Evidence Tables on Course and Prognostic Factors in WAD 1 Table 1. Course of WAD. Author(s), Year, Study Design Setting and Subjects Follow-up Course Number (n) Enrolled 1 Adult car drivers, insured by one Follow-up in at 7 years after collision 39.6% of those with WAD after a Berglund, 2000 Cohort company in Sweden, involved in rear- by mailed survey collision reported a 3-month period end collisions in 1987-1988. N=182 prevalence (often or always) of neck with WAD; N=136 without WAD. or shoulder pain at 7 years, compared Compared with random sample of with 14.0% for those not injured 7 persons insured by same company, no years earlier and 11.1% of those who history of collision. had not been in a collision. Borchgrevink et al., 1996 2 Patients registered with neck sprain Follow-up 2.5 to 8.5 years post- 27% of those with WAD were on sick Cohort injury from car collision, 1985-1990, collision, using administrative Social leave. 14% had sick leave for less at hospitals in 4 cities in Norway Security data. than 2 weeks immediately after (representing 7.3% of population of Outcomes: presence, duration and collision, 8% for more than 2 weeks Norway) (n=473) timing of sick leave immediately after collision and 5% sometime later over follow-up. At follow-up, 58% reported symptoms and 5% claimed rehabilitation or permanent disability pension. Boyd et al., 20023 Children aged 4-16 in northwest Followed until asymptomatic or up to Mean duration of symptoms was 8.8 Cohort England with Grades I and II WAD 56 days via clinical exam followed by days (range was 3-70 days). None after car crash; consecutive telephone call to confirm continued had symptoms lasting more than 2 presentations to 3 urban ERs. asymptomatic status. months. Excludes those needing admission. (n=49) Bylund et al., 1998 4 Passenger car occupants aged 16-64 y Follow-up at 2.5 years post-injury and During the 2.5 years following the car Cohort involved in car accidents in the city of on January 1, 1996 (4-6 years post- accident 40% (103) had been on sick Umea Sweden from January 1, 1990 injury), using data from Social leave totaling 12,500 days for total to December 31, 1991 who were Insurance Office records (universal benefits of 0.8 million US dollars. registered by the Accident Analysis coverage) to assess days on sick Cervical strains accounted for 75% of Group at the University Hospital leave, costs of sick leave and total sick-leave days. Within 2.5 (n=255) disability pension. years, only 18 (7%) still on sick leave. By 4-6 years after injury, 9 people Evidence Tables: Course and Prognosis in WAD 2 had been approved for disability pension (all with cervical strains) and 9 others were on full or partial sick leave. Disability pension costs estimated between $1.1 and 3.8 million (USD). Cassidy at al., 2000 5 All adults submitting personal injury Follow-up of time to claim closure by Median time to claim closure was 433 Cohort claims after motor vehicle injury in administrative database to 1997; (95% CI 409-457) days under the tort Saskatchewan, Canada, 1994-1995; claim closure in both tort and no fault system and 194 (95% CI 182-206) self-reported neck or shoulder pain system validated against self-reported days under the subsequent no fault after collision. Excluded reopened recovery in depression, neck pain and system. claims, hospitalized for more than 2 physical functioning. days. (n=5,398) Cassidy et al., 2007 6 All adults submitting personal injury Follow-up by telephone interview at 6 Median time to recovery was 4 Cohort claims after motor vehicle injury in weeks, 3, 6, 9 and 12 months. Self- months. Saskatchewan, Canada, 1997-1998; reported global recovery, as self-reported collision-related neck determined by endorsement of ‘all pain. Excluded those hospitalized for better’ or ‘quite a bit of more than 2 days. (n=6,021) improvement’. Drottning et al., 2002 7 Patients with possible WAD attending Initial questionnaire at 4 weeks, 8.2% of patients had cervicogenic Descriptive emergency department in Oslo after a followed by examination for headache at 6 weeks, 4.4% at 6 traffic collision; 1993-1995. (n=587). cervicogenic headache at 6 weeks and months and 3.4% at 1 year. At 1 year, follow-up at 6 months and 1 year. 44% of whole sample had neck pain (12% had daily neck pain). Of those with cervicogenic headache at 1 year, 90% had concurrent neck pain (35% had daily neck pain) Gargan et al., 1994 8 Patients attending the emergency Symptoms assessed within 7 days by 82% had neck pain within 7 days of Cohort department in Swindon, England from examination and after three months, the collision and another 4% had later May to September, 1991, following a via temporal records symptoms. After 3 months, 66% rear-end collision; most were reported neck pain. symptomatic. All were given soft collars and non-steroidal medication. Evidence Tables: Course and Prognosis in WAD 3 (n=50) Holm et al. 1999 9 Swedish population with a permanent Outcome assessed average of 4 years In those judged to have permanent Cross-sectional medical impairment of 10% or more after injury. medical impairment of 10% or more due to road traffic injury during years Outcomes: prevalence of medical due to WAD, 63% had returned to full 1989 or 1994. (n=184 impaired due impairment, reduced or full work working capacity in 1989 and 69% in to WAD in 1989 and n=481 in 1994). disability 1994. Jónsson et al., 1994 10 Consecutive patients with a WAD- Questionnaires and physical At 6 weeks, 26 (52%) had recovered Cohort (Phase 1) type injury in automobile collisions examination at 6 weeks, one year and and resumed their previous activities presenting to the only available 5 years without restriction; 24 (48%) had emergency primary care trauma persistent or aggravated neck pain; center in Uppsala, Sweden during a and of these, 19 had radiating pain. 13 month period. Of the 26 asymptomatic at 6 weeks, (n=50) 19 (73%) were asymptomatic at 5 years. Of the 24 symptomatic at 6 weeks, 14 (58%) reported neck pain at 5 years (11-point VAS of 1-6) and had extensive treatment (physical therapy, chiropractic, surgery). Kasch et al., 2003 11 Consecutive adult patients in Aarhus Questionnaires, interview and clinical At 1 month, overall pain decreased Cohort area attending emergency department examination at 1 week and 1, 3, 6 and from 23 to 16 on the 100 mm VAS. with neck pain or headache after 12 months. Median neck pain fell from 32 at 1 exposure to rear collision; January week to 23 at 1 month 1997 through January 1998. Excludes those with prior neck or low back disorder or head trauma. (n=141 with WAD) Mayou et al, 2002 12 Patients with WAD attending the Follow-up questionnaires at 3 months. 3 months after injury, 64% reported Cohort Accident and Emergency Department ‘minor/major’ problems; 37% had at John Radcliffe Hospital in Oxford, ‘moderate to very severe pain’; 57% England over a 1-year period. No saw a general practitioner; 24% had date range given for this 1-year post-traumatic stress disorders; 21% period. Excludes head injuries with > had anxiety or depression; 21% had Evidence Tables: Course and Prognosis in WAD 4 15 minutes loss of consciousness. phobic travel anxiety; 37% had (N=278). psychological consequences; 47% had ‘minor/major’ financial problems; 15 had ‘moderate to extreme’ limitations of daily activities in the past month; and 62% were claiming compensation. Miettinen et al., 2004 13 Insurance claimants with neck pain 1-year and 3 year follow-ups. Frequency of sick leave: 61% had no Cohort after a motor vehicle collision in Outcomes were frequency of sick sick leave; 12.6% had sick leave less Finland in 1998. (n=312 respondents leave and health impairment than 1 week; 14.8% for 1 week to 1 Miettinen et al., 2004 14 at baseline; 182 at one year and 144 at compared to pre-injury status (judged month, and 11.5% for more than one Cohort 3 years) by participants as due to injury). month. Norris et al., 1983 15 Presentation to a British accident At least 6 months: Mean follow-up Time to return to work (weeks): 2.4 Cohort department with neck injury from times in months: Group 1 - 19.7; (s.d. 2) for Group 1; 4.5 (s.d. 3) for rear-end MVC between September Group 2 – 23.9; Group 3 – 24.7. Group 2 and 10.3 (s.d. 3.3) for Group 1977 and May 1980 (n=61). 3 Follow-up data ascertained at clinic 3. severity groups: Group 1 symptoms visit through self-report and physical Free of symptoms at follow-up: but no physical findings (n=27); examination Group 1 (56%); Group 2 (19%) and Group 2 symptoms and reduced range group 3 (10%). of movement, no neurological signs (n=24); Group 3 symptoms, reduced movement and neurological loss on examination (n=10). Obelieniene et al., 1999 16 Adults in Kaunas, Lithuania, mid Follow-up at 2 and 12 months after Median duration of neck pain was 3 Cohort 1990’s. Subjects exposed to rear-end the collision through mailed survey. days (range < 3 hours to 17 days). collisions, reported to police (n=59 with neck pain after the collision) Partheni et al., 2000 17 Patients from an emergency Follow-up at 1, 3 and 6 months post- Proportion reporting neck pain fell Cohort department in Patras, Greece from collision by questionnaire from 100% in the first three days July 1995-July 1998, involved in rear, post-injury, to 9.4% at 1 month, 1.7% lateral or frontal motor vehicle at 3 months and 1.1% at 6 months. collision with WAD Grades I or II with symptom onset within 2 days of Evidence Tables: Course and Prognosis in WAD 5 collision (n=180) Sterling et al., (2003) 18 Volunteers with WAD (n=66; neck Follow-up at 1, 2 and 3 months by At three months, 38% recovered; 33% Cohort pain after motor vehicle crash). examination (ROM, joint position had mild and 29% had Healthy volunteers (n=20) error, EMG) and fear of movement moderate/severe pain. Those with questionnaire (TAMPA). moderate/severe pain at three months had decreased ROM, decreased joint function, more EMG activity and high fear of movement at each measurement point. Mild group became more like the recovered group over follow-up. Suissa et al., 1995 19 All WAD claims from MVC (ICD 9 Follow-up to claim closure, 22% were on benefits for less than 1 Cohort code 847.0) receiving compensation ascertained through administrative week. Overall, 50% claims closed from SAAQ in Québec in 1987; with database or May 1993. within 1 month, 64% within 60 days, collision-related data from police 87% within 6 months and 97% within report. (n=3014). 1 year. Suissa et al., 2006 20 WAD traffic injury claimants in Follow-up to claim closure, using At one year, 40% of patients Cohort Québec presenting to treatment administrative database, or for 1 year. attending and over 50% of patients centres between March and not attending treatment programs September, 2001. Comparison group were still on compensation. was WAD claimants not seen at the centres. (n=2163) Evidence Tables: Course and Prognosis in WAD 6 Table 2. Prognostic factors for recovery after WAD. Author(s), Year, Study Setting and Subjects Prognostic Factors Follow-up and Outcomes Key Findings Design Number (n) Enrolled Considered Measured Berglund et al, 200121 Adult car drivers, insured by Exposure to rear-end Follow-up in at 7 years after Compared to unexposed Cohort (Phase II) one company in Sweden, collision, with or without collision by mailed survey. subjects, exposed subjects involved in rear-end claim for WAD adjusted for Outcomes: 3-month period with WAD were more likely collisions in 1987-1988. age, gender prevalence of general health, to experience headache (OR- N=232 exposed to rear-end fatigue, depressive mode, =3.7, 95% CI 2.6-5.3), collision. N=157 with neck sleep disturbance, headache, thoracic pain (OR= 3.1, 95% injuries alone; N=75 with thoracic pain, low back pain CI 2.0-4.8), low back pain neck and other injuries; and stomach ache. (OR= 1.7, 95% CI 1.3-2.4), N=204 without neck injuries; ill health (OR= 3.3, 95% CI N=3688 unexposed subjects. 2.2-5.0), sleep disturbance (OR= 2.4, 95% CI 1.5-3.9) and fatigue (OR= 1.6, 95% CI 1.1-2.3). Exposed subjects without WAD and unexposed subjects equally likely to experience symptoms at 7 years. Berglund et al., 200622 Swedish adults with acute Gender, age, income, Follow-up by mailed At 2 years, higher intensity of Cohort (Phase II) WAD from a car collision, education, position in vehicle, questionnaire at 1 month, 6 neck pain was predicted by 1993-94, and making an direction of collision, months, 1 year, 2 years post- higher initial neck pain injury claim. (n=2280 awareness of collision, use of injury. (severe pain OR=8.4, 95% CI enrolled) headrest, use of seat belt, Outcomes: neck pain 6.5-10.9), being female head position, broken car intensity, disability (OR=1.3, 95% CI 1.0-1.6), seat, initial neck pain (Disability Rating Index), higher (self-rated) WAD intensity, initial headache, anxiety and depression grade (WAD II OR=1.5, 95% self-reported WAD severity, (HADS), sick leave CI 1.1-1.9; for WAD III, helplessness (to control exceeding 14 days. OR=2.4, 1.8-3.2), initial consequences of pain), health headache (OR=1.3, 95% CI locus of control (latter two 1.1-1.7), high helplessness measured at one month). (OR=2.7, 95% CI 2.1-3.4) and low education (OR=1.8, Evidence Tables: Course and Prognosis in WAD 7 95% CI 1.3-2.4). Greater disability was predicted by higher initial neck pain (severe pain OR=6.4, 95% CI 4.9-8.4), being female (OR=1.3, 95% CI 1.1-1.6), higher self-rated WAD grade (WAD II OR=1.6, 95% CI 1.2-2.1; for WAD III, OR=3.4, 95% CI 2.5-4.5), initial headache (1.7, 95%CI 1.4-2.1), high helplessness (OR=2.2, 1.7-2.8) and low education (OR=1.4, 95% CI 1.1-2.0). Borchgrevink et al., 19962 Patients registered with neck Presence and duration of sick Follow-up 2.5 to 8.5 years Chronic symptoms associated Cohort (Phase I) sprain injury from car leave for neck problems in post-collision using Social with female gender (neck collision, 1985-1990, at the 2-8 years prior to Security data. pain RR=1.2; dizziness hospitals in 4 cities in collision, gender Outcomes: presence, RR=1.5; nausea RR=2.5), Norway (representing 7.3% duration and timing of sick longer or later sick leave of population of Norway) leave (Social Security data); associated with past history (n=473) symptoms; quality of life, of sick leave for neck pain. analgesic use; rehabilitation or permanent disability pension. Boyd et al., 2002 3 Children aged 4-16 in WAD severity: Grade I Followed until asymptomatic Symptoms lasted longer for Cohort (Phase I) northwest England with (n=40) and Grade II (n=9) or up to 56 days via clinical Grade II than for Grade I WAD after car crash; exam followed by telephone (19.7 days vs. 6.4 days). consecutive presentations to 3 call to confirm continued urban ERs. Excludes those asymptomatic status. needing admission. Outcome: time to recovery (n=49) (defined as no neck pain). Bylund et al., 19984 WAD injuries in traffic Gender, mechanism of injury Days of sick leave Women had a longer average Cohort (Phase 1) collisions in Umea, Sweden; sick leave than did men, Evidence Tables: Course and Prognosis in WAD 8 January 1, 1990 to December (RR=2.9) and a higher 31 1991; ages 16-64; proportion of women took registered by the Accident sick leave (RR= 2.4). Those Analysis Group at the in rear-end collisions had the University Hospital. (n=255) longest average sick leave (RR=2.8). Carroll et al., 200623 Traffic injuries in Pain coping strategies Follow-up to recovery or up Passive coping predicted Cohort (Phase III) Saskatchewan, Canada measured at 6-weeks post- to one year. slower recovery (OR=0.45, between December 1997- injury (controlling for Outcome: Time to self- 95% CI 0.36-0.56), especially November 1999, aged 18 and demographic and reported global recovery. in the presence of concurrent over; with self-reported neck socioeconomic factors, initial depression (OR =0.25, 95% pain after the collision. pain intensity and extent, CI 0.17-0.39). Depression at (n=2320) post-injury symptoms, prior six weeks predicted slower health) recovery (HRR=0.68, 95% CI 0.62-0.76). Active coping did not predict time to recovery (OR=1.08, 95% CI 0.87- 1.33). Cassidy at al., 2000; Côté et All personal injury claimants Compensation system (tort or Follow-up by administrative Longer time to claim closure al., 20015;24 after motor vehicle injury in no fault), age, gender, marital database up to 1997 (n=5398) in tort than no fault system. Cohort (Phase II) Saskatchewan, Canada, July status, education, and at 6 weeks, 4, 8 and 12 For all claims, longer claim 1994 to December 1995; 18 employment, characteristics months by mailed self-report duration associated with years or older; self-reported of collision, seat belt use, questionnaire (n=2783). female gender (HRR=0.84 neck or shoulder pain after headrest, initial pain intensity Outcomes: time to claim (0.77-0.91), more neck pain collision. Excluded reopened and extent, prior health, other closure (n=5,398). Outcome (HRR=0.63, 0.52-0.76 for claims, hospitalized for more associated injuries and of claim closure validated VAS 80-100 in tort system) , than 2 days. Population- symptoms, at fault for against self-reported recovery higher % of body in pain based. (total n=5,398) collision, lawyer retained, in depression, neck pain and (HRR=0.59 for 40-100% in type of care provider. physical functioning.24 tort system), retaining a lawyer (HRR=0.60, 0.53-0.68 in tort system, 0.61, 0.49-0.75 in no fault system), type of initial health care provider (HRR=0.61 for MD + Chiropractor in tort system, Evidence Tables: Course and Prognosis in WAD 9 and 0.61 for Chiropractor in no fault system). Shorter duration of claims in low education (HRR=1.56, 95% CI 1.27-1.92 for < grade 8). For tort claims only, longer claim duration in those with painful jaw (HRR=0.80, 0.70- 0.92) and those not at fault for collision (HRR=0.70, 0.61-0.80). For no fault claims only, longer duration in those with arm pain (HRR=0.84, 0.77-0.92) or fractures (0.70, 0.55-0.89). Cassidy et al., 2007 6 All adults submitting personal Prognostic actors: Type and Follow-up by telephone Attendance at rehabilitation Cohort (Phase III) injury claims after motor timing of rehabilitation interview at 6 weeks, 3, 6, 9 programs predicted slower vehicle injury in program compared to usual and 12 months. Self-reported recovery. Rehabilitation Saskatchewan, Canada, 1997- care; controlling for global recovery, as type, Fitness training: 1998; self-reported collision- demographic and determined by endorsement Attended before 70 days of related neck pain. Excluded socioeconomic factors, of ‘all better’ or ‘quite a bit of injury (HRR= .68, 95% CI those hospitalized for more collision factors, initial pain improvement’. .54-.86). Outpatient than 2 days. (n=6,021) and symptoms, initial health Rehabilitation: Attended care providers before 120 days of injury, (HRR=. 50, 95% CI .33-.77). Côté et al., 200525 All personal injury claimants Prognostic factors: Type and Follow-up to claim closure by Fastest recovery times in Cohort (Phase III) after motor vehicle injury in intensity of health care during administrative database. those with 1-2 visits to Saskatchewan, Canada, July the first 30 days after traffic- Outcome of claim closure general practitioners in the Côté et al., 200726 1994 to December 1995; 18 related neck injury (WAD), validated against self- first month post-injury. Cohort (Phase III) years or older; self-reported controlled for demographics, reported recovery in Longer claim duration in neck or shoulder pain after injury severity, prior health, depression, neck pain and those with more frequent collision; excludes those pre-collision health care physical functioning.24 health care and those seen by making a personal injury utilization, lawyer retained chiropractors; general claim later than 30 days post- and collision characteristics. practitioners plus injury, and those whose Administrative health data chiropractors; and general Evidence Tables: Course and Prognosis in WAD 10 patterns of post-injury health used for pre- and post-injury practitioners plus specialists. care did not fit into one of 8 health care utilization. Findings were consistent over pre-determined patterns (n= both insurance systems. 1693 in the Tort cohort and GP (1-2 days): 1.00 n=2486 in the no fault cohort) GP (>2 visits): 0.73, (95% CI .61-.87) DC ( >6 visits): 0.61, (95% CI .46-.81). GP and Specialist: 0.69, (95% CI .55-.87) Gen.Med: 0.78, (95% CI .64- .95). Drottning et al., 20027 Patients with possible WAD Prognostic factors: Initial Follow-up at 6 months and 1 Cervicogenic headache at one Descriptive (Phase I) attending emergency clinical exam; prior injuries year. Outcome: year is predicted by prior car department in Oslo after a and headaches; symptoms at Cervicogenic headache, range collisions (RR= 1.55), pre- traffic collision; 1993-1995. 4 weeks, intensity of of motion existing headaches (RR= (n=587). headaches and neck pain at 4 2.70) and neck pain (RR= weeks, neurological exam for 2.9), stiffness (RR= 3.4), and those with headaches at 6 initial reduced range of weeks. motion (1.58). Hartling et al., 200227 Patients presenting to two Prognostic factors: age, Follow-up at 6 months by Older age (OR= 3.21, 95% CI Cohort (Phase II) emergency departments in gender, BMI, height, prior telephone contact. Outcome 1.62-2.18), larger number of Ontario, Canada with traffic- neck pain, characteristics of was WAD, defined as regular initial symptoms (OR= 6.71, related WAD; between the collision, initial pain and or daily moderate pain or 95% CI 2.39- 18.81- 22.67, October 1995 and March symptoms (type, frequency, occasional, regular or daily 95% CI 5.21- 98.72), and 1998. (n=380) intensity). severe pain. early development of upper back pain (OR= 2.91, 95% CI 1.65-5.12), upper extremity numbness/weakness (OR= 2.18, 95% CI 1.22-3.87), and disturbance in vision (OR= 1.96, 95% CI 1.00-3.86) predicted persistent WAD at 6 months. Evidence Tables: Course and Prognosis in WAD 11 Holm et al., 1999 9 Population based. Swedish Prognostic factors: type of Outcome assessed average of Older age (OR= 2.9, 95 % CI Cohort (Phase II) population with a permanent injury (WAD, WAD plus 4 years after injury. 1.8-4.8), greater medical medical impairment of 10% other, other injury), year of Outcomes: medical impairment (OR= 8.1, 95% or more due to WAD. impairment judgment, age, impairment, reduced or full CI 4.9-13.4) and lower (n=184 in 1989 and n=481 in gender, professional status, work disability professional status (OR= 3.6, 1994). and (with work disability 95% CI 1.9-96.9) associated outcome only) medical with partial/full work impairment rating disability at follow-up. Kasch et al., 200128 Patients presenting to Prognostic factors for return Follow-up at 1, 3, 6 and 12 Decreased range of motion Cohort (Phase II) emergency units in Aarhus, to work or daily activities: months post injury by predicted handicap (HRR= Denmark, within 2 days of a gender, age, BMI, initial pain interview and examination. 2.53, 95% CI 1.26-5.11), WAD in a rear-end collision. intensity, number of Outcome: time to return to especially in the presence of (n=141). Controls: patients symptoms, active cervical work or daily activities; and high pain intensity and non- with ankle injuries. (n=40) range of motion, speed work capacity or handicap. painful complaints. difference of cars; and Handicap defined as self- Decreased range of motion workload. report of reduced hours and plus high initial pain Prognostic factors for work capacity, job dismissal predicted failure to recover. handicap: same as above plus or change in job due to injury, More intense pain, greater lawsuit within 1 month of in job training due to injury number of symptoms, and injury, type of therapy chosen or application/receiving lawsuit during the first month at first visit (soft collar, active disability pension. showed a trend toward or passive physiotherapy, predicting handicap, but manipulation, weak precision was poor. analgesics), health behavior (assessed by the Millon Behavioral Health Inventory) Kivioja et al., 200529 Patients presenting to Coping (catastrophizing, as 1-year follow-up. When all predictors were Cohort (Phase II) emergency room in assessed by CSQ) Outcome: neck pain (‘Do included in multivariable Stockholm with WAD administered within 1 week you have neck pain now’: analysis, only prior neck pain (December 1996-June 1997); of injury, prior neck pain, yes/no). predicted neck pain at one 18-65 years old. (n=96) initial neck pain intensity, year (OR=4.5, 95% CI 1.11- age, gender. 8.76). Krafft et al., 200030 Insurance claimants with Prognostic factors were tow- One year follow-up. Presence of tow-bars on cars Cohort (Phase I) Folksam, Sweden; AIS 1 bar presence on the stricken Outcome was medical is associated with long term Evidence Tables: Course and Prognosis in WAD 12 neck injuries after rear vehicle and peak assessment of pain, function consequences (RR= 1.22), but impact; random sample of accelerations in the crash. and/or mental dysfunction. not short-term consequences. injuries between 1990 and 1993. For long-term portion of study, at least one passenger sustained loss of function, pain and/or mental dysfunction assessed at one year. (n=659 for short term and 501 for long term consequences) Krafft et al., 200231 Insurance (Folksam, Sweden) Prognostic factor was crash At least 6 month follow-up. Symptoms had longer Cohort (Phase I) claimants with Grades 0-III pulse readings Outcomes: duration of duration with greater mean WAD after a rear impact symptoms (less than one acceleration. involving car models with month vs. more than one crash recorders; crashes month; more than 6 months), occurred after 1996, car recorded on medical notes. models were 1995 and later. (n=66 crashes with 94 WAD injuries) Miettinen et al., 200413 Insurance claimants with Age, gender, education, 1-year follow-up: At one year, low education Cohort (Phase I) neck pain after a motor marital status, collision Outcomes: self-reported predicted impaired health vehicle collision in Finland in factors, WAD classification, change in health due to the (OR for primary school = 4.6, 1998. (n=330) self-reported depression collision, length of sick leave 95% CI 1.3-15.9), being (BDI), general distress due to the collision. divorced or widowed (GHQ). (OR=3.5, 95% CI 0.8-15.9, n.s.). GHQ and BDI each predicted impaired health in crude analyses. Predictors of longer sick leave (unadjusted) were being female and married/divorced/widowed marital status. At 3 years, WAD Evidence Tables: Course and Prognosis in WAD 13 classification predicted change in health. For significant change in health (compared with no change) RR=3.28 (95% CI 1.07- 10.03) for WAD III compared with WAD I. Nederhand et al., 200332 Admissions to general Prognostic factors assessed an 24 week follow-up. Outcome Mean baseline NDI score for Cohort (Phase I) hospital emergency average of 8 days post-injury: was non-disabled (defined as non-disabled, 14.2 (10th, 90th department between July disability (Neck Disability NDI score ≤ 15) vs. disabled %ile, 4.6-25.4) vs. disabled, Nederhand et al., 200433 1999 and December 2001 Index), pain intensity (VAS) (NDI score >15). 27.9 (15.4-40.0); mean Cohort (Phase I) with neck pain after motor fear of movement (Tampa baseline neck pain VAS for vehicle collision. (N=82) Scale), catastrophizing (Pain non-disabled, (33.6, s.d. 20.5) cognition List – Experimental vs. disabled, ( 60.7s.d. 19.4); version), surface mean baseline fear of electromyography. movement for non-disabled, 35.0 (10th, 90th %ile 26.0- 45.0) vs. disabled, 41.5 (33.8- 50.4); mean baseline catastrophizing for non- disabled vs. disabled (28.6s.d. 22.2 vs. 53.2s.d. 24.4) No elevated muscle reactivity (hyper reactivity) at baseline or follow-up. Isometric muscle activity, disabled (141.2 s.d. 70.3) vs. non- disabled (96 s.d. 50.1) No changes over time. All individually predicted recovery. Combining baseline neck disability with fear of movement improves the prediction of outcome. Norris et al., 1983 15 Presentation to a British WAD severity: Group 1 Average follow-up times in Severity of injury at baseline Evidence Tables: Course and Prognosis in WAD 14 Cohort (Phase I) accident department with symptoms but no physical months: Group 1: 19.7; predicted poorer recovery of neck injury from rear-end findings (n=27); Group 2 Group 2: 23.9; Group 3: 24.7. neck pain (Grp1 vs. Grp2, MVC between September symptoms and reduced range Follow-up data at clinic visit RR=1.84, Grp2 vs. Grp3, rr= 1977 and May 1980 (n=61). of movement, no neurological through self-report and 1.11, Grp1 vs. Grp3, RR= signs (n=24); Group 3 physical examination. 2.05). Group membership symptoms, reduced Outcomes: symptoms, time also predicted headaches, movement and neurological off work, neurological parasthesias; more time off loss on examination (n=10). abnormalities. work and interference with These groups were similar to leisure activities at follow-up. the subsequent WAD Grades I-III. Richter et al.; 200434 Patients with WAD Gender, collision factors, 6 month follow-up. Initial SF-36 scores and Cohort Study (Phase II) presenting to the Hanover medical history, symptoms Outcomes: Duration and initial anxiety predicted trauma centre in Germany. (presence, location, time of severity of symptoms (11- duration and severity of neck N= 43 onset and severity of neck point VAS). Other outcomes pain (no effect sizes stiffness, neck restriction, were changes in SF-36, available). Age, gender, presence of vertigo, nausea, everyday quality of life, clinical, radiological findings dysphagia, auditory and/or depression and impact of and collision parameters did visual disturbance), clinical event. not predict severity and findings (neck or occipital duration of symptoms. tenderness or pain, spinous processes, axial compression pain, active/passive range of motion), radiological and neurological findings, treatment, psychological factors (SF36, depression, impact of event, everyday life quality), collision factors (change in velocity, time and location of collision, position in vehicle, airbag deployment, restraint use, collision type, vehicles involved) Sterner et al., 200335 All persons seeking health Rear-end vs. other collision; 16-month follow-up through Predictors of WAD-related Evidence Tables: Course and Prognosis in WAD 15 Cohort (Phase II) care from physicians in Umeå prior headache, prior neck questionnaire. disability were: female (Sweden) after WAD in and prior low back pain (none Outcomes: disability: gender (OR= 2.02, 95% CI MVC. Population-based vs. sometimes/often), age, none/minor or major affecting 1.13-3.63), lower education Excludes those on sick leave gender, marital status, work or leisure. (296 (OR= 2.08, 95% CI 1.09- for neck pain prior to injury. university vs. lower responded to follow-up) 3.98), more severe WAD (n=356) education, occupation, WAD Grades II-III) (OR=2.03, 95% severity (WAD 0-1 vs. 2-3). CI 1.08-3.88) and prior neck complaints (OR= 3.17, 95% CI 1.34-7.46). Suissa et al., 1995 19 Population based: all motor Age, gender, number of Followed until time of claim From Harder et al 1998: Cohort (Phase I) vehicle crash subjects who dependents, marital status, closure or one year and seven Longer time on benefits sustained WAD (ICD-9 employment status, severity years post-crash, via predicted by: female gender Harder et al., 199836 diagnosis code of 847.0) in of collision, vehicle type, administrative records of (RR= .86, 95% CI .77-.96), Cohort (Phase II) 1987 in Québec and who driver/passenger, collision SAAQ in Québec. For one- older age (RR for > 50 years= were compensated by the with stationary/moving year follow-up, subjects .86, 95% CI .83-.90), having Suissa et al., 200337 Société d’assurance object, direction of collision, recovering within 7 days dependents (RR= .84, 95% CI Cohort (Phase II) automobile du Québec. seatbelt use, speed limit, neck were assigned a median .74-.96), not being employed Recurrences excluded. pain, tenderness on palpation, recovery time of 3.5 days. full time (RR= .86, 95% CI Suissa 200138 N=2843 for analyses of signs decreased neck mobility, For 7 year follow-up, injuries .76-.98), being injured in a Cohort (Phase II) and symptoms at 1 year; neck pain on mobilization, not eligible for compensation truck or bus (RR= .48 ,95% N=2810 with an available muscle pain, stiffness, were assigned a mean CI .39-.59), being a passenger police accident report for spasms, radiating numbness, recovery time of 305 days. (RR= .85, 95% CI .74-.97), analyses of crash dizziness/vertigo, loss of Outcome: time in days collision other than rear-end characteristics. N=2627 at 7 consciousness, vision or ENT between collision and last (RR= .85, 95% CI .76-.95) years. problems, anxiety or date of compensation. and collision with a moving insomnia object (RR= .84, 95% CI .72- .99). From Suissa 2003: Signs and symptoms associated with slower recovery were neck pain on palpation (RR= .86, 95% CI .77-.99), muscle pain (RR= .76, 95% CI .76-.1.00), radiating pain or numbness and headache (RR= .55, 95% Evidence Tables: Course and Prognosis in WAD 16 CI .55-.98) and (RR=.82, 95% CI .72-.94). Greater number of risk factors associated with greater time on benefits. From Suissa 2001: At 7 years follow -up, Neck pain on palpation (RR= .85, 95% CI .76-.96), muscle pain (RR= .85, 95% CI .74-.97), Pain or numbness radiating from neck to arms or hands (RR= .64, 95% CI .55-.76) and shoulders (RR= .83, 95% CI .71-.97) and headache (RR= .82, 95% CI .73-.92) associated with slower recovery (adjusted for age and gender.) Evidence Tables: Course and Prognosis in WAD 17 Table 3. Prognostic factors for other outcomes after WAD Author(s), Year, Study Setting and Subjects Prognostic Factors Follow-up and Outcomes Key Findings Design Number (n) Enrolled Considered Measured Buskila et al., 199739 Adults with soft tissue injury Prognostic factor: soft-tissue Follow-up 6-18 months post- At follow-up, neck injury Cohort (Phase I) to the neck reporting to an neck injury or leg fracture; trauma patients had a higher occupational clinic between making an insurance claims. Outcomes: tender point count prevalence of poor July 1994 and December and tenderness threshold, concentration, blurred vision, 1995. Excluded fractures, symptoms of pain, anxiety, dizziness, sleep disturbance, dislocations, subluxations and depression, fatigue, morning headaches, parasthesias and repetitive strain injuries. stiffness and global well subjective joint swelling; (n=102, of whom 74 injuries being (11-point scale); greater severity of fatigue, were traffic related and 28 presence of other symptoms; anxiety, depression, pain, were work related). Controls Quality of Life; physical morning stiffness and poor were patients with leg functioning from global well-being; more fractures (n=59). Fibromyalgia Impact tender points, lower pain Questionnaire. threshold, greater prevalence of fibromyalgia syndrome (13 times greater), poorer quality of life and poorer physical functioning. Neck injury patients with fibromyalgia syndrome had more symptoms. Neck injured patients making insurance claims had lower quality of life (5.6 vs. 5.0 on an 11point VAS, p= 0.039). Carroll et al., 200640 Adults with traffic injuries in Self-reported prior mental Follow-up at 6 weeks and 3, 42% developed depressive Cohort (Phase I) Saskatchewan, Canada health problems, age, gender. 6, 9 and 12 months by symptoms within 6 weeks of between December 1997 and telephone interview. WAD injury, with 38% of November 1999; reporting Outcomes: Timing and these having recurrent or neck pain after the collision. frequency of depressive persistent depression (n=6013) symptoms (measured by throughout follow-up. Self- CES-D); course of depressive reported prior mental health symptomatology problems predict persistent Evidence Tables: Course and Prognosis in WAD 18 (17.5%; 95% CI, 14.1-21.3) and recurrent (25.6%; 95% CI, 21.6-29.9) depressive symptoms, as well as later onset of depressive symptoms. Holm et al, 200741 All personal injury claimants Prognostic factors: gender, Follow-up at 6 weeks, 4, 8 21% developed widespread Cohort (Phase I) after motor vehicle injury in age, education, prior health, and 12 months. body pain at some point Saskatchewan, Canada, July prior neck pain, prior Outcome: onset of during the one year follow- 1994 to December 1995; 18 headache, post-injury widespread body pain (using up. 64% of these years or older; self-reported symptoms, neck pain a liberal case definition for subsequently improved, and neck or shoulder pain after intensity, number of areas in widespread body pain) of these, 22% had collision, and localized neck pain, depressive symptoms recurrences. Onset of injury with or without head or (CES-D) widespread pain was more back pain. (n=266) common in women (OR= 1.6, 95% CI 1.1-2.1), greater number of painful body areas initially (OR= 2.6, 95% CI 1.3-5.4), greater initial neck pain intensity (OR= 3.2, 95% CI 1.3-8.0), and more depressive symptoms (OR= 3.2, 95% CI 1.6-6.3). Kasch et al, 200142 Patients presenting to Prognostic factors: type of Follow-up at 1 week, 3 and 6 At 1 week to 3 months, WAD Cohort (Phase II) emergency units in Aarhus, injury. months. patients had greater focal Denmark, within 2 days of Outcome: Musculoskeletal sensitization (lower pressure neck injury in a rear-end sensitization, determined by pain thresholds, mean collision. (n=123). Controls: pressure-pain-detection difference = -.3, p=.008 and patients with ankle injuries. thresholds and palpation- greater tenderness, mean (n=36). score. difference = 1.6, p = <.05) than controls. No differences were present by 6 months. Kasch et al., 200543 Adult WAD patients Type of injury (WAD vs. Follow-up at 1, 3, 6 and 12 No differences in time to Cohort (Phase II) attending emergency units in ankle) months post-injury. peak pain between recovered Evidence Tables: Course and Prognosis in WAD 19 Aarhus after rear-end Outcome: pain (VAS, WAD and ankle injuries at collision, with initial numeric scale and McGill baseline or follow-up. complaints. (n=141 at Pain Questionnaire); self- Unrecovered WAD had baseline, 99 by 1 year). reported work capacity; and reduced time to peak pain at Comparison Group: Adult time to pressure pain baseline (59.1 ± 30.8 vs. patients with non-sport ankle tolerance in cold pressure 29.15 ± 10.5, p<.001) and 6 injuries. (n=40 at baseline, test. Outcomes stratified by months (55.1 ± 30.2 vs. 26.5 21 by 1 year. Initial recovered WAD; non- ± 14.9, p< .001) but not at 12 assessment 1 week after recovered WAD; and ankle months. Unrecovered WAD injury. injury. had higher pain than recovered WAD at all time points (no adjustment for initial pain analysis). Nederhand et al., 200332 Admissions to general Time since injury, baseline Follow-up at 1, 4, 8, 12 and No elevated muscle reactivity Cohort (Phase I) hospital emergency neck disability (measured by 24 weeks. Outcomes were at any point. Surface EMG of department between July NDI), fear of movement upper trapezius EMG (muscle upper trapezius muscle 1999 and December 2001 (Tampa Scale for reactivity to exercise, inversely related to neck pain with neck pain after motor Kinesiophobia). isometric and dynamic disability, but no time-related vehicle collision. (N=92 muscle activity) and disability changes in EMG. Baseline completing both baseline and status. Disability status neck disability predicts EMG follow-up for EMG and assessed by Neck Disability findings at 24 weeks. Effect disability portion; n=82 for Index (NDI), categorized into sizes not provided. fear of movement study) recovered, mild, moderate and severe/complete. Richter et al.,200434 Patients with WAD Gender, collision factors, 6 month follow-up. Initial pain intensity score >5, Cohort (Phase II) presenting to the Hanover medical history, symptoms, Outcomes: SF36, everyday duration of symptoms more trauma centre in Germany. clinical findings, radiological quality of life (EDLQ), than 28 days had significant N= 43 and neurological findings, depression (CES-D), and changes in SF36, EDLQ, treatment, psychological impact of event (IES). CES-D, and IES scores at 6 factors, collision mechanism months. Initial scores on these predicted later scores. Effect sizes not provided. Wynne-Jones et al., 200644 Adult traffic-injury claimants Gender; age; prior health, 12-month follow-up of pain 54 (7.8%) had widespread Cohort (Phase II) to one UK based insurance prior psychological health, data. Outcome: New onset body pain at one year. After company; with no widespread collision factors, post- of widespread body pain adjusting for age and gender, Evidence Tables: Course and Prognosis in WAD 20 body pain in the month before collision symptoms, pain and (same definition as at in comparison with no neck the collision. Widespread health. baseline) pain, pre-collision only neck pain defined as pain both pain RR=2.0 (95% CI 0.7- above and below the waist, in 5.5); post-collision only neck both sides of body and in the pain RR=2.8 (95% CI 1.6- axial skeleton. N=957 5.0); pre- and post-collision enrolled and 695 at follow-up neck pain RR=3.3 (95% CI (39 had pre-collision neck 1.5-6.8). Neck pain was not pain, 153 had post-collision associated with onset after neck pain and 37 had both). also adjusting for all other potential prognostic factors. Evidence Tables: Course and Prognosis in WAD 21 Reference List 1. Berglund A, Alfredsson L, Cassidy JD et al. 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