If rehabilitation interventions are to be provided accurately it seems that adopting same approach for back and neck pain may be inappropriate. Evidence from: SZ George. Spine. October (2001) Vol. 26 #19 p 2139 A refinement of the role of fear avoidance in the course of chronic pain conditions is suggested by this research. The hypothesis being tested is that fear avoidance beliefs (FAB) would have different effects on the course of two very similar injuries located in different parts of the body, the lower back and, neck. FAB believed to be determined by stressful life events, personality, previous history of pain, and pain coping strategy? However it is not clear that the effect of each of these can be independently measured. The study made assessments of cases that had been referred to a chronic pain clinic. FAB were the same for both neck pain and back pain cases, however the associated disability was worse for back cases. Pain and disability were related for back cases but not nec

The work reported here describes a randomised control trial of a locally developed book on the self-management of back pain. Reductions in pain and disability were found during week one in the booklet group and in the advice to exercise group but not in the “both” group. There was no detectable difference between groups in pain/function scores at week three. Evidence from: P Little et al. Spine. October (2001) Vol. 26 #19 p 2065 The Radar report is available to subscribers: 1#11 7

The bio mechanical model of whiplash promotes the orthodoxy that relative motions of head and torso, if eliminated, would eliminate whiplash neck injury. The novel device reported here would reduce relative motion, but its effect on claims would need to be validated. Evidence from: AF Tencer et al. Spine. November (2001) Vol. 26 #22 p 2432. A study of the relative motions of head and torso during rear end collision and the effectiveness of a head restraint air bag. New head restraint air bag was closer to the head, and absorbed some of the shock. Test speeds were below 10 kph. Relative motion was reduced. Comment If relative acceleration is important in causing injury at these speeds the new device would seem to offer some protection. Other studies have shown that even when torso and head are strapped firmly to the same rigid board, a rear end impact results in some deformation of neck alignment.

If the standard biomechanical model of causation doesn’t have any practical utility, why is it so popular? It may be that no credible alternative has been proposed, but that doesn’t mean a defectice model should be adhered to. Defective models lead to defective assumptions and defective claims handling. Evidence from: R Ferrari. Spine. October (2001) Vol. 26 #19 p 2063. An editorial on the subject of research into whiplash neck injury. There is consensus that direction of vehicle impact is not prognostic of acute or chronic problems or litigation status. So if direction doesn’t matter, protection in vehicle is irrelevant. So why continue to focus research into protection from just one direction? The best treatments take no account of detailed pathology, so why study it any more? Good treatments such as nonspecific exercise regimens and general advice do not require deep understanding of pathology. Identification of an acute lesion would not explain why some develop ch

There are currently 600,000 with Chronic Obstructive Pulmonary Disease (COPD) in the UK. Vocational rehabilitation would be more successful if the suggested options were employed.  Evidence from: A statement made by the British Thoracic Society. Thorax. November (2001) Vol.56 #11 p 827 The Radar report is available to subscribers: 1#10 20

Neck pain immediately after any violent event stimulates  of precautionary responses in medics. It is likely that these responses have a high rate of harmful effect on those not seriously injured, while preventing permanent disability in those who are. This research suggests a selection method. Evidence from: IG Stiell et al. Journal of the American Medical Association. October (2001) Vol. 286 # 15 p 1841. The Radar report is available to subscribers: 1#10 3

It could be argued that physiotherapy could play a role in recovery if it helps overcome obstacles (such as temporary pain relief) to return to normal activity. While there was no evidence in the review to support this, it would be presumed by most practitioners. Anecdotal support for this presumption is persistent and strong. Evidence from: RD Herbert et al. BMJ. October (2001) #7316 p 788. Recommendations for prevention and treatment of chronic MSK pain are: don’t get chronic get active; return to normal activity. Massage and manual therapy and other physical modalities are not proven or are variable. The Radar report is available to subscribers: 1#9 13

Evidence from: SJ Turnbull et al. Brain Injury. Sept (2001) Vol. 15 #9 p 775. PTSD is defined in part by the presence of intrusive memories of the traumatic event. It might be supposed that amnesia would lessen the impact. This was a small study designed to explore this self-evident truth. In fact it was found that groups of people with extensive amnesia or, no traumatic memories of the index event, have higher levels of psychological distress than do those with traumatic memories. Comment Amnesia does not appear to protect against adverse psychological consequences of trauma. But does protect against intrusive memories! Diagnosable harm is required for compensation purposes. It would seem PTSD should not be cited in cases of amnesia, other diagnoses should apply.   Evidence from: E Doig et al. Brain Injury. Sept (2001) Vol. 15 #9 p 747 Withdrawal from society/community following traumatic brain injury is a sign of loss of quality of life and may be considered when assessing damag

A small study of alternate therapies for PTSD. Exposure therapy (ET) is essentially a process of reliving the event in safe surroundings, this approach has been criticised and strong evidence has been found that it is worse than neutral. Cognitive Behavioural Therapy actively addresses beliefs and actions. Evidence from: N Paunovic et al. Behavioural Research and Therapy. October (2001) Vol. 39 #10 p 1183. The Radar report is available to subscribers: 1#9 3

Further evidence that non-severe head injury can lead to significant effects on daily life. Interventions are possible if detected early. Evidence from: CM Stonnington. Brain Injury. July (2001) Vol. 15 #7 p 561. The Radar report is available to subscribers: 1#7 10

Chronic pain is naturally self resolving in the great majority of cases where tissue damage is repaired. But it persists and is disabling to a significant proportion. This study examines the role of anxiety. Interventions for anxiety are possible. Evidence from: MJ Zvolensky et al. Behavioural Research and Therapy. June (2001) Vol. 39 #6 p 683. The Radar report is available to subscribers: 1#6 15

Views about head injury are evolving. Greater attention is now being paid to relatively minor symptoms which have powerful effects on quality of life and damages. Evidence from: B Gurr et al. Brain Injury. May (2001) Vol. 15 #5 p 387. A report of the effect of concussion caused by an injury event and the effectiveness of graduated exposure, in a safe environment, on rehabilitation. The report states that between 51% and 86% of minor head injuries are accompanied by post concussion syndrome (PCS): • dizziness 25-30%, • visual problems 19%, • depression >35%, • anxiety >45% Duration is often >3 months (but without stating how often and in what circumstances). The report into rehabilitation of such cases was not particularly noteworthy. Comment Treatment and the organisation of post injury services should make allowances for PCS. Therapy to prevent unnecessary chronicity and severity of the above complications may prove valuable in preventing unnecessary morbidity and disability.

The purpose of intervention in back pain can vary from one stakeholder to another. A medic might aim for pain reduction, a physio might aim for range of movement, an employer might aim for return to work. All three are inter-related and contribute to damages awards. But it isn’t as simple as that. What does the injured person aim for? Evidence from: J Guzman et al (C Bombardier). BMJ. June (2001) #7301 p 1511. A review of intervention studies and what works. The Radar report is available to subscribers: 1#6 13

Popular culture has it that back pain is a result of injury. Disability is a result of pain and injury. Objective records of actual activity during a normal day were compared with questionnaires designed to measure disability and pain. Evidence from: JA Verbunt et al. Archives of Physical Medicine and Rehabilitation. June (2000) Vol. 82 #6 p 726. There was no significant correlation between any of the three questionnaire scores and objective activity measures. There was no significant difference in objectively measured activity between cases and controls. The Radar report is available to subscribers: 1#6 4 Evidence from: T Jacob et al. Archives of Physical Medicine and Rehabilitation. June (2000) Vol. 82 #6 p 735. There was no correlation between high disability scores and low activity scores. The Radar report is available to subscribers: 1#6 5 Evidence from: JM Stevenson et al. Spine. June (2001) Vol. 26 #12 p 1370. Physical activity is protective against back pain. The Radar report i

Pain, Psychological distress, fear-avoidance beliefs, efficacy in coping were moderately good predictors of disability prior to therapy. Improvements in strength and endurance were made in all three treatments, but these were unrelated to improvements in ability or reductions in pain. Evidence from: AFMannion et al. Spine. April (2001) Vol. 26 #8 p 897 The Radar report is available to subscribers: 1#5 7

The study provides evidence that early signs of thrombosis can be prevented in healthy people. there is implied support for the use of surgical stockings in high risk travellers. Exactly what it is about long distance flights that leads to early signs of thrombosis in the calf is not known but there is speculation that prolonged sitting at a desk could have the same effect. Evidence from: JHScurr et al Lancet. May (2001) Vol. 357 #9267 p 1485. A study of the development of deep vein thrombosis during long distance flights (>8hours). 89 males and 142 females aged over 50 with no recorded history of thromboembolism volunteered in response to an advert. All were scheduled to undertake a journey involving continuous flight for more than 8 hours. 30 of them were used as controls by making measurements 2 weeks and then 2 days before travel. In this way the potential for development of signs of DVT in absence of air travel could be tentatively assessed. Those volunteers that were retained

Pain hypersensitivity could explain disability where tissue damage is absent. This preliminary study provides tentative clues about this phenomenon and its potential prognostic power. MWerneke et al. Spine. April (2001) Vol. 26 #7 p 758 A proposed new method for predicting chronicity of low back pain following an acute attack. The authors propose that centralisation of pain within weeks of the acute attack may indicate a better outcome. Centralisation phenomenon is where the pain migrates from the distal or peripheral to the proximal or central. The authors conclude that the negative assessment of centralisation in the first few weeks is a useful predictor of continuing (long-term) pain and disability. However, the study was either not well designed or poorly reported. Comment A semi objective test would be very useful in selecting back pain cases that ought to be managed more closely. The method proposed here is not validated by this study, but it is likely (given the desire to find a

Does surgery have a useful role in mitigating carpal tunnel syndrome? Evidence from: AJ Rege et al. Journal of Hand Surgery. April (2001) Vol. 26B #2 p 148 A study of the effectiveness of carpal tunnel release in the restoration of normal life. Prospective study on 96 release patients compared with healthy normal controls. Quality of life assessment by Nottingham Health Profile, before, and 4 months after, surgery. Only 58% of the initial cohort completed the study. Completers were mainly between 30 and 60 yr. old. The authors conclude that outcome (quality of life) after surgery was not dependent on physical parameters but was associated with attitude before surgery. They question the value of surgery for people with a grumbling, dissatisfied view of life. Comment Patient satisfaction and return to normal life after carpal tunnel release was once (30 years ago) regarded as a given. Non-organic factors now provide an increasing challenge to surgeons and, to those who pay for surgery.

The research explores how well the validity questionnaire can distinguish between those who intend to deceive and those who do not. Evidence from: BE McGuire et al. Journal of Clinical Psychology Mar (2001) Vol.57 #3 P401 A key issue in the design of validity questionnaires is whether they will work for specific claimant groups. This is especially pertinent when the illness itself is subjective. The Radar report is available to subscribers: 1#3 10

This review focussed on multidisciplinary biopsychosocial interventions for those suffering from sub-acute low back pain.. Biopsychosocial factors have a very strong influence on the course if back pain related disability and work absence. A simplistic view would suggest that tackling any of the most potent factors should improve prognosis, leading to reduced insurance outlay. Evidence from: Karjakainen K, et al (Cochrane Back Review Group), Spine (2001), Vol. 26 #3, p.262-9. Review of research into multidisciplinary biopsychosocial (MBP) rehabilitation for sub-acute low back pain (LBP) in working-age adults. The authors state that there is moderate evidence showing MBP for sub-acute LBP is effective. Comment Such a wide range of inhomogeneous studies examined therefore would be very hard to compare properly. This area is lacking in well designed studies. LBP is a leading cause of morbidity in the working age population and is often linked with negligence. While the validity of this li

The draft ACoP records the state of knowledge in 2001. It lays emphasis on health surveillance where there is any suspicion of risk – in addition to compliance with official exposure controls. Early signs of sensitisation should be managed. The key distinction between ‘caused or made worse‘ and, ‘made more symptomatic‘ is recorded here. Evidence from: HSE CD 164 (2001) ‘An Approved Code of Practice for Occupational Asthma.’ Radar report is available to subscribers: 1#1 1