The second pathway involves initial moderate to severe pain-related disability, with some recovery but with disability levels remaining moderate at 12 months. Around 39% of injured people are predicted to follow this pathway. The third pathway Neratinib involves initial severe pain-related disability and some recovery to moderate or severe disability, with 16% of

individuals predicted to follow this pathway. The identified pathways are illustrated in Figure 1. They may provide useful conceptualisation for clinicians of the possible recovery trajectories. With up to 50% of those sustaining a whiplash injury reporting ongoing pain and disability, it is of clinical interest to be able to identify both those at risk of poor recovery and those who will recover well. This may assist in targeting ever-shrinking health resources to those in most need of them. The most consistent risk factors for poor recovery are initially higher levels of reported pain and initially higher levels of disability.2 and 15 A recent meta-analysis indicated find more that initial pain scores of >5.5 on a visual analogue scale from 0 to 10 and scores of >29% on the Neck Disability Index are useful cut-off scores for clinical use.15 In view of the consistency of these two factors to predict poor functional recovery, they are recommended for use by physiotherapists in the assessment of patients with acute WAD. Other prognostic

factors have been identified, including psychological factors of initial moderate post-traumatic stress symptoms,

pain catastrophising and symptoms of depressed mood.2, 16 and 17 Additionally, lower expectations Adenosine of recovery have been shown to predict poor recovery.18 and 19 In other words, patients who do not expect to recover well may indeed not recover. Cold hyperalgesia has been shown to predict disability and mental health outcomes at 12 months post-injury,19, 28 and 48 and decreased cold pain tolerance measured with the cold-pressor test predicted ongoing disability.21 A recent systematic review concluded that there is now moderate evidence available to support cold hyperalgesia as an adverse prognostic indicator.22 Other sensory measures such as lowered pressure pain thresholds (mechanical hyperalgesia) show inconsistent prognostic capacity. Walton et al showed that decreased pressure pain thresholds over a distal site in the leg predicted neck pain-related disability at 3 months post-injury,23 but other studies have shown that this factor is not an independent predictor of later disability.20 The exact mechanisms underlying the hyperalgesic responses are not clearly understood, but are generally acknowledged to reflect augmented nociceptive processing in the central nervous system or central hyperexcitability.24 and 25 Some factors commonly assessed by physiotherapists do not show prognostic capacity.