Background and aims. The EU-funded Back-UP project aims to develop a cloud computer platform to guide the treatment of low back and neck pain (LBNP) in first contact care and early rehabilitation. In order to identify evidence-based treatment options that can be recommended and are accessible to people with LBNP across Europe, we conducted a systematic review of recently published guidelines. Methods. Electronic databases, including Medline, Embase, CINAHL, PsycINFO, HMIC, Epistemonikos, PEDro, TRIP, NICE, SIGN, WHO, Guidelines International Network (G-I-N) and DynaMed Plus were searched. We searched for guidelines published by European health professional or guideline development organisations since 2013, focusing on the primary care management of adult patients presenting with back or neck pain (including whiplash associated symptoms, radicular pain, and pregnancy-related LBP). The AGREE-II tool was used to assess the quality of guideline development and reporting. Results. Searches generated 3098 unique citations that were screened for eligibility. A total of 189 full-texts were retrieved, and 18 guidelines were included in the review (from the UK, Germany, France, Italy, Denmark, Poland, Belgium, and the Netherlands). Data extraction showed considerable variation in guideline development processes, especially regarding the methods used for identifying, appraising, and synthesising evidence, and for formulating, agreeing, and grading recommendations. Conclusions. Recommendations for the management of LBNP cover a wide range of treatment options, with self-management advice, analgesics, and exercise proposed as core treatments by most guidelines. A narrative synthesis, taking into account consistency, strength, and quality of guideline recommendations, will be presented. No conflicts of interest. Funding: This abstract presents independent research within the Back-UP project, which has received funding from the European Union's Horizon 2020 research and innovation programme under grant agreement No. 777090. This document reflects only the views of the authors, and the European Commission is not liable for any use that may be made of its contents. The information in this document is provided “as is”, without warranty of any kind, and accept no liability for loss or damage suffered by any person using this information

Over the past two decades much has been written regarding pain and disability following whiplash injury. Several authors have reported on the relationship between insurance claims and whiplash-associated disorders. Our own experience of over 10-years suggests that fracture may be protective of whiplash injury following road traffic accident (RTA). We exported all ‘medical legal’ cases due to RTA from our EMR system and combined this with patient-reported outcome measures. 1,482 (57%) of all medicolegal cases are due to RTA: 26% ‘head-on’, 34% ‘side-impact’ and 40% ‘rear-ended’. Over half of the vehicles involved are subsequently written-off. While the mean BMI is 27.1, ¼ of this cohort has a BMI over 30 (obese). 163 (11%) patients report a fracture occurring as a result of RTA. Type of impact is significant for fracture (p < 0.05). 47% of RTA which result in fracture are due to ‘head-on’ collision; conversely only 21% are due to ‘rear-ended’ impacts. In 1,324 (89%) of RTA without fracture, patients are twice as likely to report whiplash injury as one of their top-3 sources of pain (p < 0.01). Gender is statistically significant for age (M 44.4, F 38.6, p < 0.05). While the BMI of this cohort is alarming, it is consistent with Irish obesity statistics. Type of impact, in particular ‘head-on’ collision (high kinetic energy event), is significant for fracture. Finally, we report that fracture is significantly protective (p < 0.01) of whiplash injury following RTA

Objectives. Loss of motion following spine segment fusion results in increased strain in the adjacent motion segments. However, to date, studies on the biomechanics of the cervical spine have not assessed the role of coupled motions in the lumbar spine. Accordingly, we investigated the biomechanics of the cervical spine following cervical fusion and lumbar fusion during simulated whiplash using a whole-human finite element (FE) model to simulate coupled motions of the spine. Methods. A previously validated FE model of the human body in the driver-occupant position was used to investigate cervical hyperextension injury. The cervical spine was subjected to simulated whiplash exposure in accordance with Euro NCAP (the European New Car Assessment Programme) testing using the whole human FE model. The coupled motions between the cervical spine and lumbar spine were assessed by evaluating the biomechanical effects of simulated cervical fusion and lumbar fusion. Results. Peak anterior longitudinal ligament (ALL) strain ranged from 0.106 to 0.382 in a normal spine, and from 0.116 to 0.399 in a fused cervical spine. Strain increased from cranial to caudal levels. The mean strain increase in the motion segment immediately adjacent to the site of fusion from C2-C3 through C5-C6 was 26.1% and 50.8% following single- and two-level cervical fusion, respectively (p = 0.03, unpaired two-way t-test). Peak cervical strains following various lumbar-fusion procedures were 1.0% less than those seen in a healthy spine (p = 0.61, two-way ANOVA). Conclusion. Cervical arthrodesis increases peak ALL strain in the adjacent motion segments. C3-4 experiences greater changes in strain than C6-7. Lumbar fusion did not have a significant effect on cervical spine strain. Cite this article: H. Huang, R. W. Nightingale, A. B. C. Dang. Biomechanics of coupled motion in the cervical spine during simulated whiplash in patients with pre-existing cervical or lumbar spinal fusion: A Finite Element Study. Bone Joint Res 2018;7:28–35. DOI: 10.1302/2046-3758.71.BJR-2017-0100.R1

Whiplash injury is surrounded by controversy in both the medical and legal world. The debate on whether it is either a potentially serious medical condition or a social problem is ongoing. This paper briefly examines a selection of studies on low velocity whiplash injury (LVWI) and whiplash associated disorder (WAD) and touches upon the pathophysiological and epidemiological considerations, cultural and geographical differences and the effect of litigation on chronicity. The study concludes that the evidence for significant physical injury after LVWI is poor, and if significant disability is present after such injury, it will have to be explained in terms of psychosocial factors

Introduction. Whiplash injury following rear shunt Road traffic accident (RTA) has been associated with impingement syndrome of shoulder. However, the results of arthroscopic subacromial decompression (ASAD) for this group of patients have never been compared to the non accident group. In our study we aim to compare the results of ASAD in these patients to a group who did not sustain whiplash injury. Materials/Methods. Thirteen patients with impingement syndrome following rear shunt RTA were followed up (2004–09). After failed conservative management for at least 6 months ASAD was performed. This group was compared with a control group (not involved in an RTA) of 13 consecutive patients (age and sex matched). All patients were assessed with Oxford shoulder score preoperatively and twice post operatively (within 3 months and at one year). Results. In the RTA group all 13 patients showed improvement in their oxford score over one year. While the improvement was only Marginal (p= 0.08) at three months it was better at the end of a year (p=0.04). Comparatively in the cohort without the whiplash injury the improvement was more marked in the first three months (p=0.05) with significant improvement at the end of the year (p=0.03). The overall improvement in Oxford score was more in the cohort of patients who were not involved in a RTA as opposed to the RTA group (p= 0.05). Conclusion. The results of the study show that even though there was an improvement in shoulder scores after an arthroscopic subacromial decompression it was much slower and overall results were inferior in the RTA group as opposed to the controls and hence prognosis should be guarded when offering ASAD for patients with whiplash injury

Aims. To capture the views of various members of the healthcare system with regards to whiplash injuries and in particular, the cumulative effects of whiplash on a patient seeking compensation. Method. A questionnaire was set up on “Surveymonkey” which consisted of three scenarios outlining 1. single whiplash injury 2. Past history of neck pain with new whiplash injury 3. Chronic history of neck pain with a new whiplash injury seeking long term compensation and early retirement. The respondents were asked whether or not they agreed or disagreed with fictional expert opinions for each scenario. The questionnaire was distributed to orthopaedic surgeons, accident & emergency doctors, general practitioners and physiotherapists. Results. In Scenario 1, half of the respondents believed that after a single whiplash injury with no past history of neck pain a decision of 3 months worth of disability compensation was acceptable. In Scenario 2, 67% of respondents opined that a previous history of whiplash injury makes a patient more susceptible to further soft tissue damage. Finally, in Scenario 3 100% of respondents believe that a decision of 12 years of compensation and early retirement due to his new injury was unjustifiable. Conclusions. Our questionnaire revealed that the majority of respondents believe that whiplash injuries are cumulative in nature. They also are of the opinion that chronic neck pain, once settled, does not contribute to subsequent whiplash injury. Conflicts of Interest. None. Source of Funding. None

A total of 159 patients (84 women and 75 men, mean age of 53 (20 to 87)) with subacromial impingement were randomised to treatment with subacromial injections using lidocaine with one of hyaluronic acid (51 patients), corticosteroid (53 patients) or placebo (55 patients). Patients were followed up for 26 weeks. The primary outcome was pain on a visual analogue score (VAS), and secondary outcomes included the Constant Murley score, shoulder pain score, functional mobility score, shoulder disability questionnaire and pain-specific disability score. The different outcome measures showed similar results. After three, six and 12 weeks corticosteroid injections were superior to hyaluronic acid injections and only at six weeks significantly better than placebo injections. The mean short-term reduction in pain on the VAS score at 12 weeks was 7% (sd 2.7; 97.5% confidence interval (CI) 0.207 to 1.55; p = 0.084) in the hyaluronic acid group, 28% (sd 2.8; 97.5% CI 1.86 to 3.65; p < 0.001) in the corticosteroid group and 23% (sd 3.23; 97.5% CI 1.25 to 3.26; p < 0.001) in the placebo group. At 26 weeks there was a reduction in pain in 63% (32 of 51) of patients in the hyaluronic acid group, 72% (38 of 53) of those in the corticosteroid group and 69% (38 of 55) of those in the placebo group.

We were not able to show a convincing benefit from hyaluronic acid injections compared with corticosteroid or placebo injections. Corticosteroid injections produced a significant reduction in pain in the short term (three to 12 weeks), but in the long term the placebo injection produced the best results.

The April 2012 Trauma Roundup. 360 . looks at fibula-pro-tibia plating, galeazzi fractures, distal radial fractures in the over 65s, transverse sacral fractures, acute dislocation of the knee, posterior malleolar fractures, immobilising the broken scaphoid, the terrible triad, lower limb amputation after trauma, and whiplash injuries

The NDI is a simple 10-item questionnaire used to assess patients with neck pain. The original validation was performed on 52 patients with neck pain and the test-retest on 17 whiplash patients with a 2-day interval. The SF36 measures functional ability, wellbeing and the overall health of patients. It is used in health economics to assess the health utility, gain and economic impact of medical interventions. Objectives were to independently validate the NDI in patients with neck pain and to draw comparison between the NDI and SF36. 160 patients with neck pain attending the spinal clinic completed self-assessment questionnaires. A second questionnaire was completed in 34 patients after a period of 1-2 weeks. The internal consistency of the NDI and SF36 was calculated using Cronbach alpha. The test-retest reliability was assessed using the Bland and Altman method and the concurrent validity between the two questionnaires was assessed using Pearson correlation. Both questionnaires showed robust internal consistency: SF36 alpha = 0.878 (se=0.014, 95%CI=0.843 to 0.906) and NDI = 0.864 (se=0.017, 95%CI=0.825 to 0.894). The NDI had significant correlation to all eight domains of the SF36 (p<0.001). The individual scores for each of the ten items had significant correlation with the total disability score (p<0.001). The test-retest reliability of the NDI was acceptable. We have shown irrefutably that the NDI has good reliability and validity and that it stands up well to the SF36

Purpose: Whiplash injury occurs due to motor vehicle accidents has its long term consequence, nevertheless very little is written about its long-term follow up. The aim of the study is to find out the long-term follow up of Whiplash injury and the factors affecting the long-term follow up. Method: It is a retrospective study which was done in Russells Hall Hospital in the west midland in UK. 64 patients were selected in this study. Only 54 patients were replied. An inclusion criterion was Whiplash injury due to RTA in years 1995, 1996 and 1997. Initial examination was performed 5.6 +/ – 4.5 days after trauma, and follow-up examinations 3, 6, 12, and 24 months. Exclusion criteria were any cervical spine bony injury, associate head injury and poly-trauma patients. The outcome measures used for assessment are SF36, Whiplash Disability Questionnaire score WDQS, and questions to cover their present symptoms, work circumstances before and after the injury, current and previous treatment. Results: In our study we found that the time it takes for the patient’s symptoms to resolve varies, it took less than 6 weeks in 4 patients, between 6 weeks to 3 months in 10 patients, between 6 months to 1 year in 15 patients and more than one year in 3 patients. The average follow up time was 10.3 years. Our results did show these figures: 22 patients were still symptomatic 10 years after injury, 18 still complaining of pins & needles, 13 still having frontal headache and 7 having occipital headache. Headache was one of the symptoms which annoyed Whiplash injury patients. Headaches following Whiplash injuries were occipital, frontal or generalised. Headache was usually of Muscular contraction type, often associated with greater occipital neuralgia. 16 patients still had treatment in the form of pain killers or physiotherapy. The mean WDQS was less than 20 in 38 patients. The mean WDQS in patients with low back pain was 29.23 and for those without back pain were 12.53. In the smokers the mean whiplash score was 32.2. In the non-smokers the Whiplash score was 17.93. The mean WDQS in those who do not drink alcohol was 26.73 and in those who drink alcohol were 16.58. Conclusion: Whiplash injury patients have long term residual symptoms mainly pins & needles as well as headache and dizziness. Claiming compensation is a bad prognostic factor on the long-term outcome of Whiplash injury patients. Drinking alcohol, Gender, BMI, treatment given after the initial injury and smoking have no effect on the long-term outcome of these injuries. Age & Low back pains are bad prognostic factors. Whiplash Disability Questionnaire score, SF 36 (for body pain) and time for symptoms to be relieved are sensitive outcome measures to assess those injuries

Whiplash vertigo syndrome is often seen in victims of rear-end vehicle collisions. These patients commonly complain of headache, vertigo, tinnitus, poor concentration, irritability, and sensitivity to noise and light. Sixteen patients (medium age, 39,5 years) that they refered in orthopaedic examination because of long-lasting subjective complaints after cervical spine injury underwent clinical, laboratorial and psychometric examinations. The mean posttraumatic interval was 43 months. Ten patients were injured in road accidents, 5 during sports and one at work, all with mechanism trial of whip. Each patient was evaluated with otorhinolaryngologic examination, audiometry tests, CT: petrus – internal auditory meatus and cerebellopontine corner. Also each patient was evaluated with neurologic examination, psychological well-being scale (sf-36), and personality profile scale. None of the patients had neurologic symptoms, and no lesions of the cervical spine were identified. All the patients had negative clinical, radiological and standard laboratorial control, but may be is a critical point that the eleven of these patients had pathologic OGTT (Oral Glucose Tolerance Test). Also did not exist differentiations from the mean values in psychological well-being scale (SF-36), and personality profile scale of healthy population. Test results were unrelated to the length of the post-traumatic interval. However, 2 distinct syndromes were identified. Ten patients had cervicoencephalic whiplash type syndrome (CES), characterized by headache, vertigo, tinnitus poor concentration, and disturbed adaptation to light intensity. Six patients had the lower cervical spine whiplash type syndrome (LCSS), characterized by vertigo, tinnitus cervical and cervicobrachial pain. The verification of Whiplash Vertigo syndrome require more objective clinical means. This article proposes that exists an organic base for the syndrome, but does not promote that whiplash injury certainly cause it

The Quebec Task Force defined whiplash as “an acceleration–deceleration mechanism of energy transfer to the neck”. It is logical that the lower the velocity change following impact, the lower the risk of injury. The accepted velocity change (delta-v) for whiplash injuries following rear impact has been quoted as 5 mph. There is some debate as whether this is valid in the clinical setting. We aimed to investigate this further. A series of low speed controlled crash simulations were undertaken. There were a total of 27 runs on 23 individuals. Accelerometers were placed on the head and chest of the volunteers. Video recordings were analysed to assess relative displacement of the head and chest. The presence of symptoms was documented over a period of 7 days. The volunteers consisted of 23 males and 1 female with an average age of 38 (range 20–56). The average delta-v achieved was 2.3 mph (range 1.8–3.1 mph). The average maximum accelerations recorded were 3.46g at the chest and 2.93g at the head. The average difference was 0.53g. There was no significant displacement between the head and body. No symptoms were reported beyond 1 hour. Whiplash is triggered if the disparity between movements of the head and neck is of sufficient magnitude. It seems logical that there is a threshold below which whiplash will not occur. Our results have shown that below a delta-v of 3 mph there is little difference in the magnitude and timing of the movements of the head and chest. Therefore the whiplash mechanism of injury does not occur at these changes of velocity

We have reviewed 22 patients at a mean of 30 years (28 to 31) after a whiplash injury. A complete recovery had been made in ten (45.5%) while one continued to describe severe symptoms. Persistent disability was associated with psychological distress but both improved in the period between 15 and 30 years after injury. After 30 years, ten patients (45.5%) were more disabled by knee than by neck pain

Background: The synovial folds of the lateral atlanto-axial joints have not previously attracted significant radiological attention, being small and not routinely demonstrated on conventional MR images. However, they are considered to be a potential source of neck pain and disability, especially following whiplash injury. Purpose: The purpose of this study was to develop an imaging protocol and measurement technique to determine the normal morphology of the synovial folds in vivo and establish normative values for their dimensions. Methods: MR images of the cervical spine of 17 volunteers aged 20 to 50 years (mean 31.1, SD 5.9 years) were acquired using a 1.5T scanner. Seed growing and thresholding methods were used to identify the synovial folds and quantify their dimensions. Results: The median volume of the right ventral and right dorsal synovial folds was 92.01 mm3 and 76.44 mm3, respectively. Left ventral and left dorsal synovial fold median volume measured 79.26 mm3 and 56.44 mm3, respectively. There was a significant difference in volume between the ventral and dorsal synovial folds of the right and left lateral atlanto-axial joints (χ2(3)=17.54, P=.000). The test-retest reliability of the measurement technique was ICC 0.99 and the inter-examiner reliability ICC 0.80. Conclusion: This study is the first to establish a MR imaging protocol to visualise the synovial folds of the lateral atlanto-axial joints in vivo and quantify their morphology. The normative values established in the present study provide the basis for future studies to investigate the role of the synovial folds in patients with neck pain