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Heneghan N.R.1, Smith R.2, Tyros I.1, Falla D.1, Rushton A.1
1University of Birmingham, School of Sport, Exercise and Rehabilitation Sciences, Birmingham, United Kingdom, 2University of the West of England, Bristol, United Kingdom
Background: Research into whiplash associated disorders (WAD) has largely focused on pain and dysfunction of the cervical spine, yet people with WAD report widespread pain including pain in the thoracic region where the prevalence of pain is ~66%. Approximately 60% of patients post WAD progress to develop chronic pain and disability, resulting in high levels of associated societal and healthcare costs. With the thoracic spine contributing to cervical mobility and function, it is time to look beyond the cervical spine to fully understand musculoskeletal dysfunction associated with WAD. This may provide new directions for clinical practice and research.
Purpose: To evaluate the evidence for and nature of, dysfunction in the thoracic spine region in patients with WAD.
Methods: A systematic review and data synthesis was conducted according to a pre-defined published protocol registered with PROSPERO (CRD42015026983). All forms of observational study were included. A sensitive topic-based search strategy was designed from database inception to 1/06/16. Databases, grey literature and registers were searched using study population terms and key words derived from scoping search. Two reviewers independently searched information sources, assessed studies for inclusion using a priori criteria, and extracted data. A third reviewer checked for consistency and clarity. Extracted data included: sample size sample characteristics, outcome measures, and timescales to reflect the state of the disorder (acute, sub-acute or chronic). Risk of bias was assessed by the two reviewers using the Newcastle-Ottawa Scale. Data were tabulated to allow for semi qualitative comparison and grouped according to measurement outcome to compare across studies. Results were reported in the context of overall quality. The strength of the overall body of evidence was assessed using adapted GRADE.
Results: Thirty seven studies were included (n=>50,000) across a range of countries Results were presented for measure of pain or dysfunction and presented, where possible, according to WAD severity and time-point post injury. Key findings include: 1) high prevalence of thoracic pain (>60%); higher for those with more severe presentations and in the acute stage; 2) low prevalence of chest pain ( 22%); 3) evidence of thoracic outlet syndrome and involvement of the brachial plexus, 4) muscle dysfunction, specifically heightened sternocleidomastoid activity and delayed onset of serratus anterior action, 5) high prevalence of myofascial pain and trigger points in the scalene, sternocleidomastoid and mid/lower fibers of trapezius muscles (48-65%); 6) inconclusive evidence of postural changes and chest/thoracic mobility.
Conclusion(s): There is considerable evidence of thoracic pain and dysfunction in individuals with WAD involving nerves and/or muscles. Additional high quality research is required to further characterise dysfunction across other structures in the thoracic spine and in turn inform clinical trials targeting such dysfunction.
Implications: Musculoskeletal dysfunction post WAD includes the thoracic spine region and merits consideration by clinicians when examining patients. Research is required to further characterise thoracic dysfunction in WAD, including the effect of injury on thoracic joints/mobility; something that is a notable omission from the current evidence base.
Funding acknowledgements: None
Topic: Musculoskeletal: spine
Ethics approval: None required
All authors, affiliations and abstracts have been published as submitted.
