Clinical decision-making in the management of whiplash associated disorders

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Sterling, Michele
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Ritchie, Carolyn
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2018-07
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Abstract

This thesis investigates various aspects of clinical decisionOmaking in the management of individuals with acute whiplash associated disorders (WAD), with a primary focus on physiotherapy professionals and one available clinical prediction rule designed for the purpose of guiding prognostic judgments (the Whiplash CPR). WAD is a prevalent and frequently chronic condition that is associated with substantial personal and societal cost. It is currently challenging for healthcare practitioners to manage, as heterogeneity in the population and nil to small effect sizes from clinical trials mean that deciding on the best course of action may be difficult. Early and accurate identification of prognostic risk has the potential to lessen current rates of progression to chronic WAD, by enabling the provision of stratified care to more homogeneous groups of individuals. This body of work comprises a series of four studies using mixed methods. Study 1 comprised a systematic review of clinical prediction rules that relate to prognostic and treatment decisionOmaking for the conservative management of neck pain. The study was necessary in identifying available tools, and appraising stage of development, quality and readiness for application, with the ultimate purpose of assisting healthcare practitioners in the evaluation and selection of an appropriate tool for use in clinical practice. Two independent reviewers assessed the eligibility, risk of bias, methodological quality and stage of development of studies identified from a systematic search of six databases. The results indicated that three out of nine identified prognostic clinical prediction rules specific to acute WAD are at a stage of development that lends support to clinical use. Use of the Whiplash CPR selected as the focus of this thesis, was supported by maintenance of accuracy on validation, and the satisfaction of most methodological quality criteria used in the review.
Study 2 focused on the Whiplash CPR and sought to assess its potential clinical utility. A pragmatic crossOsectional design was used to investigate the level of agreement between physiotherapist estimatedO and Whiplash CPR classifiedO prognostic risk for adults who presented to a participating physiotherapist (n=24) with acute WAD IOIII (n=38). Agreement was found to be very low (29%, K= O0.03; 95%CI O0.17 to 0.12), and physiotherapists likely underOidentified individuals at high risk of poor recovery (3%, n=1/38). The findings of this study indicate that physiotherapists may benefit from incorporating the Whiplash CPR into usual assessment and decisionOmaking processes when attempting to gauge patient prognosis.
The presence of a validated, accurate and clinically useful clinical prediction rule, such as the Whiplash CPR, has not historically ensured widespread use. Study 3 sought to inform implementation of the Whiplash CPR through qualitative exploration of healthcare practitioners’ (n=28) awareness and practice behaviours regarding clinical prediction rules, and perceptions for using the Whiplash CPR in future practice. Six focus group discussions were conducted, audioOrecorded, transcribed verbatim and analysed using an inductive thematic approach. Many clinicians considered the Whiplash CPR to be acceptable to them. Implementation themes including the provision of an external driver of adoption, flexibility in how the Whiplash CPR could be accessed and administered, and guidance regarding communication of its output to patients, were identified as useful in promoting future use.
Finally, Study 4 related to management designed to specifically target individuals identified by the Whiplash CPR as being at heightened risk of poor recovery. A qualitative investigation was performed of physiotherapists’ (n=11) experiences of delivering a novel psychological intervention (Stress Inoculation Training) to this population as part of a randomised controlled trial. SemiOstructured interviews were conducted, audioOrecorded, transcribed verbatim, and analysed thematically using a withinO and acrossOcase strategy. Physiotherapists were found to support adding Stress Inoculation Training to usual guidelineObased management. The feasibility and use of the intervention in routine clinical practice were facilitated by confidence in the ability to deliver the program, viewing it as falling within current scope of practice, and the ability to selectively deliver the content to meet the needs of individual patients. The findings of this body of work provide support to existing preliminary evidence that physiotherapists may experience difficulty differentiating individuals who may and may not recover from acute WAD. While progress has been made towards the rigorous development of predictive tools to assist clinicians in this capacity, further validation and impact analyses of existing models are ultimately required. At present, the Whiplash CPR appears to be the most robust tool available for use in clinical practice. It is therefore recommended that clinicians commence incorporating the CPR into existing prognostic assessment and decisionOmaking processes. Physiotherapists appear receptive to the using the Whiplash CPR and delivering new management strategies that target individuals who are at heightened risk of developing chronic WAD. However, education and support are needed to facilitate widespread changes to practice.

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Thesis (PhD Doctorate)
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Doctor of Philosophy (PhD)
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School Allied Health Sciences
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The author owns the copyright in this thesis, unless stated otherwise.
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Physiotherapy professionals
Neck pain
Stress Inoculation Training
Whiplash associated disorders
Whiplash CPR
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