Elsevier

Physiotherapy

Volume 101, Issue 1, March 2015, Pages 34-43
Physiotherapy

Risk factors for chronic disability in a cohort of patients with acute whiplash associated disorders seeking physiotherapy treatment for persisting symptoms

https://doi.org/10.1016/j.physio.2014.04.004Get rights and content

Abstract

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

Prospective 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.

Participants

Participants (n = 599) with symptoms 3 weeks after injury, self-referred to physiotherapy as part of a randomised 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 resulted 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.

Introduction

Whiplash associated disorders (WAD) describe the symptoms experienced following a whiplash injury [1]. WAD are a significant public health problem as it is estimated that only 50% of individuals who develop WAD recover fully and there remains uncertainty as to the reasons for this [2].

This prospective cohort study investigated if psychological and physical factors were risk factors for the development of chronic disability following an acute whiplash injury. We were interested in identifying risk factors that were potentially modifiable and could be treatment targets for physiotherapy management. We undertook a series of systematic reviews to synthesise evidence of existing risk factors, to identify areas of uncertainty, and methods of measurement [3], [4]. In terms of psychological and behavioural factors, we concluded from the reviews that there was evidence that low self-efficacy and elevated scores on the Impact of Events Scale (post traumatic distress) were associated with chronic disability but evidence supporting other factors was less clear (fear avoidance, catastrophising, coping, depression and anxiety) [4]. Expectations of outcome and treatment preferences had yet to be investigated in acute WAD when the systematic reviews were conducted but warranted investigation. We found evidence that age, gender, initial injury severity and a history of previous neck pain were associated with poor outcome in acute WAD [2], [3], [5] but evidence for physical measures such as range of movement was inconclusive [3] and needed further investigation.

Most prospective cohort studies view risk factors in isolation, however, Carroll [6] emphasises that risk factors do not work alone. Little work has been published on understanding the impact of multiple risk factors. There is a need to further our understanding to aid the development of more effective treatments for patients with acute WAD.

Therefore, the two aims of this paper were:

  • 1.

    To identify risk factors for developing chronic disability in a cohort of patients with acute WAD seeking physiotherapy treatment for persistent symptoms at least 3 weeks post injury.

  • 2.

    To estimate the impact of the number of risk factors present at baseline on outcome.

Section snippets

Patient sample

All participants had sustained an acute whiplash injury and were experiencing neck pain at least 3 weeks after injury. Participants were part of a large cohort of patients who attended NHS emergency departments (ED) following their whiplash injury and had then self-referred to receive physiotherapy as part of a randomised controlled trial [7]. Participants were randomly allocated to one of two physiotherapy treatments (a package of physiotherapy treatment or an advice session) [8]. Individuals

Results

599 participants provided baseline data (Table 1) which was collected, on average, 32 days after injury (SD = 10.9, range = 7 to 74). 459 participants (77%) returned a complete NDI questionnaire at 12 months. 29 participants (5%) were excluded from the analysis due to missing baseline data resulting in 430 (72%) participants contributing data to the final logistic regression model. The average age of those responding to 12 month follow up was 41 years, the majority were female (298/459 [65%]) with

Discussion

Baseline measures of disability and symptoms along with psychological and behavioural factors were identified as risk factors for chronic disability. As the number of risk factors present at baseline increased so did the risk of chronic disability.

The factors selected for testing were underpinned by a biopsychosocial model of disability. We grouped together a number of factors to represent the “bio” aspect of this model (labelled injury severity and ROM) that would be traditionally assessed by

Acknowledgements

We would like to acknowledge the research clinicians who collected baseline data for this study: Liz Ball, Janet Lowe and Cheryl Ritchie (University of Warwick); Claire Hunt, Rachel Trickey and Elaine Willmore (Cheltenham General and Royal Gloucester Hospitals); Heather Shilliday (Countess of Chester Hospital); Susan Kempson (Frenchay Hospital); Bridget Gray and Elizabeth Oastler (John Radcliffe Hospital); Helen Harrison (Kettering General Hospital); Melissa Minshull and Kate Rees (Royal Gwent

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