Background The incidence of traumatic brain injuries (TBI) is about 500 cases per 100,000 inhabitants per year, a majority of which are mild TBI (MTBI). The incidence of whiplash injuries is about 300/100,000/year. There are several similarities between MTBI and whiplash injuries with regard to the causes of injury (traffic crashes and falls), the demographic profile of the injured (mostly young persons), and the type of symptoms exhibited by some of the injured (for example head/neck pain, fatigue, irritability, impaired cognitive functioning, and depression).  Main aim To investigate the epidemiology and long-term consequences in terms of symptoms, disability, and life satisfaction in cases of TBI and whiplash injuries in a well-defined population. Material and methods Data on frequencies and characteristics of TBI and whiplash injuries were extracted from the injury database at the emergency department (ED) of Umeå University Hospital (UUH). The results were presented as descriptive epidemiology. The 18-65 year-old persons who sustained an MTBI or whiplash injury in 2001, were provided a questionnaire three and five years after injury respectively, in which questions were asked about: Symptoms; Rivermead Post Concussion Symptoms Questionnaire (RPQ) Disability; Rivermead Head Injury Follow Up Questionnaire (RHFUQ) Life satisfaction; LiSat-11 A local reference population was used for comparison of the RPQ. A national cohort was used as reference for LiSat-11. Data on sick leave for the cases of whiplash injuries were analysed to calculate the cost to society for loss of productivity. Results In 2001, the incidence of TBI was 354/100,000/year. The mean age was 23 and 55% were men. Ninety-seven percent of the injuries were classified as mild (Glasgow coma scale 13-15). The main causes were falls (55%) and traffic related injury events (30%). In 8% of the cases (17% of the elderly persons) an intracranial bleeding was detected by using CT. The 3-year follow-up of the MTBI patients showed that women had more symptoms and disability (~50%) than men (~30%). Both women and men had more symptoms and lower life satisfaction compared with the reference population. The incidence of traffic-related whiplash injuries in adults was 235/100,000/year and the annual incidences were relatively stable during 2000-2009. Combining the incidences with national insurance data showed that the proportion of insurance claims decreased during the period. When looking at whiplash trauma following all causes of injury in 2001, traffic crashes caused 61% of the injuries and falls caused 14%. Neck fractures occurred in 3% of the cases. Five years after whiplash injury, the injured persons had more symptoms and lower life satisfaction than the references. Sick leave ≥15 days was granted in 14% of the cases of whiplash injuries. The median number of sick days was 298 and the cost of loss of productivity during the follow-up was 5.6 million USD. The frequencies of symptoms were relatively alike when comparing subjects with whiplash injuries to subjects with MTBI. Conclusion TBI and whiplash injuries are common, especially among young people, and the injuries render long-term symptoms, disability, and impaired life satisfaction in up to 50% of the cases. Symptoms exhibited are alike between the two types of injuries. The cost to society for loss of productivity is high, and there is a need for enhanced preventive measures aiming at reducing traffic-related injuries, sports injuries, alcohol-related injuries, and falls. Physical, mental, and social factors are important and should be addressed when examining and treating patients with persisting symptoms following TBI and whiplash injuries. / Bakgrund Skallskador utgör ett stort folkhälsoproblem, särskilt eftersom många som skadas är unga. Skallskador är också, parallellt med självmord, den vanligaste dödsorsaken hos ungdomar och unga vuxna. De flesta av skadorna klassas som ”lätta” i akutskedet men trots det så kommer en del av patienterna att drabbas av kvarstående besvär, t ex smärta, koncentrationssvårigheter, depression och nedsatt livstillfredsställelse. Whiplashskador är nästan lika vanligt förekommande som skallskador och uppkommer framförallt i trafikolyckor. Även fall- och sportskador orsakar emellertid ett betydande antal whiplashskador. I normalfallet avtar de akuta symptomen inom några veckor men en del av patienterna anger att de får kvarstående besvär. Ett flertal skademekanismer i nackens vävnader är kända men tyvärr svåra att verifiera eller utesluta. Huvudsyfte Att undersöka förekomsten av skallskador och whiplashskador i en väldefinierad population samt beskriva restsymptom, funktions-nedsättningar och livstillfredsställelse hos de drabbade tre till fem år efter skadan. Material och metod Förekomsten av skadorna (Studie I, III och IV) Studierna baseras på skadedatabasen vid Norrlands Universitetssjukhus i Umeå (NUS). I skadedatabasen registreras alla patienter som söker till akutmottagningen efter en skadehändelse, ca 10 000 fall per år. När patienterna anmäler sig i receptionen tilldelas de en skadejournal som de själva fyller i i väntan på att bli undersökta. När patienter inkommer med svårare skador får anhöriga i möjligaste mån fylla i journalen. Primärvårdens jour har under åren för studiens genomförande varit belägen på akutmottagningen under kvällar, nätter och helger vilket inneburit att de få skadefall som konsekvent missats har varit lättare skador som behandlats dagtid på vårdcentralerna i upptagningsområdet.   Långtidsuppföljning (Studie II, III och V) En uppföljande enkätundersökning bestående av ett antal validerade frågeformulär skickades till alla skall- och whiplashskadade patienter i arbetsför ålder tre respektive fem år efter skadehändelsen. De frågeformulär som analyserades var: För symptom: Rivermead Post Concussion Symptoms Questionnaire (RPQ) För funktionsnedsättning: Rivermead Head Injury Follow Up Questionnaire (RHFUQ) För livstillfredsställelse: Life Satisfaction-11 (LiSat-11) För smärta (hos de whiplashskadade): Visual Analogue Scale (VAS)  Resultaten från RPQ och LiSat-11 jämfördes med sedan tidigare tillgängligt material från åldersmatchade referenspopulationer. När det gäller de whiplashskadade genomfördes en femårsuppföljning avseende sjukskrivning. Data från Försäkringskassan analyserades och samhällskostnaden för produktionsbortfall beräknades baserat på den genomsnittliga kostnaden för en årsarbetare. Resultat Förekomsten av skallskador vid NUS under 2001 var 354 skadade per 100 000 invånare. Medelåldern på de skadade var 23 år och 55% var män. Andelen lätta skallskador var 97%. Fallolyckor orsakade flest skador (55%) och trafikolyckor var näst vanligast (30%). Minst 17% av patienterna (ofta medelålders personer) var alkoholpåverkade. Hos 8% av patienterna (17% av personer över 65 år) upptäcktes blödningar i hjärnan. I uppföljningen efter tre år noterades att de skallskadade patienterna i arbetsför ålder hade högre symptomfrekvens och lägre livstillfredsställelse än referenspopulationerna. Kvinnorna rapporterade högre förekomst av symptom och funktionsnedsättning än männen. Funktionsnedsättning av varierande grad samt så kallat postkommotionellt syndrom (med förekomst av minst tre specificerade symptom) fanns hos ca 50% av kvinnorna och hos ca 30% av männen. Medelförekomsten av whiplashskador till följd av trafikolyckor var under 2000-2009 235 fall per 100 000 invånare och år. Sammantaget var förekomsten relativt stabil under perioden; en ökning med 1% per år noterades. När siffrorna matchades mot data från Försäkringsförbundet noterades en minskning av andelen försäkringsärenden under perioden. 2001 års incidens av akuta whiplashskador efter alla typer av skadehändelser var 383 skadade per 100 000 invånare. Könsfördelningen var 56% män / 44% kvinnor och medelåldern var 32 år. Trafikolyckor orsakade 61% av whiplashskadorna medan fallolyckor stod för 14%. Frakturer i nacken var ovanliga och hittades hos 3% av patienterna. I femårsuppföljningen av whiplashpatienter i arbetsför ålder noterades att de hade högre frekvens (ca 50%) av symptom samt lägre livstillfredsställelse än referenspopulationerna. Funktionsnedsättning av varierande grad fanns hos ca 50% av patienterna. Kvinnorna skattade sin smärta högre än männen men i övrigt fanns ingen könsskillnad beträffande förekomsten av symptom, funktionsnedsättning och livstillfredsställelse. Vid jämförelse mellan whiplashskadade och skallskadade noterades att förekomsten av symptom med några få undantag inte skilde sig åt mellan grupperna. Fjorton procent av de whiplashskadade blev sjukskrivna i mer än 14 dagar. Sjukskrivningens medianlängd var 298 dagar och i 3% av fallen fortskred sjukskrivningen under hela 5-årsperioden. Trafikskadade sjukskrevs oftare än fallskadade och noterbart är också att nackfrakturer ej resulterade i längre sjukskrivningar än mjukdelsskador. Samhällskostnaden för produktionsbortfall var i snitt ca 600 000 kr per sjukskrivning. Konklusion Avhandlingen bidrar med nya grunddata som ytterligare förstärker bilden av att skallskador och whiplashskador är vanliga och att det framförallt är unga personer som drabbas. Grad och typ av kvarstående besvär är likartade efter båda skadetyper. Samhällskostnaden för skadorna är hög och lämpliga områden för skadepreventivt arbete tycks vara fallskadeprevention, trafikskadeprevention, skadeprevention inom hästsport, fotboll och ishockey samt prevention av alkoholrelaterade skador. Både fysiska, psykologiska och sociala faktorer inverkar på läkningsförloppet och symptombilden efter skadorna och det är viktigt att utvärdera och behandla patienterna med utgångspunkt från detta.

Diss. (sammanfattning) Umeå : Umeå universitet, 2008. / Härtill 5 uppsatser.

Diss. (sammanfattning) Umeå : Univ., 2008. / Härtill 4 uppsatser.

Diss. (sammanfattning) Stockholm : Karol. inst., 2002. / Härtill 4 uppsatser.

Syfte Syftet med litteraturöversikten var att beskriva förekomst av whiplashtrauma hos TMD patienter. Metod En systematisk litteratursökning av PubMed, CochraneLibrary och Bandolier databaser genomfördes för artiklar publicerade från 1 januari 1966 till 11 november 2011. Den systematiska sökningen identifierade121 artiklar. Efter borttagning av brev till redaktion och författarinlägg, utfördes en initial screening av abstract på 108 artiklar. Efter den initiala screeningen lästes 32 artiklar i fulltext med tillämpning av inklusions- och exklusionskriterier. Två av författarna utvärderade den metodologiska kvaliteten på de inkluderade studierna. Resultat Sex studier mötte inklusionskriterierna och inkluderades i rapporten. Den rapporterade förekomsten av whiplashtrauma hos TMD populationerna varierade mellan 8,4 % och 70 % (median 35 %). Förekomst av whiplashtrauma hos kontrollgrupperna varierade mellan 1,7 % och 18 %. TMD patienter med historik av whiplashtrauma rapporterade gravare TMD symptom och mer smärta jämfört med TMD patienter utan nackskada.Konklusion Resultaten från denna litteraturöversikt visar en högre förekomst av whiplashtrauma hos TMD patienter vilket tyder på att whiplashtrauma kan vara en riskfaktor för TMD. Stora variationer sågs mellan de olika inkluderade studierna och i samtliga studier fanns också brister gällande diagnoskriterier. Sammantaget så gör dessa begränsningar det svårt att bedöma traumaförekomst hos TMD patienter och i vilken utsträckning whiplashskada kan bidra till utvecklingen av TMD. Fler väldesignade studier som använder tydligt definierade diagnostiska kriterier med hög reliabilitet och validitet som t.ex RDC/TMD behövs för att kunna dra en säkrare slutsats om TMD vid whiplashtrauma. / Aim The aim ofthis systemic literature review was to describe the prevalence of whiplash trauma in TMD populations. Method A systemic literature search of the PubMed, Cochrane Library and Bandolier databases was carried out for articles published from 1 January 1966 to 11 November 2011. This systemic search identified 121 articles. After exclusion of letters to editor and author replies, an initial screening of the abstracts of 108 articles was carried out. After the initial screening 32 articles were read in full text applying the inclusion and exclusion criteria. Two of the authors evaluated the methodological quality of the included studies. Result Six studies matched the inclusion criteria and were included in the review. The reported prevalence of whiplash trauma in the TMD populations varied from 8.4% to 70% (median 35%). The prevalence of whiplash trauma in the control groups varied from1.7% to 18%.TMD patients with a history of whiplash trauma reported more TMD symptom and more pain compared to TMD patient without a neck injury.Conclusion The results from this literature review show a higher prevalence of whiplash trauma in TMD patients which indicate that whiplash trauma could be risk factor for TMD. A large variation could be seen between the included studies and there were also weaknesses with regard to the diagnostic criteria. In summery we suggest that these limitations make it difficult to assess the prevalence of neck trauma in TMD patients and to which extent a whiplash injury can contribute to the development of TMD. More well designed studies using the RDC/TMD criteria and well-defined criteria with high reliability and validity for whiplash trauma are needed in order to make a more reliable conclusion.

Neck-shoulder pain is common in the general population and causes individual suffering as well as large costs for the society. Despite substantial efforts, there is still a shortage of methods for objective diagnosis and effective rehabilitation of such disorders. Thus, there is a great need to develop and evaluate new methods for these purposes. From clinical observations and recent research it has become evident that sensorimotor control can be impaired in people with neck-shoulder pain and may play a role in the pathogenesis of these disorders. In this thesis, precision of goal-directed arm movements, a previously unstudied class of movements in neck-shoulder pain, was studied. The main aim of the thesis was to investigate if people with chronic neck-shoulder pain have a reduced acuity of goal-directed movements of the upper extremity. A second aim was to study associations between reduced movement acuity and symptoms and self-rated characteristics. Upper limb repositioning acuity was assessed in blindfolded subjects performing tests of active, ipsilateral position-matching of two target positions (long and short) in movements constrained to horizontal-adduction of the shoulder. Reduced repositioning acuity, suggesting impaired shoulder proprioception, was found for both subjects with whiplash associated disorders (WAD) and non-specific neck-shoulder pain (NS). The degree of reduced acuity was shown to correlate with self-ratings of various health concepts, functioning and pain. A conspicuous finding was that there was lack of correlation between short and long target errors, along with the fact that associations between repositioning acuity and symptoms and self-rated characteristics was primarily found for the short target position. To further investigate the possible mechanisms underlying the disassociation between long and short target movement control, the association pattern between the outcome of several variants of ipsilateral position matching and velocity-discrimination tests, were studied. It was found that the perception of limb position in position-matching of short target locations appears to be predominantly based on movement velocity, whereas perception of limb position in movements to longer target locations may rely on a location-based perception mechanism. To extend the research on reduced upper extremity proprioception in neck-shoulder pain to a more natural movement situation, acuity of goal-directed pointing including full vision and 3D multi-joint movements was investigated in WAD, NS and healthy controls subjects. The results revealed a reduced acuity for both neck-pain groups. Moreover, distinct associations between end-point acuity and neck movement problems, limitations of some physical functions and, in WAD; some aspects of pain, were revealed. The findings demonstrate that the precision of upper limb movements can be reduced in chronic neck-shoulder pain. Substantial associations with symptoms and self-rated functioning suggest a clinical relevance of acuity measures of goal-directed arm movements. The findings indicate that tests of sensorimotor control can provide objective measures that may be useful in biopsychosocial profiling and characterization of subgroups of patients with chronic neck-shoulder pain, and that training target control of goal-directed movements should be considered in rehabilitation programs of people with these disorders.

Diss. (sammanfattning) Umeå : Univ., 2006. / Härtill 5 uppsatser.

Diss. (sammanfattning) Umeå : Umeå Universitet, 2009. / Härtill 5 uppsatser.

Chronic pain is usually defined as pain of more than three months duration. The prevalence of chronic pain among the general population in Sweden is 18%. Compared with the general population, these patients report lower life satisfaction, decreased activity in daily life and higher levels of depression with decreased work ability, and increased sick leave. Research indicates that multimodal rehabilitation (MMR) programmes, including cognitive behavioural approaches for patients disabled by chronic pain, are effective for return to work. The primary aim of this thesis was to assess outcomes by a long-term follow-up of patients with chronic musculoskeletal pain. Furthermore, the aim was to evaluate two different rehabilitation strategies regarding impact on pain intensity, activity, depression, life satisfactions, and sick leave. Two groups, comprising 255 (between the years 1999-2002) and 296 (between 2007-2008) patients respectively, from the Pain Rehabilitation Clinic at Umeå University Hospital, Sweden, were all assessed by interdisciplinary teams. They completed questionnaires regarding pain intensity, disability, life satisfaction, anxiety and depression, and sick leave, before intervention, immediately after intervention (only the first group; n=255), and at one-year follow-up, after participating in a MMR programme in a specialist clinic, or after receiving a rehabilitation plan (RP) with follow-up in primary care. Allocation to either of the two groups was based on the initial interdisciplinary team assessment. Furthermore, a five-year follow-up of 158 patients with whiplash injury was conducted. Pain intensity decreased and life satisfaction increased significantly regarding somatic health in both groups, at follow-up. In addition, depression improved and disability decreased to a higher extent after participating in the MMR programme as compared to RP and subsequent follow-up in primary care. Patients’ positive beliefs about recovery, and positive expectations about work correlated with favourable rehabilitation outcomes. Sick leave at one year follow-up decreased in both groups. Regarding whiplash injury, patients who reported moderate or severe disability also reported significantly higher pain intensity, depression and post-traumatic stress scores and lower perception of general health compared with patients who reported mild or no disability. In conclusion, MMR programmes seem to be beneficial by decreasing pain intensity, depression, disability and sick leave among patients with chronic musculoskeletal pain. Furthermore, patients’ positive beliefs correlate with more favourable long-term outcomes. An interdisciplinary team assessment based on a biopsychosocial approach may be of value for selection of rehabilitation strategy.

Submitted to the Faculty of Health Sciences at the Durban University of Technology in partial compliance with the requirements for a Master’s Degree in Technology: Chiropractic, Department of Chiropractic, Durban University of Technology, Durban, South Africa, 2016. / Background: Neck pain is an extremely common condition and the treatment of neck pain forms an integral part of chiropractic practice. The optimal treatment of neck pain is provided when practitioners incorporate available evidence, experience, and knowledge regarding the clinical presentation of the patient into their treatment regimes. Current evidence suggests that a combination of manual therapy, specifically manipulation and/or mobilization, and rehabilitation may offer the optimum treatment for mechanical neck pain. However, numerous factors other than available evidence, experience and clinical presentation may influence treatment choices made by practitioners. Through the assessment of practice patterns, one may asses if the optimal treatment for a neck pain is being provided by practitioners and assess if factors specific to a practitioner may influence the treatment of neck pain. Objectives: The aim of this study is to determine the chiropractic treatment and management of mechanical neck pain, to compare this to evidence based recommendations for the conservative treatment of mechanical neck pain and to assess if factors other than the available evidence may influence the treatment of mechanical neck pain. Method: A quantitative, cross-sectional descriptive survey compiled using available literature and validated by means of a focus group and pilot testing, was administered to chiropractors practicing in KwaZulu-Natal. Upon completion of the questionnaire, the data was coded into an Excel spread sheet and imported into IBM SPSS version 20 for statistical analysis. This research protocol was approved by the Durban University of Technology Institutional Research Ethics Committee (REC 82/13) and the study took place from March to July 2014. Results: Ninety-six practitioners responded to the study which is a response rate of greater than 70%. Practitioners favoured the use of spinal manipulation, auxiliary therapeutic techniques (specifically those which were manual in nature), rehabilitation, and numerous forms of education. Specific variations in treatment pattern existed when comparing various patient presentations indicating that practitioner based factors impacted on treatment choices made by practitioners. The most significant findings included the increased utilisation of auxiliary therapeutic techniques by female practitioners, the increased utilisation of traction by practitioners identifying with the straight philosophy of chiropractic. Other significant findings included the increased utilisation of cervical collars by practitioners of increased age and experience and the increased utilisation of auxiliary therapeutic techniques by practitioners who did not attend health related conferences at least once every second year or did not attend short courses or subscribe to journals or magazines since qualification. Conclusions: This study indicates that treatment for mechanical neck pain offered by chiropractors in KwaZulu-Natal is in line with current evidence based recommendations for the treatment of mechanical neck pain, with practitioners commonly using modalities which were recommended, whilst rarely using modalities which were not recommended. The use of rehabilitation was, however, slightly lower than expected. Patient presentation and practitioner based factors were found to influence the treatment of mechanical neck pain; however, as a whole these variations were small with the majority of practitioners favouring the use of modalities which were recommended within the literature. Future studies should address the gap in the literature regarding the conservative treatment of cervical radiculopathy. / M