study protocol describes the details of a cluster r and omised controlled trial . Ninety-two general practice s ( clusters ) , which include at least one consenting general practitioner , will be r and omised to an intervention or control arm using restricted r and omisation . Patients aged 18 years or older who visit a participating practitioner for acute non-specific low back pain of less than three months duration will be eligible for inclusion . An average of twenty-five patients per general practice will be recruited , providing a total of 2,300 patient participants . General practitioners in the control arm will receive access to the guideline using the existing dissemination strategy . Practitioners in the intervention arm will be invited to participate in facilitated face-to-face workshops that have been underpinned by behavioural theory . Investigators ( not involved in the delivery of the intervention ) , patients , outcome assessors and the study statistician will be blinded to group allocation . Trial registration Australian New Zeal and Clinical Trials Registry ACTRN012606000098538 ( date registered 14/03/2006 ) Objective : To evaluate the effects of a physical training programme which is supervised and tailored to meet the needs of patients with subacute whiplash-associated disorders . Design : A r and omized controlled trial with follow-up at three and nine months after r and omization . Setting : An interdisciplinary rehabilitation centre . Subjects : Forty-seven patients with subacute disorders following a whiplash trauma . Interventions : Patients were r and omized to a supervised training group or a self-administered home training group . Main measures : Primary outcome measures were the Self-Efficacy Scale , the Tampa Scale for Kinesiophobia and the Pain Disability Index . Secondary outcome measures were neck pain intensity , sensory and affective dimensions of pain , pain location and duration , muscle tenderness , grip strength , cervical mobility , sick leave and analgesic consumption . Results : Forty patients ( 85 % ) completed the intervention period , and the drop-outs were followed up by intention-to-treat . The results showed that supervised training was significantly more favourable than home training , with a more rapid improvement in self-efficacy ( P=0.03 ) , fear of movement/(re)injury ( P=0.03 ) and pain disability ( P=0.03 ) at three months . Further , supervised training significantly reduced the frequency of analgesic consumption ( P=0.03 ) . The improvements were partly maintained at nine months , even though there was no amelioration in pain and physical disorders . Despite the favourable outcome , supervised intervention did not reduce sick leave . Conclusions : The findings indicate a treatment approach that is feasible in the rehabilitation of patients with subacute whiplash-associated disorders in the short term , but additional research is needed to extend these findings and eluci date treatment strategies that also are cost effective Background Variability between clinical practice guideline recommendations and actual clinical practice exists in many areas of health care . A 2004 systematic review examining the effectiveness of guideline implementation interventions concluded there was a lack of evidence to support decisions about effective interventions to promote the uptake of guidelines . Further , the review recommended the use of theory in the development of implementation interventions . A clinical practice guideline for the management of acute low-back pain has been developed in Australia ( 2003 ) . Acute low-back pain is a common condition , has a high burden , and there is some indication of an evidence - practice gap in the allied health setting . This provides an opportunity to develop and test a theory-based implementation intervention which , if effective , may provide benefits for patients with this condition . Aims This study aims to estimate the effectiveness of a theory-based intervention  to increase allied health practitioners ' ( physiotherapists and chiropractors in Victoria , Australia ) compliance with a clinical practice guideline for acute non-specific low back pain ( LBP ) , compared with providing practitioners with a printed copy of the guideline . Specifically , our primary objectives are to establish if the intervention is effective in reducing the percentage of acute non-specific LBP patients who are either referred for or receive an x-ray  , and improving mean level of disability for patients three months post-onset of acute LBP . Methods The design of the study is a cluster r and omised trial . Restricted r and omisation was used to r and omise 210 practice s ( clusters ) to an intervention or control group . Practitioners in the control group received a printed copy of the guideline . Practitioners in the intervention group received a theory-based intervention developed to address prospect ively identified barriers to practitioner compliance with the guideline . The intervention primarily consisted of an educational symposium .  Patients aged 18 years or older who visit a participating practitioner for acute non-specific LBP of less than three months duration over a two-week data collection period , three months post the intervention symposia , are eligible for inclusion . Sample size calculations are based on recruiting between 15 to 40 patients per practice . Outcome assessors will be blinded to group allocation . Trial registration Australian New Zeal and Clinical Trials Registry ACTRN12609001022257 ( date registered 25th November 2009 Background Anxiety and depressive disorders are highly prevalent disorders and are mostly treated in primary care . The management of these disorders by general practitioners is not always consistent with prevailing guidelines because of a variety of factors . Design ing implementation strategies tailored to prospect ively identified barriers could lead to more guideline -recommended care . Although tailoring of implementation strategies is promoted in practice , little is known about the effect on improving the quality of care for the early recognition , diagnosis , and stepped care treatment allocation in patients with anxiety or depressive disorders in general practice . This study examines whether the tailored strategy supplemented with training and feedback is more effective than providing training and feedback alone . Methods In this cluster r and omised controlled trial , a total of 22 general practice s will be assigned to one of two conditions : ( 1 ) training , feedback , and tailored interventions and ( 2 ) training and feedback . The primary outcome measure is the proportion of patients who have been recognised to have anxiety and /or depressive disorder .  The secondary outcome measures in patients are severity of anxiety and depressive symptoms , level of functioning , expectation towards and experience with care , quality of life , and economic costs . Measures are taken after the start of the intervention at baseline and at three- and six-month follow-ups . Secondary outcome measures in general practitioners are adherence to guideline -recommended care in care that has been delivered , the proportion of antidepressant prescriptions , and number of referrals to specialised mental healthcare facilities . Data will be gathered from the electronic medical patient records from the patients included in the study . In a process evaluation , the identification of barriers to change and the relations between prospect ively identified barriers and improvement interventions selected for use will be described , as well as the factors that influence the provision of guideline -recommended care . Discussion It is hypothesised that the adherence to guideline recommendations will be improved by design ing implementation interventions that are tailored to prospect ively identified barriers in the local context of general practitioners . Currently , there is insufficient evidence on the most effective and efficient approaches to tailoring , including how barriers should be identified and how interventions should be selected to address the barriers . Trial registration Objective . The aim of this study was to investigate the effect of a specific therapeutic jaw exercise on the temporom and ibular disorders of patients with chronic whiplash-associated disorders . Material and methods . Ninety-four consecutive patients with whiplash-related conditions were referred to and accepted for a treatment period at a center for functional evaluation and rehabilitation during 2001–2002 . The patients followed a program of physical therapy , occupational therapy , and pain management . At the start of their stay , they were examined by a physician specialized in rehabilitation medicine and also by a dentist who performed a functional examination of the stomatognathic system . Of the 93 patients who accepted participation in the study , 55 were diagnosed with temporom and ibular disorders and chronic whiplash-associated disorders in accordance with the inclusion criteria . They were r and omized into a jaw exercise group ( n=25 ) , who performed specific therapeutic jaw exercises , and a control group ( n=30 ) . Both groups undertook the whiplash rehabilitation program at the center . Results . There were no inter- or intra-group differences in symptoms and signs of temporom and ibular disorders at baseline , nor at the 3-week and 6-month follow-ups , except for an increase of maximum active mouth-opening capacity in the control group . Conclusions . In conclusion , the therapeutic jaw exercises , in addition to the regular whiplash rehabilitation program , did not reduce symptoms and signs of temporom and ibular disorders in patients with chronic whiplash-associated disorders 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 BACKGROUND Whiplash concerns a considerable problem to health care . Available evidence from systematic review s indicates beneficial effects of active interventions for patients with whiplash injury . In order to evaluate whether a general practitioner or a physiotherapist should provide these active interventions , we have design ed a r and omized clinical trial . OBJECTIVE The purpose of this article is to present the design of the trial and to provide transparency into the dynamic treatment protocol used . PATIENTS Patients with whiplash-associated disorders grade I and II who still have symptoms and disabilities 4 weeks after the accident . INTERVENTIONS A dynamic treatment protocol consisting of 4 different sub protocol s. The primary aim is to increase their activities and to improve their quality of life . Content and intensity of treatment are described . Outcome measures The primary outcome measures are pain and disability . The short-term effects are measured at 12 weeks and long-term effects at 1 year after the trauma . CONCLUSION To date , generally the effect of one intervention compared to another intervention has been examined . In our opinion , this can not be considered as usual care for physiotherapy or general practice . Therefore , a dynamic treatment protocol has been developed to structure the black box of usual physiotherapy and general practice treatment . The results of this trial will be available in 0.5 year & 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 BACKGROUND CONTEXT The process through which new scientific developments are incorporated into clinical practice is referred to as " knowledge transfer " and is currently the subject of great interest in many areas of clinical medicine . Family physicians managing patients with acute low back pain have been shown to have a poor overall rate of concordance with clinical practice guideline -recommended treatments . New methods need to be developed to help physicians bridge the guideline implementation gap . PURPOSE To determine the efficacy of a knowledge transfer method that communicates clinical practice guidelines to family physicians and their patients using patient-specific , physician-to-physician communications . STUDY DESIGN A prospect i ve r and omized controlled study . PATIENT SAMPLE 428 patients with acute mechanical low back pain and accepted Workers ' Compensation Board cl aims were studied . OUTCOME MEASURES Concordance with specific clinical practice guideline -derived history taking items , physical examination procedures and treatment recommendations was determined . METHODS Patients with acute mechanical back pain of less than 4 weeks duration and accepted Workers ' Compensation Board cl aims were r and omly assigned to one of three groups . In Group 1 ( control group ) neither the patients nor their family physicians received any information concerning the guidelines . In Group 2 , family physicians alone or as well as their patients ( Group 3 ) received a summary of clinical practice guidelines at approximately 2 weeks postinjury . In addition , both Groups 2 and 3 received reminders summarizing the recommended guidelines for patients at three specific stages of their clinical course . All guideline correspondence was addressed to a specific family physician or patient , signed by the study physician-investigators , and specified the patient by name . RESULTS Family physicians in the control and intervention groups demonstrated a high degree of concordance with the guideline -recommended history taking and physical examination procedures , but were generally highly discordant with guideline -recommended treatments . Significant improvement in guideline -concordant treatments was seen only with diminished recommendations of prolonged bed rest and passive therapies and an increase in recommended aerobic exercise . Concordance with guideline recommendations relating to the use of spinal manipulative therapy was poor in all study groups . CONCLUSIONS A knowledge transfer method that involved patient-specific , physician-to-physician communication to family physicians or their patients at three stages of the patient 's clinical course was largely unsuccessful in improving concordance with guideline treatment recommendations BACKGROUND The release of the Agency for Health Care Policy and Research ( AHCPR ) 's Guideline for the Detection and Treatment of Depression in Primary Care created an opportunity to evaluate under naturalistic conditions the effectiveness of two clinical practice guideline implementation methods : continuous quality improvement ( CQI ) and academic detailing . A study conducted in 1993 - 1994 at Kaiser Permanente Northwest Division , a large , not-for-profit prepaid group practice ( group-model ) HMO , tested the hypotheses that each method would increase the number of members receiving depression treatment and would relieve depressive symptoms . METHODS Two trials were conducted simultaneously among adult primary care physicians , physician assistants , and nurse practitioners , using the same guideline document , measurement methods , and one-year follow-up period . The academic detailing trial was r and omized at the clinician level . CQI was assigned to one of the setting 's two geographic areas . To account for intraclinician correlation , both trials were evaluated using generalized equations analysis . RESULTS Most of the CQI team 's recommendations were not implemented . Academic detailing  increased treatment rates , but -- in a cohort of patients with probable chronic depressive disorder -- it failed to improve symptoms and reduced measures of overall functional status . CONCLUSIONS New organizational structures may be necessary before CQI teams and academic detailing can substantially change complex processes such as the primary care of depression . New research and treatment guidelines are needed to improve the management of persons with chronic or recurring major depressive disorder The direct and indirect costs of low back pain , one of the most common symptoms in adults , are estimated at $ 60 billion annually in the United States [ 1 , 2 ] . Practice guidelines recently developed in the United States recommend spinal manipulation for patients with uncomplicated acute low back pain [ 3 ] . If followed , these guidelines can be expected to significantly increase the number of patients referred by medical physicians to chiropractors , who provide most manipulative therapy delivered in the United States [ 4 ] . Concerns have been raised about the quality of chiropractic care [ 5 ] , but systematic data are lacking . How are patients and medical physicians to have confidence in chiropractors in the absence of data on the quality of chiropractic care ? To assess the appropriateness of the use of spinal manipulation for patients with low back pain , we used a method for assessing appropriateness that has been used to study various medical procedures in North America and Europe [ 6 - 16 ] . In these studies , predetermined criteria for the appropriateness ( as defined by expected risk versus benefit ) of the study procedure ( for example , hysterectomy or coronary angioplasty ) are used to retrospectively assess the care delivered . We report the results of our evaluation of the use of chiropractic spinal manipulation at five geographic sites in the United States and one site in Canada . Methods Development of Appropriateness Criteria and Record Abstract ion System For our study , spinal manipulation was defined as a manual procedure that involves specific short-lever dynamic thrusts ( or spinal adjustments ) or nonspecific long-lever manipulation . Nonthrust procedures , such as flexion-distraction and mobilization , were not considered part of manipulative therapy . The development of appropriateness criteria for spinal manipulation for low back pain has been described in detail elsewhere [ 17 ] . In brief , we first performed a systematic review of the literature . A 9-member panel of back experts was convened , consisting of 3 chiropractors , 2 orthopedic spine surgeons , 1 osteopathic spine surgeon , 1 neurologist , 1 internist , and 1 family practitioner . Six panel members were in academic practice , 3 were in private practice , and 4 performed spinal manipulation as part of their practice . The panel members represented all major geographic regions of the United States . The panel used a scale of expected risk and benefit ( ranging from 1 to 9 ) to rate the appropriateness of a comprehensive array of indications , or clinical scenarios , in patients who might present to a chiropractor 's office . We defined appropriate as an indication for which the expected health benefits exceeded the expected health risks by a sufficiently wide margin that spinal manipulation was worth doing . We used a formal group-judgment process , which incorporated two rounds of ratings , a group discussion , and feedback of group ratings between rounds . Experts were to use their best clinical judgment in addition to the evidence from the systematic review we presented them . Panel disagreement on an indication occurred when two or more panelists rated the indication as appropriate and two or more panelists rated it as inappropriate . This definition of disagreement is arbitrary but is based on a face-value assessment of what constitutes disagreement among experts . The final result of the process is a rating of appropriate , inappropriate , or uncertain ( depending on net expected health benefits ) for each indication . Indications with a median panel rating of 7 to 9 , without disagreement , were classified as appropriate . Indications with a median panel rating of 1 to 3 , without disagreement , were classified as inappropriate . Indications with a median panel rating of 4 to 6 and all indications with disagreement were classified as uncertain . The panel of experts met in April 1990 , before the beginning of the Agency for Health Care Policy and Research ( AHCPR ) Low Back Problems Clinical Practice Guideline effort in 1992 . Four members of our panel later participated in the AHCPR process . The AHCPR guidelines cover patients with acute and subacute low back pain only and are similar to the appropriateness criteria created for our project . We developed a chiropractic record abstract ion system that allows collection of data from a chiropractic office record about the patient , history of the back problem , findings on physical examination and diagnostic studies , and treatment rendered . The system is design ed to collect sufficient information to allow the classification of delivered care as appropriate , inappropriate , or uncertain , according to the panel 's ratings . The abstract ion instrument collects data on more than 70 clinical variables that may be present in the record . The instrument uses skip-pattern logic so that only relevant clinical variables are sought . For example , if the patient 's onset of back pain was associated with trauma , additional information about the type of trauma was sought . We pilot-tested our system on numerous chiropractic records obtained from colleagues around the United States and pilot-tested our methods for data collection and analysis on a small sample of chiropractors in southern California [ 18 ] . Identification of Sample We chose San Diego , California ; Portl and , Oregon ; Vancouver , Washington ; Minneapolis-St . Paul , Minnesota ; Miami , Florida ; and Toronto , Ontario , Canada , as sites for our study because of their geographic diversity and because they reflect a varying concentration of practicing chiropractors and differ in the chiropractic scope of practice allowed . We also included the rural areas surrounding the Portl and , Minneapolis-St . Paul , and Toronto areas . We have previously shown that the base population s at the U.S. sites are similar to the general U.S. population in terms of the variables known to affect chiropractic use [ 19 ] . The geographic sampling area around Toronto encompasses 75 % of the population of Ontario . At each site , we constructed our sampling frame from a combination of the telephone book yellow pages , the state or provincial board licensing list , and the mailing list of the local chiropractic college , if any . The final list was the summation ( excluding duplicates ) of the individual lists . We drew a r and om sample from this list and sent the sample d chiropractors a letter that explained the study and invited them to participate . Each letter was accompanied by cover letters from the national chiropractic association and the local chiropractic association or chiropractic college , indicating support for the study . We followed this mailing with a telephone call to determine eligibility and request participation . To be eligible , a chiropractor must have been practicing in the geographic area since 1990 . Eligible chiropractors who declined our initial invitation were contacted by one or more influential state , provincial , or local chiropractors and were again urged to participate . Participating chiropractors and their staff were given , in total , a $ 130 ( in both U.S. and Canadian dollars ) honorarium for participation . Data Collection Trained chiropractic data collectors ( senior chiropractic students or recent graduates ) visited participating chiropractors during regular working hours . These data collectors underwent 2 days of training conducted by two of the authors . The data collectors were unaware of the details of the appropriateness criteria . The reliability and accuracy of the data collection were assessed in several ways . First , after classroom training , the data collectors abstract ed a common set of test records obtained from various different practice s and geographic areas . These were returned to one of the authors for correction , and any errors in abstract ion were review ed with the data collectors . Second , the same author accompanied the data collectors on a practice session with a local volunteer chiropractor , who agreed to let the collectors practice sampling and data abstract ion in his or her office during working hours . Again , errors in either process were review ed with the data collectors . Finally , the same author accompanied the data collectors on one of the early office visits to a chiropractor included in the sample at each geographic site . Here , the author review ed all abstract ed records ; if more than one data collector was working , both data collectors abstract ed a few records . Any discrepancies were review ed with this author . In all , about 4 % of records included in the sample were assessed for reliability and validity . We did not calculate formal reliability statistics . To select records , all office records were measured in inches as if they were books on a shelf . A r and om-number table was used to select a r and om number of inches measured from the start . To avoid fat-chart bias , we selected the record immediately to the right of the record located at the specified number of inches . This chart was then pulled and examined to see whether it described a first visit for low back pain that occurred between 1 January 1985 and 31 December 1991 . If so , data were abstract ed by using the research instrument . This process was repeated until 10 records for low back pain were abstract ed from each participating practitioner 's office . If more than one chiropractor practice d in the same office , we abstract ed data from the records of only one practitioner . Consultation with back pain experts suggested that 10 records per office is a sufficient number that is likely to fairly represent the diversity of that office 's practice . Data Analysis We compiled descriptive data on the patients and the care that they received . The care of patients was classified into appropriateness categories by using the criteria determined by the expert panel . This was done with a computer program that uses unique combinations of variables that define individual indications . The reliability of this program was verified by drawing a r and om sample of records and Background Anxiety is a common mental health problem seen in primary care . However , its management in clinical practice varies greatly . Clinical practice guidelines ( CPGs ) have the potential to reduce variations and improve the care received by patients by promoting interventions of proven benefit . However , uptake and adherence to their recommendations can be low . Method / design This study involves a community based on cluster r and omized trial in primary healthcare centres in the Madrid Region ( Spain ) . The project aims to determine whether the use of implementation strategy ( including training session , information , opinion leader , reminders , audit , and feed-back ) of CPG for patients with anxiety disorders in primary care is more effective than usual diffusion . The number of patients required is 296 ( 148 in each arm ) , all older than 18 years and diagnosed with generalized anxiety disorder , panic disorder , and panic attacks by the Diagnostic and Statistical Manual of Mental Disorders-IV ( DSM-IV ) . They are chosen by consecutive sampling . The main outcome variable is the change in two or more points into Goldberg anxiety scale at six and twelve months . Secondary outcome variables include quality of life ( EuroQol 5D ) , and degree of compliance with the CPG recommendations on treatment , information , and referrals to mental health services . Main effectiveness will be analyzed by comparing the patients percentage improvement on the Goldberg scale between the intervention group and the control group . Logistic regression with r and om effects will be used to adjust for prognostic factors . Confounding factors or factors that might alter the effect recorded will be taken into account in this analysis . Discussion There is a need to identify effective implementation strategies for CPG for the management of anxiety disorders present in primary care . Ensuring the appropriate uptake of guideline recommendations can reduce clinical variation and improve the care patients receive . Trial registration IS RCT N : IS RCT We performed a prospect i ve study of patients with a whiplash trauma to the cervical spine to describe the incidence of these injuries and to evaluate prognostic factors for disability and recovery .  A total of 356 patients were enrolled in the study . All the patients received a comprehensive question naire after the injury , and 296 cases responded to the follow-up protocol more than 1 year after the accident . Disability related to the whiplash trauma was used as the outcome variable for the assessment of prognostic factors . The annual incidence of acute whiplash trauma in the catchment area was 4.2 per 1,000 inhabitants and 3.2 per 1,000 for whiplash-associated disorder grade s 1–3 . Thirty-two percent reported persisting disability at follow-up . The following factors were significantly associated with a poor prognosis : pretraumatic neck pain , low educational level , female gender , and whiplash-associated disorder grade s 2–3 BACKGROUND Anxiety disorders are prevalent in primary care . Psychological treatment is effective but time-consuming , and there are waiting lists for secondary care . Interest has therefore grown in developing guidelines for treatment that would be feasible in primary care . AIM To compare the effectiveness and feasibility of guided self-help , the Anxiety Disorder Guidelines of the Netherl and s College of General Practitioners and cognitive behavioural therapy ( CBT ) . DESIGN OF STUDY R and omised controlled study lasting 12 weeks with follow-up at 3 and 9 months for primary care patients with panic disorder and /or generalised anxiety disorder . SETTING The first two forms of treatment were carried out by 46 GPs who were r and omly assigned to one or the other form .  CBT was carried out by cognitive behaviour therapists in a psychiatric outpatient clinic . METHOD Participants ( n = 154 ) were r and omly assigned to one of the three forms of treatment . The main outcome measure used was the state subscale of the Spielberger Anxiety Inventory . RESULTS All three forms of treatment gave significant improvement between pre-test and post-test , and this improvement remained stable between post-test and the follow-ups . The results obtained with the three treatment forms did not differ significantly over time . The feasibility of the Anxiety Disorder Guidelines was low compared with that of guided self-help . CONCLUSION Our results indicate that primary care patients with prevalent anxiety disorders for whom the GP does not find referral necessary can be adequately treated by the GP . Psychiatric outpatient clinic referral does not give superior results . Guided self-help is easier for the GP to carry out than a less highly-structured treatment like that laid down in the Anxiety Disorder Guidelines Outpatient medication adherence is a major problem , especially for patients repeatedly hospitalized for psychiatric disorders . This study included 39 such patients who were receiving case management services from a community mental health center . Patients were matched and r and omly assigned to receive in a single session either ( 1 ) information regarding medication and its benefits , ( 2 ) guidelines for assuring adherence which encompassed all phases related to pill-taking including filling prescriptions , use of a pill container , transportation , self-reminders , doctor 's appointments and so forth , or ( 3 ) the same guidelines as ( 2 ) above but given in the presence of a family member who was enlisted in support . The results showed that adherence increased to about 94 % after the guidelines were given for both the individual and family guideline procedure , whereas adherence remained unchanged at 73 % after the medication information procedure . These results suggest a practical means for assuring a high level of medication adherence for patients with psychiatric disorders PURPOSE Acute uncomplicated urinary tract infection is a common and costly disorder in women . To reduce potentially unnecessary expense and inconvenience , a large staff-model health maintenance organization instituted a telephone-based clinical practice guideline for managing presumed cystitis in which women 18 to 55 years of age who met specific criteria were managed without a clinic visit or laboratory testing . We sought to evaluate the effects of the guideline . SUBJECTS AND METHODS We performed a population -based , before- and -after study with concurrent control groups at 24 primary care clinics to assess the effect of guideline implementation on re source utilization and on the occurrence of potential adverse outcomes . We measured the proportion of patients with presumed uncomplicated cystitis who had a return office visit for cystitis or sexually transmitted disease or who developed pyelonephritis within 60 days of the initial diagnosis .  Relative risks ( RR ) and 95 % confidence intervals ( CI ) were estimated , adjusting for the effects of clustering within clinics . RESULTS A total of 3,889 eligible patients with presumed acute uncomplicated cystitis were evaluated . As compared with baseline , guideline implementation significantly decreased the proportion of patients with presumed cystitis who received urinalysis ( RR = 0.75 ; CI , 0.70 to 0.80 ) , urine culture ( RR = 0.73 ; CI , 0.68 to 0.79 ) , and an initial office visit ( RR = 0.67 ; CI , 0.62 to 0.73 ) , while increasing the proportion who received a guideline -recommended antibiotic 2.9-fold ( CI , 2.4 to 3.7-fold ) . In the prospect i ve comparison of the 22 intervention and two control clinics , the guideline decreased the proportion of patients who had urinalyses performed ( RR = 0.80 ; CI , 0.65 to 0.98 ) and increased the proportion of patients who were prescribed a guideline -recommended antibiotic ( RR = 1.53 ; CI , 1.01 to 2.33 ) . Adverse outcomes did not increase significantly in either comparison . CONCLUSION Guideline use decreased laboratory utilization and overall costs while maintaining or improving the quality of care for patients who were presumptively treated for acute uncomplicated cystitis The majority of general practitioners in the Netherl and s have replaced traditional paper-based patient records with computer-based records ; physicians enter patient data themselves in the computer during patient encounters ( 1 ) . The use of electronic patient records creates new opportunities to influence physician behavior through implementation of decision support systems ( 2 - 7 ) . In recent years , research ers have documented various computer-based decision support systems that have influenced physician behavior ( 8 - 17 ) . Other investigators , however , have reported that computer-based decision support has not affected patient care ( 18 ) . To resolve the issue , investigators have compared the results of studies that were conducted in different setting s , used different methods , and involved different population s ( 19 ) . Studies comparing different methods of providing computer-based decision support in r and omized trials are not available . In the Netherl and s , 3 % to 4 % of patient encounters with general practitioners in primary care result in the ordering of blood tests ( 20 ) . However , ordering of blood tests is not always appropriate ( 21 - 29 ) . Research ers argue that excessive ordering of tests causes physicians to pursue evaluation of false-positive results , which in turn leads to additional unnecessary diagnostic examinations ( 30 - 35 ) . Two methods have proven effective in reducing the number of tests ordered by Dutch general practitioners . The first method is based on restricting the number of tests that are listed on an order form . Zaat and colleagues ( 36 , 37 ) developed a restricted paper order form that replaced the existing form . The second method involves introduction of indication-oriented order forms that are based on clinical practice guidelines ( 38 - 40 ) . We hypothesized that an indication-oriented order form based on guidelines , which would provide an optimally restricted list of tests that are relevant for a specific indication , would be more effective in decreasing the number of tests ordered compared with an order form that provides an initially limited list of tests . We therefore conducted a r and omized trial to compare the effect of two versions of BloodLink , a computer-based clinical decision support system , on blood test ordering  among Dutch general practitioners . Methods Participants In August and September 1995 , all 64 practice s ( 94 general practitioners ) in the region of Delft , the Netherl and s , were invited to participate in the study . Only practice s that had replaced their paper-based patient records with electronic records and were using the computer during patient encounters were eligible . A total of 46 practice s ( 62 general practitioners ) agreed to participate . R and omization To avoid contamination , we performed r and om allocation at the level of the practice ( 41 , 42 ) . The practice s were first stratified by type : solo practice s or group practice s ( two or more general practitioners in the same practice ) . Each practice was subsequently assigned by simple r and om allocation to use BloodLink-Restricted or BloodLink- Guideline for the full study period . A research er who was not involved in the study and was blinded to the identity of the practice s performed the r and omization by using a r and om-numbers table . After r and omization , 22 practice s involving 30 general practitioners were assigned to use BloodLink-Restricted  and 24 practice s involving 32 general practitioners were assigned to use BloodLink- Guideline  . Intervention We developed two versions of BloodLink , a computer-based decision support system . BloodLink-Restricted initially displays a reduced list of tests , whereas BloodLink- Guideline is based on the guidelines of the Dutch College of General Practitioners . Both versions of BloodLink are integrated with the computer-based patient record ( 43 ) . The option to use BloodLink was added to the screen that the general practitioner uses when entering data in the electronic patient record during patient encounters . The general practitioner can activate BloodLink to order blood tests as an alternative to using paper order forms . Because the total number of tests that can be ordered is too large to display on a computer screen , a set of tests is presented for selection . If the physician requires additional tests that are not currently displayed , he or she can type the first few letters of the names of the required tests , and the system will present all possible matches ( including those corresponding to possible typing errors of the general practitioner ) for selection . The number of tests that the general practitioners had at their disposal was the same both before and during the intervention ( 52 clinical chemistry tests and 46 microbiological tests ) . Options for specific instructions to the laboratory ( for example , urgent processing or fasting values ) are available . Once the physician has made his or her selection s , BloodLink prints a patient-specific test order form and instructions for the laboratory and up date s the patient record with the tests that have been ordered . The only difference between the two versions of BloodLink is the method used to present the initial set of tests to the general practitioner . BloodLink-Restricted is based on the idea of a restricted order form . It offers the general practitioner an initial set of 15 tests that have been shown to cover most of the clinical situations seen in primary care ( 36 ) . BloodLink-Restricted can be viewed as a general electronic order form that presents only 15 tests on the screen , together with a field labeled other tests that allows the physician to request any other blood test ( 43 ) . The 15 tests are alanine aminotransferase , aspartate aminotransferase , total bilirubin , cholesterol , creatinine , erythrocyte sedimentation rate , free thyroxine , -glutamyltransferase , glucose ( and fasting glucose ) , glycosylated hemoglobin , hemoglobin , mean corpuscular volume , PaulBunnell , potassium , and thyroid-stimulating hormone . At any time , the physician can customize tests for individual patients by adding or deleting tests . BloodLink- Guideline is based on the guidelines of the Dutch College of General Practitioners . By January 1996 , the Dutch College of General Practitioners had published 54 guidelines . Some guidelines focus on symptoms that are frequently seen in the primary care setting , such as acute diarrhea , acute sore throat , low back pain , alcohol abuse , fever in children , and sleeping disorders . Other guidelines focus on common diseases in primary care , such as diabetes , asthma , depression , dementia , and eczema . Finally , a set of guidelines covers preventive medicine . We review ed the most recent version of each guideline , available in January 1996 , and noted whether it contained a reference to a blood test ( 44 ) . We determined the clinical situation in which the test should be performed ( indication ) and the tests that should be performed in that situation ( advised tests ) . When general practitioners activate the system , BloodLink- Guideline first provides an overview of the available guidelines . The names of these guidelines are familiar to Dutch general practitioners . The general practitioner selects the appropriate guideline . A guideline may describe several different indications for requesting blood tests ; for example , the guideline for blood tests and liver disease mentions 10 different indications . After the indication has been identified , the system proposes the relevant tests . The general practitioner then decides whether to adhere to the protocol . At any time , the physician can customize tests for individual patients by adding or removing tests from the proposed list . Although new guidelines are published at regular intervals , the currently available guidelines cover only a limited set of indications for blood tests ( 44 ) . In the absence of national guidelines , local or regional guidelines may be used . The version of BloodLink- Guideline used during the clinical trial in the Delft region included three regional guidelines for anemia , AIDS , and clotting disorders , in addition to all national guidelines . Even with these additional guidelines , BloodLink- Guideline does not cover all possible indications for blood tests in primary care . To deal with these situations , the general practitioner can select the heading other indication and order any test . Protocol Before the study , the general practitioners were using two paper order forms : one for clinical chemistry and one for microbiology . After BloodLink was installed , one of the authors gave a brief orientation presentation to the participating practitioners . During a 3-month phase-in period , the general practitioners were allowed to use BloodLink in their practice s to become acquainted with the system . After this period , the general practitioners were asked whether they were willing to participate in the trial . The study period was March 1996 through February 1997 . Physicians always had the choice to use either the BloodLink software or the paper forms to order clinical chemistry and microbiology tests ; thus , paper order forms were still available during the entire intervention period . When the general practitioner ordered blood tests during a patient encounter , only one order form was generated regardless of whether the general practitioner used paper forms or BloodLink . The electronic patient record monitored use of BloodLink by the practitioners . To include the requests for blood tests that were made by using traditional paper forms , we retrieved from the regional laboratory all requests for blood tests . Outcomes We counted the number of order forms that the laboratory received from the general practitioners and the number of tests on each form . The main outcome measure was the average number of tests per order form ( including paper forms ) per practice ( summary variable ) . We defined the most frequently ordered tests as the tests that accounted for 80 % of the total number of tests ordered . For these tests , we Abstract Objective : To determine whether locally developed guidelines on asthma and diabetes disseminated through practice based education improve quality of care in non-training , inner city general practice s. Design : R and omised controlled trial with each practice receiving one set of guidelines but providing data on the management of both conditions . Subjects:24 inner city , non-training general practice s. Setting : East London . Main outcome measures : Recording of key variables in patient records ( asthma : peak flow rate , review of inhaler technique , review of asthma symptoms , prophylaxis , occupation , and smoking habit ; diabetes : blood glucose concentration , glycaemic control , funduscopy , feet examination , weight , and smoking habit ) ; size of practice disease registers ; prescribing in asthma ; and use of structured consultation “ prompts . ” Results : In practice s receiving diabetes guidelines , significant improvements in recording were seen for all seven diabetes variables . Both groups of practice s showed improved recording of review of inhaler technique , smoking habit , and review of asthma symptoms . In practice s receiving asthma guidelines , further improvement was seen only in recording of review of inhaler technique and quality of prescribing in asthma . Sizes of disease registers were unchanged . The use of structured prompts was associated with improved recording of four of seven variables on diabetes and all six variables on asthma . Conclusions : Local guidelines disseminated via practice based education improve the management of diabetes and possibly of asthma in inner city , non-training practice s. The use of simple prompts may enhance this improvement Objective : To evaluate the clinical and cost effectiveness of two training strategies to promote the use of research evidence in speech and language therapy ( SLT ) management  of poststroke dysphagia . Design : Pragmatic , cluster r and omized trial . Setting : Seventeen SLT departments in north-west Engl and . Participants : Two SLTs from each department received training and cascaded information across their department . Process of care was measured from the notes of 708 patients with acute poststroke dysphagia across eight departments allocated to training strategy A , and 762 patients across nine departments in strategy B. Interventions : Strategy A : training on the critical appraisal of published research papers and practice guidelines . Strategy B : strategy A plus training on management of change in clinical practice . Main outcome measures : Pre- and post-training adherence to practice guidelines in poststroke dysphagia management , based on a review of case notes . Incremental cost of increased adherence to clinical guidelines . Results : Departments ' practice differed in adherence to guidelines . Departments changed following training ( F=2.22 , df 16 , 1436 , p=0.004 ) . The effect of training strategy on clinical practice was not significant . Strategy B departments engaged in more activities relating to research use following training than strategy A. Total costs of training averaged £ 2001 , t2892 , $ 3886 ( SD £ 502 , t726 , $ 975 ) for strategy A and £ 3366 , t4866 , $ 6537 ( SD £ 2121 , t3066 , $ 4119 ) for strategy B. Conclusions : Training in research implementation in addition to critical appraisal and guideline introduction is associated with increased dissemination activities and awareness of research information , but not with changes in clinical practice within six months of training . The department in which SLTs work influences their use of research . The process of poststroke dysphagia management can be measured using a tool developed from practice guidelines Background Chronic whiplash is a common and costly problem . Sensory hypersensitivity is a feature of chronic whiplash that is associated with poor responsiveness to physical treatments such as exercise . Modalities such as dry-needling have shown some capacity to modulate sensory hypersensitivity , suggesting that when combined with advice and exercise , such an approach may be more effective in the management of chronic whiplash . The primary aim of this project is to investigate the effectiveness of  dry-needling , advice and exercise for chronic whiplash . Method / Design A double-blind r and omised controlled trial will be conducted . 120 participants with chronic whiplash , grade II will be r and omised to receive either 1 ) dry-needling , advice and exercise or 2 ) sham dry-needling , advice and exercise . All participants will receive an educational booklet on whiplash . Participants who are r and omised to Group 1 will receive 6 treatments of combined dry-needling and exercise delivered in the first 3 weeks of the 6 week program , and 4 treatments of exercise only in the last 3 weeks of the program . Participants r and omised to Group 2 will receive an identical protocol , except that a sham dry-needling technique will be used instead of dry-needling . The primary outcome measures are the Neck Disability Index ( NDI ) and participants ' perceived recovery . Outcomes will be measured at 6 , 12 , 24 and 52 weeks after r and omization by an assessor who is blind to the group allocation of the participants . In parallel , an economic analysis will be conducted . Discussion This trial will utilise high quality trial method ologies in accordance with CONSORT guidelines . The successful completion of this trial will provide evidence of the effectiveness and cost-effectiveness of a combined treatment approach for the management of chronic whiplash . Trial registration Study Design . Cluster r and omized controlled trial for a multifaceted implementation strategy . Objectives . To assess the effectiveness of tailored  interventions ( multifaceted implementation strategy ) to implement the  Dutch low back pain guideline for general practitioners with regard to adherence to guideline recommendations . Summary of Background Data . Guidelines for the management of low back pain in primary care have been developed in various countries , but little is known about the optimal implementation strategy . A multifaceted implementation strategy was developed to overcome identified barriers to the implementation of the Dutch low back pain guideline for general practitioners . Methods . General practitioners were r and omized to an intervention or a control group . The general practitioners in the intervention group ( n = 21 ) received tailored interventions consisting of the Dutch low back pain guideline for general practitioners , a 2-hour educational and clinical practice workshop ; two scientific articles on low back pain management ; the guideline for occupational physicians ; a tool for patient education ; and a tool for reaching agreement on low back care with physical , exercise , and manual therapists . The control group ( n = 20 ) received no intervention . The participating general practitioners were asked to recruit consecutive patients with a new episode of low back pain as the main reason for consultation . General practitioners completed registration forms of each individual consultation with regard to the main outcome measures : advice and information , referral to other health-care providers , and prescription of medication . Results . Forty-one of the 67 r and omized general practitioners reported on a total of 616 consultations for 531 patients with nonspecific low back pain . The advice and explanation provided by the general practitioners , the prescription of paracetamol or nonsteroidal anti-inflammatory drugs , and prescription of pain medication on atime contingent or a pain contingent basis showed no statistically significant differences between the intervention and control groups . There were also no differences in overall referral rate . However , in follow-up consultations fewer patients were referred to a physical or exercise therapist by the general practitioners in the intervention group than in the control group . Conclusions . The multifaceted intervention strategy modestly improved implementation ( for parts of the recommendations in ) the Dutch low back pain guideline by general practitioners and produced small concomitant changes in patient management . The implementation strategy produced fewer referrals to therapists during follow-up consultations The Pituitary Society in conjunction with the European Neuroendocrine Association held a consensus workshop to develop guidelines for diagnosis and treatment of the co-morbid complications of acromegaly . Fifty nine pituitary specialists ( endocrinologists , neurosurgeons and cardiologists ) assessed the current published literature on acromegaly complications in light of recent advances in maintaining tight therapeutic control of GH hypersecretion . The impact of elevated GH levels on cardiovascular disease , hypertension , diabetes , sleep apnea , colon polyps , bone disease , reproductive disorders , and neuropsychologic complications were considered . Guidelines are proposed for effective management of these complications in the context of overall acromegaly control . When appropriate , requirements for prospect i ve evidence -based studies and surveillance data base development are enunciated . Effective management of co-morbid acromegaly complications will lead to improved morbidity and mortality in acromegaly Abstract Patients with chronic whiplash associated disorders present with varied sensory , motor and psychological features . In this first instance it was question ed whether a multimodal program of physical therapies was an appropriate management to be broadly prescribed for these patients when it was known that some would have sensory features suggestive of a notable pain syndrome . A r and omised controlled trial was conducted with 71 participants with persistent neck pain following a motor vehicle crash to explore this question . Participants were r and omly allocated to receive either a multimodal physiotherapy program ( MPT ) or a self‐management program ( SMP ) ( advice and exercise ) . In the r and omisation process , participants were stratified according to the presence or not of widespread mechanical or cold hyperalgesia . The intervention period was 10 weeks and outcomes were assessed immediately following treatment . Even with the presence of sensory hypersensitivity in 72.5 % of subjects , both groups reported some relief of neck pain and disability ( Neck Disability Index ) and it was superior in the group receiving multimodal physiotherapy ( p = 0.04 ) . Post‐hoc observations however suggested that relief was marginal in the subgroup with both widespread mechanical and cold hyperalgesia . Further research is required to test the validity of this sub‐group observation and to test the effect of the intervention in the long term Neuropathic pain ( NeP ) , generated by disorders of the peripheral and central nervous system , can be particularly severe and disabling . Prevalence estimates indicate that 2 % to 3 % of the population in the developed world suffer from NeP , which suggests that up to one million Canadians have this disabling condition . Evidence -based guidelines for the pharmacological management of NeP are therefore urgently needed . R and omized , controlled trials , systematic review s and existing guidelines focusing on the pharmacological management of NeP were evaluated at a consensus meeting . Medications are recommended in the guidelines if their analgesic efficacy was supported by at least one method ologically sound , r and omized , controlled trial showing significant benefit relative to placebo or another relevant control group . Recommendations for treatment are based on degree of evidence of analgesic efficacy , safety , ease of use and cost-effectiveness .  Analgesic agents recommended for first-line treatments are certain antidepressants ( tricyclics ) and anticonvulsants ( gabapentin and pregabalin ) . Second-line treatments recommended are serotonin noradrenaline reuptake inhibitors and topical lidocaine . Tramadol and controlled-release opioid analgesics are recommended as third-line treatments for moderate to severe pain . Recommended fourth-line treatments include cannabinoids , methadone and anticonvulsants with lesser evidence of efficacy , such as lamotrigine , topiramate and valproic acid . Treatment must be individualized for each patient based on efficacy , side-effect profile and drug accessibility , including cost . Further studies are required to examine head-to-head comparisons among analgesics , combinations of analgesics , long-term outcomes , and treatment of pediatric and central OBJECTIVE This study aims to determine if cervical medial branch radiofrequency neurotomy reduces psychophysical indicators of augmented central pain processing and improves motor function in individuals with chronic whiplash symptoms . DESIGN Prospect i ve observational study of consecutive patients with healthy control comparison . SETTING Tertiary spinal intervention centre in Calgary , Alberta , Canada . SUBJECTS Fifty-three individuals with chronic whiplash associated disorder symptoms ( Grade 2 ) ; 30 healthy controls . METHODS Measures were made at four time points : two prior to radiofrequency neurotomy , and 1- and 3-months post-radiofrequency neurotomy . Measures included : comprehensive quantitative sensory testing ( including brachial plexus provocation test ) , nociceptive flexion reflex , and motor function ( cervical range of movement , superficial neck flexor activity during the craniocervical flexion test ) . Self-report pain and disability measures were also collected . One-way repeated measures analysis of variance and Friedman 's tests were performed to investigate the effect of time on the earlier measures . Differences between the whiplash and healthy control groups were investigated with two-tailed independent sample s t-test or Mann-Whitney tests . RESULTS Following cervical radiofrequency neurotomy , there were significant early ( within 1 month ) and sustained ( 3 months ) improvements in pain , disability , local and widespread hyperalgesia to pressure and thermal stimuli , nociceptive flexor reflex threshold , and brachial plexus provocation test responses as well as increased neck range of motion ( all P < 0.0001 ) . A nonsignificant trend for reduced muscle activity with the craniocervical flexion test ( P > 0.13 ) was measured . CONCLUSIONS Attenuation of psychophysical measures of augmented central pain processing and improved cervical movement imply that these processes are maintained by peripheral nociceptive input Study Design . Cost-effectiveness analysis alongside a cluster r and omized controlled trial . Objective . To study the cost-effectiveness of 2 low back pain guideline implementation ( GI ) strategies . Summary of Background Data . Several evidence -based guidelines on management of low back pain have been published . However , there is still no consensus on the effective implementation strategy . Especially studies on the economic impact of different implementation strategies are lacking . Methods . This analysis was performed alongside a cluster r and omized controlled trial on the effectiveness of 2 GI strategies ( physician education alone [ GI ] or physician education in combination with motivational counseling [ MC ] by practice nurses)-–both compared with the postal dissemination of the guideline ( control group , C ) . Sociodemographic data , pain characteristics , and cost data were collected by interview at baseline and after 6 and 12 months . low back pain – related health care costs were valued for 2004 from the societal perspective . Results . For the cost analysis , 1322 patients from 126 general practice s were included . Both interventions showed lower direct and indirect costs as well as better patient outcomes during follow-up compared with controls . In addition , both intervention arms showed superiority of cost-effectiveness to C. The effects attenuated when adjusting for differences of health care utilization prior to patient recruitment and for clustering of data . Conclusion . Trends in cost-effectiveness are visible but need to be confirmed in future studies . Research ers performing cost-evaluation studies should test for baseline imbalances of health care utilization data instead of judging on the r and omization success by review ing non-cost parameters like clinical data alone
For workers with persistent neck and shoulder pain , evidence supports mixed supervised and unsupervised high-intensity strength training or advice alone ( grade s I-III NAD ) .
A multimodal approach including manual therapy , self-management advice , and exercise is an effective treatment strategy for both recent-onset and persistent neck pain
OBJECTIVE The objective was to develop a clinical practice guideline on the management of neck pain-associated disorders ( NADs ) and whiplash-associated disorders ( WADs ) .
This guideline replaces 2 prior chiropractic guidelines on NADs and WADs .