Factors Influencing Neck Pain Intensity in Whiplash-associated Disorders in Sweden

Impact of comorbidity on health outcome after a transport-related injury

INTRODUCTION

Understanding the impact of comorbidity on health outcomes is important given that comorbidities can affect survival, morbidity, service delivery costs and healthcare utilisation. However, little is known about the types of comorbidities affecting specific health outcomes after minor to moderate road trauma.

METHODS

This study involved 1574 participants who claimed injury compensation following transport-related injury. Cross sectional data were collected. Health outcomes were assessed using the EQ-5D-3L specific domains and summary score. Twelve self-reported pre-existing chronic conditions were assessed using a multivariate logistic regression, adjusting for demographic and injury characteristics.

RESULTS

Out of 1574 participants, only 17 (1%) participants reported no pre-existing comorbidities, 72% reported one, 13% reported two and 14% reported three or more comorbidities. Hypertension (15%), depression (14%) and anxiety (14%) were the most commonly reported comorbidities, followed by arthritis (13%), chronic pain (11%) and asthma (11%). Participants with a history of arthritis (adjusted odds ratio [AOR] 1.90, 95% CI 1.24 to 2.91); chronic back pain (AOR 1.59, 95% CI, 1.04 to 2.43); other chronic pain (AOR 2.73, 95% CI 1.42 to 4.24); depression (AOR 2.55, 95% CI 1.60 to 4.05) and anxiety (AOR 2.08, 95% CI 1.32 to 3.26) were at increased risk of poorer health outcomes, after controlling for age, gender, type of injury and time since injury.

CONCLUSION

This study found that comorbidities such as arthritis, chronic back pain, other chronic pain, depression and anxiety significantly increase the odds of poorer health postinjury, regardless of the time since injury. Regular screening of comorbid conditions may help identify people likely to have poorer outcomes, thereby enabling the implementation of interventions to optimise health despite the presence of comorbidities.

Biopsychosocial factors associated with non-recovery after a minor transport-related injury: A systematic review

Background

Globally, road transport accidents contribute significantly to mortality and burden of disability. Up to 50 million people suffer a transport-related non-fatal injury each year, which often leads to long-term disability. A substantial number of people with minor injuries struggle to recover and little is known about the factors leading to poor or non-recovery. The aim of this paper is to present a systematic review of biopsychosocial factors related to poor or non-recovery after a minor transport-related injury.

Methods and findings

Studies were selected through searches of PubMed, Medline, Embase, and Cochrane library. Methodological quality was assessed using a Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklist for quantitative cohort studies and Standards for Reporting Qualitative Research (SRQR) checklist for qualitative articles. Data were extracted using the Cochrane data extraction tool based on the biopsychosocial model of health (BPS). In total, there were 37 articles included. However, heterogeneity of the techniques and tools used to assess factors and outcomes across studies meant that pooling of results to determine biopsychosocial factors most predictive of poor or non-recovery was not possible. Hence, a narrative synthesis was conducted and shown multiple factors to be associated with poorer outcomes or non-recovery, most being identified in the biological and psychological domain of the BPS model. Factors that were the most representative across studies and have shown to have the strongest associations with poor or non-recovery were high initial pain intensity, pain duration and severity, pre-accident physical and mental health status and pain catastrophising.

Conclusions

This review demonstrates the complexity of recovery and a challenge in reporting on predictors of recovery. It is evident that a range of multi-factorial biopsychosocial factors impact recovery. These factors are often inter-connected and multi-faceted and therefore, it was not feasible to select or focus on one single factor. In defining the most predictive factors, further research is required, yet the consensus around which tools to use to measure recovery outcomes is needed and is highly recommended. Regardless of the descriptive nature, the review demonstrated that high levels of post-injury pain are associated with poorer outcomes such as chronic pain and physical and mental disability. Therefore, early targeting of modifiable factors such as pain, pain catastrophizing and arising comorbidities such as PTSD, depression and anxiety may assist in reducing chronic pain and ongoing related disabilities.

Systematic review trial registration number

Systematic review protocol was registered in International Prospective Register for Systematic Reviews (PROSPERO) on 14 December 2016. Registration number CRD42016052276.

Does restraint status in motor vehicle crash with rollover predict the need for trauma team presence on arrival? An ATOMAC study

PURPOSE

Restraint status has not been combined with mechanistic criteria for trauma team activation. This study aims to assess the relationship between motor vehicle crash rollover (MVC-R) mechanism with and without proper restraint and need for trauma team activation.

METHODS

Patients <16years old involved in an MVC-R between November 2007 and November 2012 at 6 Level 1 pediatric trauma centers were included. Restraint status, the need for transfusion or intervention in the emergency department (ED), hospital and intensive care length of stay and mortality were assessed.

RESULTS

Of 690 cases reviewed, 48% were improperly restrained. Improperly restrained children were more likely to require intubation (OR 10.24; 95% CI 2.42 to 91.69), receive blood in the ED (OR 4.06; 95% CI 1.43 to 14.17) and require intensive care (ICU) (OR; 3.11; 95% CI 1.96 to 4.93) than the properly restrained group. The improperly restrained group had a longer hospital length of stay (p<0.001), and a higher mortality (3.4% vs. 0.8%; OR 4.09; 95% CI 1.07 to 23.02) than the properly restrained group.

CONCLUSION

Unrestrained children in MVC-R had higher injury severity and were significantly more likely to need urgent interventions compared to properly restrained children. This supports a modification to include restraint status with the rollover criterion for trauma team activation.

Sick Leave within 5 Years of Whiplash Trauma Predicts Recovery: A Prospective Cohort and Register-Based Study

BACKGROUND

10-22% of individuals sustaining whiplash trauma develop persistent symptoms resulting in reduced working ability and decreased quality of life, but it is poorly understood why some people do not recover. Various collision and post-collision risk factors have been studied, but little is known about pre-collision risk factors. In particular, the impact of sickness and socioeconomic factors before the collision on recovery is sparsely explored. The aim of this study was to examine if welfare payments received within five years pre-collision predict neck pain and negative change in provisional situation one year post-collision.

METHODS AND FINDINGS

719 individuals with acute whiplash trauma consecutively recruited from emergency departments or primary care after car accidents in Denmark completed questionnaires on socio-demographic and health factors immediately after the collision. After 12 months, a visual analogue scale on neck pain intensity was completed. 3595 matched controls in the general population were sampled, and national public register data on social benefits and any other welfare payments were obtained for participants with acute whiplash trauma and controls from five years pre-collision to 15 months after. Participants with acute whiplash trauma who had received sickness benefit for more than 12 weeks pre-collision had increased odds for negative change in future provisional situation (Odds Ratio (OR) (95% Confidence Interval (CI) = 3.8 (2.1;7.1)) and future neck pain (OR (95%CI) = 3.3 (1.8;6.3)), controlling for other known risk factors. Participants with acute whiplash trauma had weaker attachment to labour market (more weeks of sick leave (χ2(2) = 36.7, p < 0.001) and unemployment (χ2(2) = 12.5, p = 0.002)) pre-collision compared with controls. Experiencing a whiplash trauma raised the odds for future negative change in provisional situation (OR (95%CI) = 3.1 (2.3;4.4)) compared with controls.

CONCLUSIONS

Sick leave before the collision strongly predicted prolonged recovery following whiplash trauma. Participants with acute whiplash trauma had weaker attachment to labour market pre-collision compared with the general population. Neck pain at inclusion predicted future neck pain. Acute whiplash trauma may trigger pre-existing vulnerabilities increasing risk of developing whiplash-associated disorders.

Reported characteristics of participants in physical therapy-related clinical trials

BACKGROUND

The inclusion of sociodemographic and anthropometric variables in published clinical trials enables physical therapists to determine the applicability of trial results to patients in their clinics.

OBJECTIVE

The aim of this study was to examine the reporting of participant sociodemographic and anthropometric characteristics in published physical therapy-related clinical trials.

DESIGN

This was a retrospective review of clinical trials from 2 samples drawn from literature applicable to physical therapy.

METHODS

Two reviewers independently extracted data from a random sample of 152 clinical trials from the Physiotherapy Evidence Database (PEDro) and a purposive sample of 85 clinical trials published in the journal Physical Therapy (PTJ). A database containing the occurrence of sociodemographic (age, sex, race/ethnicity, level of education, marital status) and anthropometric variables (height, weight, body mass index) in each article was created to generate descriptive statistics about both samples.

RESULTS

Among the sociodemographic variables, at least 90% of articles reported the sex and age of trial participants. Additional sociodemographic characteristics that were reported in 20% to 26% of articles were participant level of education and participant race/ethnicity. The reporting of anthropometric data differed between the 2 samples, with body mass index being most commonly reported in the PEDro sample (48.0%) and weight being most commonly reported in the PTJ sample (38.8%).

LIMITATIONS

Articles reviewed were limited by year of publication (from 2008 to 2012 for PTJ articles and 2010 for clinical trials from PEDro) and to English-language-only literature.

CONCLUSIONS

The physical therapy literature would benefit from enhanced reporting requirements for both sociodemographic and anthropometric data about participants.

Efficacy of therapeutic ultrasound in pain and joint mobility in whiplash traumatic acute and subacute phases

To determine if ultrasound (US) is effective in reducing pain and mobility limitation in the treatment of traumatic cervical sprain, we performed an experimental study. The sample comprised 54 diagnosed subjects with a mean age of 36.54 y (standard deviation = 12.245), assigned by simple random selection to an experimental group with ultrasound treatment and a control group with placebo ultrasound. Treatment consisted of 10 sessions of an ultrasound treatment protocol, followed by 15 sessions of a protocol identical for both groups without ultrasound. The variables assessed were pain and joint mobility. There was no significant difference (p > 0.05) between groups in the first 10 sessions of treatment. However, there was a statistically significant difference (p < 0.05) between groups on the pain variable, 20 days after completion of the US. High-active ultrasound treatment is more effective than placebo in reducing pain.

Healthcare consultation and sick leave before and after neck injury: a cohort study with matched population-based references

OBJECTIVES

Recent studies based on self-assessed data on exposure and outcome suggest a negative association between poor health before neck injury and recovery. Our aim was to study actual healthcare consultation and work disability before and after neck injury (whiplash).

DESIGN

Cohort study with matched references studied prospectively and retrospectively via regional and national held registers.

SETTING

Population-based study in Region Skåne, Sweden (population=1.21 million) including all levels of healthcare.

PARTICIPANTS

1443 participants aged ≥18 (54% women) with acute neck injury, Whiplash, (International Classification of Diseases-10-SE code S13.4*) in 2007 or 2008 and no such diagnosis since 1998. Each patient with a neck injury was assigned four randomly selected population references matched for age, sex and area of residence (97% of the patients and 94% of the references were followed during the whole study period).

PRIMARY AND SECONDARY OUTCOME MEASURES

We studied changes in healthcare consultations 3 years before to 3 years after diagnosis as well as sick leave episodes. Analyses were also stratified by preinjury frequency of consultation.

RESULTS

Before the injury, the mean number of total consultations over 36 months among the neck injured (n=1443) and references (n=5772) was 9.3 vs 7.2 (p<0.0001) and postneck injury 12.7 vs 7.8 (p<0.0001). In the group of high-frequent consulters, there were more women compared with frequent and low-frequent consulters (70.6% vs 32.8%; p<0.0001). Among low-frequent and frequent consulters preinjury (n=967, 67% of the cohort), 16% became high-frequent consulters attributable to the injury. The number of days of sick leave preinjury was correlated with the number of preinjury and postinjury consultations (r=0.47 (99% CI 0.38 to 0.49), r=0.32 (99% CI 0.25 to 0.37)).

CONCLUSIONS

People with a neck injury constitute a heterogeneous group. The preinjury level of healthcare consultation is associated with the postinjury level of consultation.

The Stomatognathic System's Role in the Postural Stabilization in Subjects Suffering from Whiplash Injury Part 1: Patients with Physiological Occlusion

Aim of this study is analyze the effects of dental occlusion on postural stability in patients with previous whiplash and normal occlusion. Materials and methods: 36 adult patients with previous whiplash and normal occlusion (good alignment, 1st class or mild 2nd class deep bite for mandibular retrusion) were selected. The patients were suffering from masticatory muscles pain caused by clenching during sleep. Exclusion criteria: use of psych drugs. To simulate the conditions of sleep (with a reduction of proprio-and esteroceptive inputs for postural management performed by CNS), we used postural Romberg analysis (feet together, closed eyes)on stabilometric platform changing occlusal parameters only, under the following conditions: 1) in occlusal rest position, 2) in centric occlusion, 3) in clenching, 4) with occlusal disengage with cotton rolls and 5) in clenching on cotton rolls. Time of each test: 15 seconds. It was performed a statistical analysis with T-test comparing between them the mean of all tests. Results: stabilometry data (postural ball and ellipse) show better postural performances in centric occlusion and clenching in centric occlusion, and a worsening in all tests with occlusal disengage (with statistically significant difference - p<0.05). Conclusions: postural instability caused by whiplash increases muscles tone and dental clenching as compensatory effects, with onset of facial pain. An occlusal disengage (like an occlusal splint to reduce clenching)induces a postural worsening in patients with normal occlusion, while centricocclusion increases the stability. These results suggest that stomatognathic organ has a new physiological function: the posture stabilization.

Pre-injury health-related factors in relation to self-reported whiplash: longitudinal data from the HUNT study, Norway

PURPOSE

To examine if pre-injury health-related factors are associated with the subsequent report of whiplash, and more specifically, both whiplash and neck pain.

METHODS

Longitudinal population study of 40,751 persons participating in two consecutive health surveys with 11 years interval. We used logistic regression to estimate odds ratio (OR) for reporting whiplash or whiplash with neck pain lasting at least 3 months last year, related to pre-injury health as indicated by subjective health, mental and physical impairment, use of health services, and use of medication. All associations were adjusted for socio-demographic factors.

RESULTS

The OR for reporting whiplash was increased in people reporting poor health at baseline. The ORs varied from 1.47 (95% CI 1.13-1.91) in people visiting a general practitioner (GP) last year to 3.07 (95% CI 2.00-4.73) in people who reported poor subjective health. The OR associated with physical impairment and mental impairment was 2.69 (95% CI 1.75-4.14) and 2.49 (95% CI 1.31-4.74), respectively. Analysis of reporting both whiplash and neck pain gave somewhat stronger association, with ORs varying from 1.50 (95% CI 1.07-2.09) in people visiting a GP last year to 5.70 (95% CI 3.18-10.23) in people reporting poor subjective health. Physical impairment was associated with an OR of 3.48 (95% CI 2.12-5.69) and mental impairment with an OR of 3.02 (95% CI 1.46-6.22).

CONCLUSION

Impaired self-reported pre-injury health was strongly associated with the reporting of a whiplash trauma, especially in conjunction with neck pain. This may indicate that individuals have, already before the trauma, adopted an illness role or behaviour which is extended into and influence the report of a whiplash injury. The finding is in support of a functional somatic disorder model for whiplash.

Total number and severity of comorbidities do not differ based on anatomical region of musculoskeletal pain

STUDY DESIGN

Secondary analysis, cross-sectional study.

OBJECTIVES

To (1) compare differences in individual comorbidity rates among patients with cervical, lumbar, and extremity pain complaints and (2) compare rates based on total number and severity in these same patient groups.

BACKGROUND

Comorbidities can impact recovery, prognosis, and potentially hinder participation in rehabilitation. Few studies have compared comorbidity rates among patients with different anatomical region of pain, to determine whether specific screening is warranted in physical therapy settings.

METHODS

Included in the analyses were 2375 patients who reported complete demographic, clinical, and comorbidity information using Patient Inquiry software. Comorbidity data were collected from the Functional Comorbidity Index (18 items) and 6 additional comorbidities, to assess the presence of medical disease across multiple body systems. Comorbidities were further classified as "nonsevere" or "severe," based on inclusion in the Charlson Comorbidity Index. Chi-square analyses investigated differences in the rates of total number and severe comorbidities. Odds ratios (OR) and 95% confidence intervals (CIs) were calculated on rates with statistically significant differences (P<.001), using the lumbar spine as the reference group.

RESULTS

Of the 24 comorbid conditions included in this analysis, 3 nonsevere medical conditions (degenerative disc disease, obesity, and headache) had different rates among anatomical region. A lower rate for degenerative disc disease was associated with the extremity conditions (χ2 = 66.3; OR = 0.40; 95% CI: 0.32, 0.50). Higher rate of headache (χ2 = 115.3; OR = 3.01; 95% CI: 2.45, 3.70) and lower rate of obesity (χ2 = 16.2; OR = 0.64; 95% CI: 0.51, 0.80) were associated with cervical conditions. There were no differences among the 3 anatomical regions for total number or severe comorbidities.

CONCLUSION

Focused screening for degenerative disc disease, obesity, and headache may be warranted. However, the same strategy was not supported for total number or severe comorbidities, at least when considering comparative rates from this cohort. Physical therapists should consider the potential influence of total number and severe comorbidities equally for all anatomical regions of musculoskeletal pain.

LEVEL OF EVIDENCE

Differential diagnosis/symptom prevalence, level 3b.

The relationship between cognitive functions, somatization and behavioural coping in patients with multiple functional somatic symptoms

BACKGROUND AND AIMS

Patients with multiple functional somatic symptoms (MFS) often express cognitive complaints. The aim of this descriptive study was to investigate whether these patients have cognitive deficits and whether the patients' cognitive functioning relates to their experience of physical and psychological distress and to their use of pain-related coping strategies.

METHODS

Neuropsychological assessment of verbal ability, psychomotor speed, attention, working memory, perceptual organization and memory, was conducted on 22 MFS patients and 27 healthy age- and gender-matched controls. Psychological distress, health anxiety, health status and pain coping were measured with questionnaires [Symptom Checklist 90-Revised (SCL-somatization, SCL-depression, SCL-anxiety), the Whiteley-7 scale, the Short Form (SF-36) and the Coping Strategies Questionnaire (CSQ)].

RESULTS

For patients, a high score on the SCL-somatization subscale was associated with poor performance on tests of attention and psychomotor speed, and with a high score on the coping scale Increasing behavioural activities. A high score on this coping scale was associated with poor performance on tests of verbal ability and executive functioning. After controlling for years of education, controls performed significantly better than patients on verbal as well as performance IQ scales but not on tests of memory.

CONCLUSION

In the present study, we found that physical complaints are related to deficits in attention and psychomotor speed. Moreover, our results suggest that poor verbal skills may play a role in the development of MFS because of an increased tendency to apply behavioural/avoidant coping strategies. We suggest that treatment of MFS should involve training of attention as well as practicing the use of cognitive coping strategies.

Is it all central sensitization? Role of peripheral tissue nociception in chronic musculoskeletal pain

Fibromyalgia syndrome (FM) is a highly prevalent musculoskeletal disorder that is often accompanied by somatic hyperalgesia (enhanced pain from noxious stimuli). Neural mechanisms of somatic hyperalgesia have been analyzed via quantitative sensory testing of FM patients. Results of these studies suggest that FM pain is associated with widespread primary and secondary cutaneous hyperalgesia, which are dynamically maintained by tonic impulse input from deep tissues and likely by brain-to-spinal cord facilitation. Enhanced somatic pains are accompanied by mechanical hyperalgesia and allodynia in FM patients as compared with healthy controls. FM pain is likely to be at least partially maintained by peripheral impulse input from deep tissues. This conclusion is supported by results of several studies showing that injection of local anesthetics into painful muscles normalizes somatic hyperalgesia in FM patients.

The Course of Symptoms for Whiplash-Associated Disorders in Sweden: 6-Month Followup Study

Objective.

To describe symptom patterns and the course for recovery in persons with whiplash-associated disorders (WAD) over 6 months after a car collision, and to investigate associated gender differences.

Methods.

The study population was based on insurance claimants, 18–74 years of age, who reported WAD after a collision, between January 2004 and January 2005. At baseline and again 6 months later they were asked to complete a questionnaire that included questions about presence and severity of pain and other possible WAD symptoms. It also included measurements of posttraumatic stress as well as anxiety and depression.

Results.

A total of 1105 persons were studied. The most common symptoms at baseline after neck pain were reduced cervical range of motion (in 83.9% of men, 82.2% of women), headache (61.0% and 69.3%, respectively), and low back pain (35.9% and 36.1%). Some symptoms were already transient at baseline and symptoms such as neck pain, reduced cervical range of motion, headache, and low back pain decreased further over the 6 months. Baseline prevalence of depression was around 5% in both women and men, whereas posttraumatic stress and anxiety were more common in women (19.7% and 11.7%, respectively) compared to men (13.2% and 8.6%). The majority of all reported associated symptoms were mild at both baseline and followup.

Conclusion.

Our findings support that the symptom pattern of WAD and the prevalence for many of the symptoms decreased over a 6-month period.

The importance of vehicle rollover as a field triage criterion

BACKGROUND

The objective of this article was to review the importance of vehicle rollover as a field triage criterion. In 1987, field triage criteria were developed by the American College of Surgeons Committee on Trauma that have been propagated repeatedly over the subsequent 20+ years. The field triage decision scheme is based on abnormal physiology, obvious abnormal anatomy, mechanism of injury likely to result in severe injury, and other factors (age, etc.) and was supported by available science at that time. In 2005, the triage scheme was revised by a committee, and vehicle rollover as a crash scene triage criterion was dropped in 2006.

METHODS

The medical literature and data from the Department of Transportation/National Highway Traffic Safety Administration (NHTSA) Fatal Accident Reporting System and the National Automotive Sampling System were analyzed to determine the contribution of rollover to morbidity and mortality.

RESULTS

Vehicle rollovers represent a small but significant percentage of crashes; of the almost 12 million vehicle crashes reported by NHTSA in 2004, only 2.4% were rollovers, but these accounted for one-third of all crash-related occupant deaths and about 25,000 serious injuries every year. Rollovers are associated with the second highest number of vehicle occupant deaths by crash mode, three times the risk of injury when compared with other impact directions (p < 0.0001), specific types of injury such as head and spinal cord injuries, and a risk of death >15 times the risk in nonrollover crashes.

CONCLUSION

The data and literature unequivocally show a strong and disproportionate association between vehicle rollover and injury severity and death. Because it is difficult to devise simple, accurate decision rules for point of wounding and vehicle crash scene triage, simple, powerful relationships should be used when possible. Thus, the exclusion of rollover as a triage criterion seems to be ill advised.