Pain after whiplash: a prospective controlled inception cohort study

Headache features in people with whiplash associated disorders: A scoping review

BACKGROUND

Whiplash-associated headache (WAH) is one of the most common symptoms after a whiplash injury, leading to high disability. Nevertheless, the clinical characteristics of WAH have not been well described.

OBJECTIVE

To synthesise the existing literature on the clinical characteristics of WAH.

DESIGN

Scoping review.

METHODS

The protocol for this scoping review was registered in Open Science Framework and the PRISMA extension for Scoping Reviews tool was used to ensure methodological and reporting quality. A systematic search was conducted in PubMed, EMBASE, CINAHL, Web of Science and Scopus. The search was performed by one author and the screening of articles was conducted by two authors independently.

RESULTS

A total of 11363 articles were initially identified and finally 26 studies were included in the review. Headache intensity was the most commonly reported feature. Headache duration, frequency and location were also reported in at least four studies. Few studies reported physical impairments that may be related to the presence of WAH. A differentiation with concussion characteristics was only performed in eight studies.

CONCLUSION

WAH appears to be of mild to moderate intensity, typically with episodes of short duration which is commonly experienced in the occipital region amongst other regions, and with a tendency to reduce in intensity over time.

Predictors of high-cost patients with acute whiplash-associated disorder in Japan

INTRODUCTION

The proportion of neck injuries due to traffic accidents is increasing. Little is known about high-cost patients with acute whiplash-associated disorder (WAD). The present study aimed to investigate whether time to first visit for conventional medicine, multiple doctor visits, or alternative medicine could predict high-cost patients with acute WAD in Japan.

METHODS

Data from a compulsory, no-fault, government automobile liability insurance agency in Japan between 2014 and 2019 were used. The primary economic outcome was the total cost of healthcare per person. Treatment-related variables were assessed based on the time to first visit for conventional and alternative medicine, multiple doctor visits, and visits for alternative medicine. Patients were categorized according to total healthcare cost (low, medium, and high cost). The variables were subjected to univariate and multivariate analysis to compare high-cost and low-cost patients.

RESULTS

A total of 104,911 participants with a median age of 42 years were analyzed. The median total healthcare cost per person was 67,366 yen. The cost for consecutive medicine, for consecutive and alternative medicine, and total healthcare costs were significantly associated with all clinical outcomes. Female sex, being a homemaker, a history of WAD claim, residential area, patient responsibility in a traffic accident, multiple doctor visits, and visits for alternative medicine were identified as independent predictive factors for a high cost in multivariate analysis. Multiple doctor visits and visits for alternative medicine showed large differences between groups (odds ratios 2673 and 694, respectively). Patients with multiple doctor visits and visits for alternative medicine showed a significantly high total healthcare cost per person (292,346 yen) compared to those without (53,587 yen).

CONCLUSIONS

A high total healthcare cost is strongly associated with multiple doctor visits and visits for alternative medicine in patients with acute WAD in Japan.

Reconsidering Fordyce's classic article, "Pain and suffering: what is the unit?" to help make our model of chronic pain truly biopsychosocial

ABSTRACT

The biopsychosocial model (BPS) of chronic pain aspires to be comprehensive, incorporating psychological and social factors omitted from biomedical models. Although psychosocial factors are viewed as highly influential in understanding behavioral and psychological responses to pain, these factors are usually viewed as modifiers of biological causes of the experience of pain itself, rather than as equal contributors to pain. To further advance the BPS model, we re-examine a classic 1994 article by Wilbert "Bill" Fordyce, "Pain and suffering: what is the unit?" In this article, Fordyce suggested that pain-related disability and suffering should be viewed as "transdermal," as having causes both inside and outside the body. We consider Fordyce's article theoretically important because this concept allows us to more fully break free of the medical model of chronic pain than customary formulations of the BPS model. It makes it possible to place psychological and social factors on an equal footing with biological ones in explaining pain itself and to remove distinctions between pain mechanisms and pain meanings. The brain's salience network now offers a platform on which diverse influences on pain experience-from nociception to multisensory indicators of safety or danger-can be integrated, bridging the gap between impersonal nociceptive mechanisms and personal meanings. We also argue that Fordyce's article is practically important because this concept expands the BPS model beyond the bounds of the clinical encounter, opening the door to the full range of social, psychological, and biological interventions, empowering patients and nonmedical providers to tackle chronic pain.

[Distortion of the cervical spine : Pathophysiology, diagnostics, treatment and assessment]

Distortion or whiplash trauma of the cervical spine is an injury pattern associated with motor vehicle collisions and typically occurs after rear impact collisions, but is not limited to this type of collision and accident. The vast majority of these injuries are low-grade injuries according to the Quebec Task Force (QTF) classification, whereby no objective morphological correlates can be determined in clinical and radiological examinations. The prognosis is predominantly favorable and the condition is self-limiting; however, care must be taken with respect to complex courses with chronic pain and the manifestation of neuropsychiatric complaints. Due to the mechanism of the accident this injury pattern is particularly frequent in accidents associated with third party liability insurance claims. The discrepancy between subjective complaints and the presence of objective findings is a particular challenge for the assessment by the medical expert.

A Systematic Review of the Variation in Pain Catastrophizing Scale Reference Scores Based on Language Version and Country in Patients with Chronic Primary (Non-specific) Pain

INTRODUCTION

This systematic review aimed to investigate variations of reference scores for the Pain Catastrophizing Scale (PCS) between language versions and between countries in patients with chronic primary pain (CPP) or chronic primary pain, not otherwise specified (CPP-NOS).

METHODS

Electronic searches of the Ovid/Embase, Ovid/MEDLINE, and Ovid/PsycINFO databases were conducted to retrieve studies assessing PCS scores in adults with CPP or CPP-NOS proposed by the International Classification of Diseases, Eleventh Revision for any country where the translated PCS was available. The protocol for this systematic review was prospectively registered on the International Prospective Register of Systematic Reviews 2018 (registration number: CRD 42018086719).

RESULTS

A total of 3634 articles were screened after removal of duplicates. From these, 241 articles reporting on 32,282 patients with chronic pain were included in the review. The mean (± standard deviation) weighted PCS score across all articles was 25.04 ± 12.87. Of the 12 language versions and 21 countries included in the review, the weighted mean PCS score in Asian languages or Asian countries was significantly higher than that in English, European, and other languages or Western and other countries. The highest mean score of the weighted PCS based on language was in Japanese (mean 33.55), and the lowest was in Russian (mean 20.32). The highest mean score of the weighted PCS based on country was from Japan (mean 33.55), and the lowest was from Australia (mean 19.80).

CONCLUSION

The weighted PCS scores for people with CPP or CPP-NOS were significantly higher in Asian language versions/Asian countries than in English, European and other language versions or Western and other countries.

Higher Neck Pain Intensity and the Presence of Psychosocial Factors are More Likely when Headache is Present After Whiplash Associated Disorders: A Case-Control Study

BACKGROUND

Several factors such as neck pain intensity, disability, anxiety, depression, female sex or a previous history of headache, are associated with post-whiplash headache. However, the possible role of psychosocial factors contributing to the presence of headache or worsening of headache after a whiplash trauma remains unclear. To address this gap in knowledge, there is the need to assess psychosocial factors concerning headache shortly after a whiplash injury.

OBJECTIVE

To evaluate psychological features, pain and disability in people with acute Whiplash Associated Disorders (WAD) and compare these features between those with and without headache.

DESIGN

case-control study.

SETTING

A secondary care traumatology center.

METHODS

Forty-seven people with acute WAD were recruited; 28 with headache, and 19 without. All participants completed self-reported questionnaires including Visual Analogue Scale (VAS) for neck pain intensity, the Neck Disability Index (NDI), Pain Catastrophizing Scale (PCS), Tampa Scale Kinesiophobia-11 (TSK-11) and State-Trait Anxiety Inventory.

RESULTS

Neck pain intensity (p < 0.001), neck disability (p < 0.001), pain catastrophising (p < 0.001), kinesiophobia (p < 0.001) and anxiety state (p = 0.007) and trait (p = 0.05) were higher in those with headache when compared to those without. In addition, high levels of neck pain (p = 0.025), moderate levels of neck disability (p < 0.001), moderate levels of pain catastrophising (p = 0.015), and moderate (p = 0.002) and severe (p = 0.016) levels of kinesiophobia were related to the presence of headache.

CONCLUSION

The level of neck pain intensity and disability, kinesiophobia, catastrophising and anxiety were all greater in people with acute WAD who presented with a headache compared to those without headache.

The Long-term Impact of Whiplash Injuries on Patient Symptoms and the Associated Degenerative Changes Detected Using MRI: A Prospective 20-year Follow-up Study Comparing Patients with Whiplash-associated Disorders with Asymptomatic Subjects

STUDY DESIGN

A longitudinal, 20-year comparative study of patients with whiplash-associated disorders (WAD).

OBJECTIVE

The aim of this study was to clarify the long-term impact of WAD on patient symptoms and on magnetic resonance imaging (MRI) findings of the cervical spine, in comparison with asymptomatic volunteers.

SUMMARY OF BACKGROUND DATA

The long-term impact of WAD has not been fully elucidated.

METHODS

Between 1993 and 1996, we conducted a cross-sectional comparative study of 508 acute WAD patients and 497 asymptomatic volunteers, all of whom underwent MRI on cervical spine and physical examinations. For this 20-year follow-up comparative study, 75 WAD patients and 181 control subjects aged <60 years were recruited from the original cohort. The MRI findings, including discs' signal intensities, posterior disc protrusions, anterior dural compressions, spinal cord disc space narrowing, and foraminal stenoses, were evaluated using two to four numerical grades. The results of the WAD patients and control subjects were compared.

RESULTS

In this follow-up, the prevalence of shoulder stiffness (72.0% vs. 45.9%), headache (24.0% vs. 12.2%), and arm pain (13.3% vs. 3.9%) were significantly greater in WAD patients than in control subjects. The multiregression analysis revealed that a history of WAD was associated with shoulder stiffness (odds ratio [OR]: 3.36), headache (OR: 2.39), and arm pain (OR: 3.82). Although MRI findings in WAD patients were more degenerated than in control subjects in the initial study, all MRI findings were similar at the 20-year follow-up. There were no significant correlations between clinical cervical symptoms and progression in each MR finding in either group.

CONCLUSION

After 20 years, whiplash injuries significantly impacted the residual symptoms of shoulder stiffness, headache, and arm pain when compared with initially asymptomatic volunteers. The progression of degenerative changes in the cervical intervertebral discs after 20 years revealed no association with existing whiplash injuries, neither did the residual cervical-related symptoms.Level of Evidence: 3.

Neck pain and headache after whiplash injury: a systematic review and meta-analysis

Neck pain and headache are 2 of the most common complications of whiplash injury. Therefore, we performed a systematic literature search on PubMed and Embase for publications reporting on the prevalence of neck pain and headache after whiplash injury. The literature search identified 2709 citations of which 44 contained relevant original data. Of these, 27 studies provided data for the quantitative analysis. For non-population-based studies, the present meta-analysis showed that a pooled relative frequency of neck pain was 84% confidence interval (68%-95%) and a pooled relative frequency of headache was 60% (46%-73%), within 7 days after whiplash injury. At 12 months after injury, 38% (32%-45%) of patients with whiplash still experienced neck pain, while 38% (18%-60%) of whiplash patients reported headache at the same time interval after injury. However, we also found considerable heterogeneity among studies with I-values ranging from 89% to 98% for the aforementioned meta-analyses. We believe that the considerable heterogeneity among studies underscores the need for clear-cut definitions of whiplash injury and standardized reporting guidelines for postwhiplash sequelae such as neck pain and headache. Future studies should seek to optimize these aspects paving the way for a better understanding of the clinical characteristics and natural course of whiplash-associated sequelae.

The nosological classification of whiplash-associated disorder: a narrative review

Whiplash-associated disorder (WAD) is the most common complaint and purported cause of chronic disability associated with motor vehicle collisions in North America. However, its construct validity remains controversial. This narrative review of the literature summarises the evidence underlying the most commonly theorised biological and psychosocial mechanisms of WAD pathogenesis. While the face validity of WAD is good, empirical evidence supporting the various constructs suggesting a causal link between a trauma mechanism and the development of symptoms is poor. Because individual expectations of recovery are outcome-predictive, future research is necessary to develop a better understanding of how to enhance expectancies in order to help affected motorists gain a greater sense of control over their health and wellbeing.

Defining pain and interference recovery trajectories after acute non-catastrophic musculoskeletal trauma through growth mixture modeling

BACKGROUND

Recovery trajectories support early identification of delayed recovery and can inform personalized management or phenotyping of risk profiles in patients. The objective of this study was to investigate the trajectories in pain severity and functional interference following non-catastrophic musculoskeletal (MSK) trauma in an international, mixed injury sample.

METHODS

A prospective longitudinal cohort (n = 241) was formed from patients identified within four weeks of trauma, from attendance at emergency or urgent care centres located in London, ON, Canada, or Chicago, IL, USA. Pain interference was measured via the Brief Pain Inventory (London cohort) or the Neck Disability Index (Chicago cohort). Pain severity was captured in both cohorts using the numeric pain rating scale. Growth mixture modeling and RM repeated measures ANOVA approaches identified distinct trajectories of recovery within pain interference and pain severity data.

RESULTS

For pain interference, the three trajectories were labeled accordingly: Class 1 = Rapid recovery (lowest intercept, full or near full recovery by 3 months, 32.0% of the sample); Class 2 = Delayed recovery (higher intercept, recovery by 12 months, 26.7% of the sample); Class 3 = Minimal or no recovery (higher intercept, persistently high interference scores at 12 months, 41.3% of the sample). For pain severity, the two trajectories were labeled: Class 1 = Rapid recovery (lower intercept, recovery by 3 months, 81.3% of the sample); and Class 2 = Minimal or no recovery (higher intercept, flat curve, 18.7% of the sample). The "Minimal or No Recovery" trajectory could be predicted by female sex and axial (vs. peripheral) region of trauma with 74.3% accuracy across the 3 classes for the % Interference outcome. For the Pain Severity outcome, only region (axial trauma, 81.3% accuracy) predicted the "Minimal or No Recovery" trajectory.

CONCLUSIONS

These results suggest that three meaningful recovery trajectories can be identified in an international, mixed-injury sample when pain interference is the outcome, and two recovery trajectories emerge when pain severity is the outcome. Females in the sample or people who suffered axial injuries (head, neck, or low back) were more likely to be classed in poor outcome trajectories.

TRIAL REGISTRATION

National Institutes of Health - clinicaltrials.gov ( NCT02711085 ; Retrospectively registered Mar 17, 2016).

Exposure to a Motor Vehicle Collision and the Risk of Future Neck Pain: A Systematic Review and Meta-Analysis

OBJECTIVE

To summarize the literature that has examined the association between a motor vehicle collision (MVC) related neck injury and future neck pain (NP) in comparison with the population that has not been exposed to neck injury from an MVC.

LITERATURE SURVEY

Neck injury resulting from an MVC is associated with a high rate of chronicity. Prognosis studies indicate 50% of injured people continue to experience NP a year after the collision. This is difficult to interpret due to the high prevalence of NP in the general population.

METHODOLOGY

We performed a systematic review of the literature using five electronic databases, searching for risk studies on exposure to an MVC and future NP published from 1998 to 2018. The outcome of interest was future NP. Eligible risk studies were critically appraised using the modified Quality in Prognosis Studies (QUIPS) instrument. The results were summarized using best-evidence synthesis principles, a random effects meta-analysis, metaregression, and testing for publication bias was performed with the pooled data.

SYNTHESIS

Eight articles were identified of which seven were of lower risk of bias. Six studies reported a positive association between a neck injury in an MVC and future NP compared to those without a neck injury in an MVC. Pooled analysis of the six studies indicated an unadjusted relative risk of future NP in the MVC exposed population with neck injury of 2.3 (95% CI [1.8, 3.1]), which equates to a 57% attributable risk under the exposed. In two studies where exposed participants were either not injured or injury status was unknown, there was no increased risk of future NP.

CONCLUSIONS

There was a consistent positive association among studies that have examined the association between MVC-related neck injury and future NP. These findings are of potential interest to clinicians, insurers, patients, governmental agencies, and the courts.

LEVEL OF EVIDENCE

I.

A preliminary study to investigate the prevalence of pain in international event riders during competition, in the United Kingdom

The aim of the study was to investigate the prevalence of riders at the international levels in eventing, competing with pain, the location of their pain, factors affecting their pain and whether they perceived this pain to have an effect on their performance. 331 questionnaires were completed by international event riders (FEI CCI*, CCI**, CIC***) at the Hartpury International Horse Trials, UK, to establish the prevalence of riders competing with pain. 96% of international event riders competed while experiencing pain, 76% of riders stated that this pain was in the neck, upper back or shoulders. All female riders reported pain, giving a significant correlation between gender and pain (X=-0.479, P=0.006). 55% of riders felt their pain affected their riding performance, giving an odds ratio of 1.14, compared to those riders who felt their pain did not effect their performance. Pain was perceived to influence performance by affecting fatigue, their concentration, and anxiety levels. 96% of riders reporting pain used medication to alleviate their symptoms. This high incidence of international event riders who compete with pain, particularly back pain, could be problematic given the longevity of a rider’s career, which can span over four decades and could potentially increase the risk of a serious or fatal fall in the cross-country phase. This research reports rider’s perceptions and self-reported pain and management options, which may affect the data. Further research is needed to establish the causes of back pain and appropriate management strategies.

Isometric muscle fatigue of the paravertebral and upper extremity muscles after whiplash injury

BACKGROUND

Whiplash-associated disorders (WAD) result from injury of neck structures that most often occur during traffic accidents as a result of rapid acceleration-deceleration. The dominant symptoms manifest in the musculoskeletal system and include increased fatigue. Because of the frequency of whiplash injuries, a simple, cheap and useful diagnostic tool is needed to differentiate whiplash injury from healthy patients or those faking symptoms.

OBJECTIVES

To determine muscle fatigue in patients with whiplash injury in six body positions.

DESIGN

Analytical cross-sectional study.

SETTING

Emergency center, university hospital.

PATIENTS AND METHODS

We studied patients with whiplash injury from vehicular traffic accidents who presented to the emergency center within 6 hours of sustaining the injury. We determined whiplash injury grade according to the Quebec Task Force (QTF) classification and measured isometric muscle endurance in six different body positions. Control subjects for each patient were matched by age, gender and anthropomorphic characteristics. Cut-off values were determined to distinguish patients with whiplash injury from controls and for determination of injury grade .

MAIN OUTCOME MEASURE(S)

QTF grade, time to muscle fatigue in seconds.

RESULTS

From September 2013 to September 2016, we enrolled 75 patients with whiplash injury and 75 matching control subjects. In all six positions, the patients with whiplash injury felt muscle fatigue faster than equivalent controls (P < .05) and the time to onset of muscle fatigue decreased with increasing injury grades in all six positions. Assignment to the patient or control group and to injury grade could be predicted with more than 90% accuracy on the basis of time to muscle fatigue. The most efficient position was the highest injury grade, by which 99.9% of the patients were accurately categorized. Isometric muscle endurance correlated with whiplash injury grade in all six positions (P < .01).

CONCLUSION

Under clinical conditions, muscle endurance and the appearance of isometric muscle fatigue during testing can be a useful indicator of whiplash injury and grade.

LIMITATIONS

The size of the sample was small. An objective parameter such as electromyography is needed to confirm isometric muscle fatigue.

Whiplash Syndrome Reloaded: Digital Echoes of Whiplash Syndrome in the European Internet Search Engine Context

Background

In many Western countries, after a motor vehicle collision, those involved seek health care for the assessment of injuries and for insurance documentation purposes. In contrast, in many less wealthy countries, there may be limited access to care and no insurance or compensation system.

Objective

The purpose of this infodemiology study was to investigate the global pattern of evolving Internet usage in countries with and without insurance and the corresponding compensation systems for whiplash injury.

Methods

We used the Internet search engine analytics via Google Trends to study the health information-seeking behavior concerning whiplash injury at national population levels in Europe.

Results

We found that the search for “whiplash” is strikingly and consistently often associated with the search for “compensation” in countries or cultures with a tort system. Frequent or traumatic painful injuries; diseases or disorders such as arthritis, headache, radius, and hip fracture; depressive disorders; and fibromyalgia were not associated similarly with searches on “compensation.”

Conclusions

In this study, we present evidence from the evolving viewpoint of naturalistic Internet search engine analytics that the expectations for receiving compensation may influence Internet search behavior in relation to whiplash injury.

Behavioral Treatments for Post-Traumatic Headache

PURPOSE OF REVIEW

Post-traumatic headache (PTH) is a common headache type after traumatic brain injury (TBI). There are no FDA approved medications for PTH, and it is unknown how medications can affect the brain's ability to recover from TBI. Thus, we sought to examine the biopsychosocial factors that influence PTH and the non-pharmacologic treatments studied for headache treatment. We also sought to determine if there is literature examining whether the non-pharmacologic treatments influence the biopsychosocial factors. The non-pharmacologic treatments assessed included cognitive behavioral therapy (CBT), biofeedback, progressive muscle relaxation therapy (PMR), acupuncture, and physical therapy (PT).

RECENT FINDINGS

Factors associated with prognosis in PTH may include the following: severity of TBI, stress, post-traumatic stress disorder, other psychiatric comorbidities, sociocultural and psychosocial factors, litigation, base rate misattribution, expectation as etiology, and chronic pain. There are few high quality studies on the non-pharmacologic treatments for PTH. Thermal and EMG biofeedback appear to have been examined the most followed by CBT. Studies did not have secondary outcomes examining the psychosocial factors related to PTH. Most of the behavioral studies involved a multi-modality intervention limiting the ability to assess the individual non-pharmacologic interventions we sought to study. There were very few randomized clinical trials evaluating the efficacy of non-pharmacologic interventions. Therefore, future research, which considers the noted biopsychosocial factors, is needed in the field to determine if these interventions reduce PTH.

Chronic pain following trauma

Trauma is increasingly recognized as a factor in the development of chronic pain. Complex regional pain syndrome (CRPS) and phantom limb pain are distinct chronic conditions associated with trauma; they are also a challenge to treat and can lead to life-long suffering with a significant drain on healthcare resources. This review explores the underlying pathophysiology of acute pain after trauma and its transition to become chronic. In doing so it will provide a better understanding of treatment options. The evidence is increasing that treating injury well in the acute phase can prevent chronic pain from developing (Katz et al., 1996). Once chronic pain has developed it is more difficult to treat.

Prospective PC-interactive Pressure Algesimetry of Post-Traumatic Neck pain after Whiplash Injury

Cervical pain is a prominent symptom in both acute whiplash injury and late whiplash syndrome. However, no systematic analysis of post-traumatic pain development covering several weeks has yet been performed in whiplash patients. It was the aim of the present study to analyse the duration and course of post-traumatic muscle pain due to whiplash injury in a prospective follow-up examination with short investigation intervals. A recovery of initially increased muscle pain after whiplash injury within 1 month was hypothesized. Pressure pain of the splenius and trapezius muscles was recorded using PC-interactive pressure algesimetry. Whiplash patients were investigated during the acute injury stage and after 3, 4, and 6 weeks and compared with matched controls. We found significantly increased pressure pain of the splenius and trapezius muscles in the acute stage of whiplash injury. After 4 weeks patients' scores of pain parameters were comparable to those of healthy control subjects. Within the patient group the first changes of pressure pain were observed within 3 (splenius) and 4 weeks (trapezius). For most patients the recovery dynamics lasted 4-6 weeks. A minority of patients did not show any improvement after 6 weeks. The present study shows that the dynamics of pressure pain due to whiplash injury can be quantified by means of PC-interactive pressure algesimetry. Our results confirm the clinical experience that the acute post-traumatic cervical syndrome normally subsides within weeks.

The Role of the Trigemino Cervical Complex in Chronic Whiplash Associated Headache: A Cross Sectional Study

OBJECTIVE

To investigate signs of central sensitization in a cohort of patients with chronic whiplash associated headache (CWAH).

BACKGROUND

Central sensitization is one of the mechanisms leading to chronicity of primary headache, and thus might contribute to CWAH. However, the pathophysiological mechanism of CWAH is poorly understood and whether it is simply an expression of the primary headache or has a distinct pathogenesis remains unclear. Thus, the factors involved in the genesis of CWAH require further investigation.

METHODS

Twenty-two patients with CWAH (20 females, 2 males; age 25-50 years, mean age 36.3 years) and 25 asymptomatic participants (13 females, 12 males; age 18-50 years, mean age 35.6 years) rated glare and light-induced discomfort in response to light from an ophthalmoscope. Hyperalgesia evoked by a pressure algometer was assessed bilaterally on the forehead, temples, occipital base, and the middle phalanx of the third finger. The number, latency, area under the curve, and recovery cycle of nociceptive blink reflexes elicited by a supraorbital electrical stimulus were also recorded.

RESULTS

Eight and 6 CWAH patients had migrainous and tension-type headache (TTH) profiles, respectively; the remainder had features attributable to both migraine and TTH. Patients in the whiplash group reported significantly greater light-induced pain than controls (8.48 ± .35 vs 6.66 ± .43 on a 0-10 scale; P = .001). The CWAH patients reported significantly lower pressure pain thresholds at all sites. For stimuli delivered at 20 second intervals, whiplash patients were more responsive than controls (4.8 ± .6 blinks vs 3.0 ± .6 blinks in a block of 10 stimuli; P = .036). While R2 latencies and the area under the curve for the 20 second interval trials were comparable in both groups, there was a significant reduction of the area under the curve from the first to the second of the 2-second interval trials only in controls (99 ± 8% of baseline in whiplash patients vs 68 ± 7% in controls; P = .009). The recovery cycle was comparable for both groups.

CONCLUSIONS

Our results corroborate previous findings of mechanical hypersensitivity and photophobia in CWAH patients. The neurophysiological data provide further evidence for hyperexcitability in central nociceptive pathways, and endorse the hypothesis that CWAH may be driven by central sensitization.

Prognosis of functional neurologic disorders

The prognosis of functional (psychogenic) neurologic disorders is important in being able to help answer patients' and carers' questions, determine whether treatment is worthwhile, and to find out which factors predict outcome. We reviewed data on prognosis of functional neurologic disorders from two systematic reviews on functional motor disorders and dissociative (nonepileptic) seizures as well as additional studies on functional visual and sensory symptoms. Methodologic problems include heterogeneity in studied samples and outcome measures, diagnostic suspicion and referral bias, small size and retrospective design of available studies, possible treatments during follow-up, and literature review bias. With these caveats, the prognosis of functional neurologic disorders does appear to be generally unfavorable. In most studies, functional motor symptoms and psychogenic nonepileptic attacks remain the same or are worse in the majority of patients at follow-up. Measures of quality of life and working status were often poor at follow-up. Frequency of misdiagnosis at follow-up was as low as other neurologic and psychiatric disorders. Long duration of symptoms was the most distinct negative predictor. Early diagnosis and young age seem to predict good outcome. Emotional disorders and personality disorders were inconsistent predictors. Litigation and state benefits were found to be negative predictors in some studies, but others found they did not influence outcome.

Delayed transient post-traumatic quadriplegia

Transient neurological deficit following cervical trauma have been reported following sports injuries, and has been referred to as cervical cord neurapraxia. The so-called "whiplash injuries" following minor motor vehicle collisions usually do not produce any neurological deficit. Here we report the case of a whiplash type of injury presenting with a delayed onset neurological deficit, which was followed by rapid and complete recovery. The patient, an otherwise healthy 34-year-old male, attended the emergency department of Sultan Qaboos University Hospital following a rear-end motor vehicle collision. We present images showing degenerative disc disease causing spinal canal narrowing and mild cord compression in the patient, but no spinal instability. Differential diagnoses are also discussed.

On matters of causation in personal injury cases: Considerations in forensic examination

Rheumatologists are often called to be independent examiners of injured claimants and to address the question: "What is causing the injured person's symptoms?" This article deals with the legal principles that arise in these cases, including causation, convenient focus, secondary gain, and thin skull rules. We shall first set out two hypothetical scenarios of personal injury cases that set the scene for a discussion of legal principles in personal injury law. With the same two scenarios of personal injury in mind, we shall review the legal principles and the biopsychosocial models of the illnesses concerned and consider the importance of examiners going beyond diagnostic labels towards a more in-depth analysis of illness factors and mechanisms that in turn assist the trier of facts.

The health status of people claiming compensation for musculoskeletal injuries following road traffic crashes is not altered by an early intervention programme: a comparative study

OBJECTIVE

To compare health outcomes among claimants compared to those who were ineligible or choose not to lodge a compensation claim. We also evaluated the effect of an early intervention programme on the health outcomes of the participants.

DESIGN

Prospective comparative study using sequential cohorts.

SUBJECTS

People presenting to hospital emergency departments with mild to moderate musculoskeletal injuries following road traffic crashes.

INTERVENTION

referral to an early intervention programme for assessment by musculoskeletal physician, pain management education, promotion of self-management and encouragement of early activity.

MAIN OUTCOMES

The 36-Item Short-Form Survey (SF-36); Hospital Anxiety and Depression Scale (HADS) and Functional Rating Index (FRI) scores were assessed at post-crash and at 12 months.

RESULTS

At 12 months, mean scores in six and five of the SF-36 domains were significantly lower among participants who claimed compensation versus those who chose not to claim or were ineligible, respectively. Differences in mean SF-36 scores ranged from 3.0 ('general health perception') to 8.0 units ('role limitations due to physical problems'). Participants who claimed compensation had 6.3- and 4.6-units lower SF-36 physical component score compared to those who were ineligible (p=0.001) or chose not to claim (p=0.01), respectively. Participants who claimed compensation reported a worse HADS-depression score of 6.46 versus 4.97 and 4.69 observed in those who were ineligible (p=0.04) or did not claim (p=0.01). Claimants had worse FRI scores compared to non-claimants (p=0.01) and those who were ineligible (p=0.01). The early intervention did not improve health outcomes, 12 months after injury.

CONCLUSIONS

Claiming compensation was associated with a worse health status for people with soft tissue injuries caused by road traffic crashes. The health status in people claiming compensation was not altered by an early intervention programme.

Physiotherapists' Beliefs About Whiplash-associated Disorder: A Comparison Between Singapore and Queensland, Australia

BACKGROUND AND PURPOSE

Healthcare providers' beliefs may play a role in the outcome of whiplash-associated disorders (WAD), a condition which is proposed to be culturally dependent. Clinical practice guidelines recommend an active approach for the management of WAD, which is often delivered by physiotherapists. However, there is no data on physiotherapists' whiplash beliefs. Our primary objective was to determine physiotherapists' beliefs from Queensland (Australia) and Singapore, two cultures with differing prevalence of chronic musculoskeletal pain and chronic WAD.

METHODS

A pen and paper survey of musculoskeletal physiotherapists practicing in Queensland and Singapore was conducted. Participants completed questionnaires consisting of patient vignettes and statements inquiring knowledge and attitudes towards WAD. Chi-square tests of significance were used to compare the responses of physiotherapists from both samples.

RESULTS

Ninety-one (response rate 45%) Queensland-based and 94 (response rate 98%) Singapore-based physiotherapists participated in the study. The beliefs in the management strategies for the patient vignettes were generally consistent with practice guidelines. A higher proportion of Queensland-based physiotherapists expected permanent disabilities for the patient vignette depicting chronic WAD (Queensland: 55% Singapore: 28% Pearson chi-sq 18.76, p < 0.005).Up to 99% of the physiotherapists from both samples believed in encouragement of physical activity, the effectiveness of exercise and multimodal physiotherapy for WAD. Significantly higher proportions of Singapore-based physiotherapists believed in ordering radiographs for acute WAD (Pearson chi-sq 41.98, p < 0.001) and also believed in a psychogenic origin of chronic WAD (Pearson chi-sq 22.57, p  0.001).

CONCLUSION

The majority of beliefs between physiotherapists in Queensland and Singapore were similar but there were specific differences. Physiotherapists' whiplash beliefs in Queensland and Singapore did not clearly reflect the difference in prevalence of chronic musculoskeletal pain or chronic WAD in Queensland and Singapore.

An early intervention programme had no detectable influence on the health status of people with musculoskeletal injuries following road traffic crashes: comparative study

OBJECTIVE

To compare the health status of people with minor injuries from road traffic crashes that are exposed to an early, active intervention programme (intervention group) with those receiving usual care (control group) over a 12 month period.

DESIGN

Prospective comparative study using sequential cohorts.

SUBJECTS

People presenting to hospital emergency departments with mild to moderate musculoskeletal injuries following road traffic crashes.

MAIN OUTCOME MEASURES

Physical Component Score (PCS) and Mental Component Score (MCS) of the Short Form 36 (SF-36) health status measure; Hospital Anxiety and Depression Scale (HADS) and the Functional Rating Index (FRI) recorded immediately post-crash, at 6 months and at 12 months after injury.

RESULTS

There were 95 participants allocated to the control group and 98 allocated to the intervention group. Participants were enrolled at a mean of 9.3 days following the crash. There were no significant differences in baseline health measures between the groups. Apart from a small improvement in anxiety for the intervention group, there were no significant differences in health status between the groups. Twenty percent of participants in the intervention group received treatment from external healthcare providers that was inconsistent with the recommendations of the intervention programme.

CONCLUSIONS

The intervention programme failed to result in a clinically significant improvement in health outcomes compared with usual care. There is some evidence to suggest that the intervention had some psychological benefits, as evidenced by the small improvement in anxiety levels. Limited adherence, frequent use of co-interventions, or other factors (such as intervention content or intensity) may have reduced its effect.

Laypersons' expectations of recovery and beliefs about whiplash injury: a cross-cultural comparison between Australians and Singaporeans

BACKGROUND

Beliefs and expectations are thought to influence outcome following whiplash injury. Studies have proposed a link between rates of chronic whiplash and laypersons' expectations about outcome following a motor vehicle accident. The prevalence of chronic whiplash is relatively high in Australia and apparently low in Singapore. This study's objectives were to compare laypersons' beliefs and expectations of recovery of whiplash injury in Brisbane and Singapore and to assess the effect of demographic factors on whiplash beliefs.

METHODS

A cross-sectional study using online surveys was conducted on adult Internet users in Brisbane (Australia) and Singapore. The 14-item whiplash beliefs questionnaire (WBQ) was used to evaluate whiplash beliefs. Two additional items assessed expectations of recovery. Individual items of WBQ, WBQ score and expectations of recovery were analysed. Stratified analysis was performed to adjust for sampling bias due to quota sampling.

RESULTS

A total of 402 participants from Singapore and 411 participants from Brisbane, Australia, completed the survey. While participants from Singapore demonstrated slightly more negative whiplash beliefs than participants from Brisbane [t(811)  = -5.72; p < 0.0001], participants from both samples were similar in their expectations of quick recovery and return to normal activities following whiplash injury. Only gender had a significant effect on whiplash beliefs [estimated marginal means of WBQ score for men = 21.5; standard error (SE) = 0.20; women = 22.5; SE = 0.20; F(1,810)  = 11.2; p = 0.001].

CONCLUSIONS

Laypersons' expectations of recovery and beliefs about whiplash injury in Brisbane and Singapore were generally similar and mostly positive. Our results demonstrate that cultural differences reflected by laypersons' beliefs may not reflect the differences in prevalence of chronic whiplash between countries.

Subgroups based on thermal and pressure pain thresholds in women with chronic whiplash display differences in clinical presentation - an explorative study

PURPOSE

To investigate the presence of subgroups in chronic whiplash-associated disorders (WAD) based on pain thresholds for pressure (PPT), cold (CPT), and heat (HPT) and to compare these subgroups with respect to symptomatology, disability, and health aspects.

METHODS

Two groups of female subjects - patients with chronic WAD (n = 28) and healthy controls (CON; n = 29) - were investigated. Quantitative sensory testing (QST) for thermal thresholds and algometry for PPT at four sites in the body (over the trapezius and tibialis anterior bilaterally) were determined. Habitual pain intensities, psychological strain, disability, and health aspects were registered using a questionnaire.

RESULTS

A CLUSTER ANALYSIS BASED ON PPT, CPT, AND HPT IDENTIFIED TWO SUBGROUPS OF CHRONIC WAD: one sensitive subgroup (s-WAD; n = 21), and one less sensitive subgroup (ls-WAD; n = 6). S-WAD displayed widespread hyperalgesia, whereas ls-WAD had localized hyperalgesia in the neck area, with tendencies to supernormal values in remote areas of the body. Generally, s-WAD had a significantly worse situation than the CON with respect to symptomatology, disability, and health aspects. The ls-WAD group was intermediary between s-WAD and CON in these aspects.

CONCLUSION

Different explanations, eg, severity of the pain condition per se, etiological factors, and pre-trauma differences in pain sensitivity, may exist for the differences in pain thresholds between the two subgroups. Future research should investigate the role of pain thresholds in the chronic stage to determine the efficacy of treatment interventions.

Dysfunctional pain inhibition in patients with chronic whiplash-associated disorders: an experimental study

Inefficient endogenous pain inhibition, in particular impaired conditioned pain modulation (CPM), may disturb central pain processing in patients with chronic whiplash-associated disorders (WAD). Previous studies revealed that abnormal central pain processing is responsible for a wide range of symptoms in patients with chronic WAD. Hence, the present study aimed at examining the functioning of descending pain inhibitory pathways, and in particular CPM, in patients with chronic WAD. Thirty-five patients with chronic WAD and 31 healthy controls were subjected to an experiment evaluating CPM. CPM was induced by an inflated occlusion cuff and evaluated by comparing temporal summation (TS) of pressure pain prior to and during cuff inflation. Temporal summation was provoked by means of 10 consecutive pressure pulses at upper and lower limb location. Pain intensity of first, fifth, and 10th pressure pulse was rated. During heterotopic noxious conditioning stimulation, TS of pressure pain was significantly depleted among healthy controls. In contrast, TS was quite similar prior to and during cuff inflation in chronic WAD, providing evidence for dysfunctional CPM in patients with chronic WAD. The present study demonstrates a lack of endogenous pain inhibitory pathways, and in particularly CPM, in patients with chronic WAD, and hence provides additional evidence for the presence of central sensitization in chronic WAD.

The influence of fault on health in the immediate post-crash period following road traffic crashes

OBJECTIVE

To compare the early health status of people who sustained injuries during road traffic crashes (RTC) in which they were at fault (AF), with people who sustained injuries in RTC in which they were not at fault (NAF).

DESIGN

Prospective cohort study.

SUBJECTS

People presenting to the emergency department with mild to moderate musculoskeletal injuries following RTC.

MAIN OUTCOME MEASURES

Physical Component Score (PCS) and Mental Component Score (MCS) of the Short Form 36 (SF-36) health status measure; Hospital Anxiety and Depression Scale (HADS) and the Functional Rating Index (FRI) recorded immediately post-crash.

RESULTS

193 people participated in the study and were enrolled a mean of 9.3 days following the crash. The mean age was 37 years and 60% were female. 71% were NAF. There was a significantly higher number of females in the NAF group (65% compared with 35% males; p<0.001). Neck and back injuries were reported by 90.4% of the NAF group compared to 69.1% of the AF group (p<0.001). There were no significant differences in PCS, FRI or pain intensity between the two groups at a mean of 9.3 days after the crash. The mean MCS for the NAF group was significantly worse than for the AF group (31.4 compared to 37.3; p = 0.005). The SF-36 domain revealed a significantly worse adjusted mean role emotional score for the NAF group (23.4 compared to 32.5, p = 0.002). Females had significantly worse MCS score than males (30.6 and 38.1 respectively; p<0.001) and worse adjusted mean anxiety and depression scores (10 compared to 7.8; p = 0.002 and 7.6 compared to 5.5; p = 0.002 respectively).

CONCLUSIONS

Despite there being no difference in physical health status, the NAF group demonstrated more emotional and mental disturbance than the AF group; and this was significantly worse for females. Treatment strategies should focus on addressing early pain and disability as well as providing appropriate psychological interventions, particularly for people not at fault following RTC.

Mechanisms of chronic pain from whiplash injury

This article is to provide insights into the mechanisms underlying chronic pain from whiplash injury. Studies show that injury produces plasticity changes of different neuronal structures that are responsible for amplification of nociception and exaggerated pain responses. There is consistent evidence for hypersensitivity of the central nervous system to sensory stimulation in chronic pain after whiplash injury. Tissue damage, detected or not by the available diagnostic methods, is probably the main determinant of central hypersensitivity. Different mechanisms underlie and co-exist in the chronic whiplash condition. Spinal cord hyperexcitability in patients with chronic pain after whiplash injury can cause exaggerated pain following low intensity nociceptive or innocuous peripheral stimulation. Spinal hypersensitivity may explain pain in the absence of detectable tissue damage. Whiplash is a heterogeneous condition with some individuals showing features suggestive of neuropathic pain. A predominantly neuropathic pain component is related to a higher pain/disability level.

Whiplash Associated Disorders (WAD): Responses to pharmacological challenges and psychometric tests

Objectives The present study challenges chronic Whiplash Associated Disorders (WAD)-subjects to a pharmacological intravenous (i.v.) test with morphine, ketamine, and active placebo (midazolam). The aim was to describe the short-term responses to drugs and the assumed heterogeneity in the patterns of responses. We related the different responder groups to the results from psychometric tests. Methods The study includes 95 patients, all with chronic WAD and referred to our departments. They answered a questionnaire including the following psychometric instruments relevant for chronic pain: Beck Depression Inventory, Coping Strategies Questionnaire, Multidimensional Pain Inventory, Life Satisfaction Checklist, SF36 and EuroQol. The subjects also went through sessions with separate infusions of morphine (0.3 mg/kg), ketamine (0.3 mg/kg) and midazolam (0.05 mg/kg). Infusion time was 30 min followed by a 2-h post-infusion assessment. Assessments were made using a Visual Analogue Scale (VAS) for pain intensity and unpleasantness and by statements of per cent pain relieved. A categorical pain rating scale was also used. A positive response was defined as ≥50% decrease of the VAS-level on two consecutive assessment points during the test sessions, anything less was a non response. The placebo responders were defined as those with a positive response to the active placebo infusion. Results The tests were completed by 94 subjects and 26% of these were placebo responders. Among the placebo non responders, 47% responded to morphine, 41% to ketamine, 25% to both drugs and 37% to neither morphine nor ketamine (pain intensity assessments). Similar proportions were found in the assessments of pain unpleasantness and per cent pain relieved. Approximately one in four subjects (27%, pain intensity assessment) did not respond to any of the drugs tested. This relatively high proportion of non responders seemed to be worst cases in some aspects of the psychometric tests. Generally, this non responder group had a trend to score worse for most items in the psychometric tests with some reaching significance in a univariate analysis. This result was confirmed in a multivariate context, although the results indicated only small differences between the groups. All three substances showed significant pain relief compared to baseline on all assessment points. On most variables, morphine and ketamine were significantly more effective compared to the active placebo. Conclusions There are different subgroups among subjects with chronic WAD with variations in responses to i.v. morphine, ketamine, and midazolam (active placebo). Subjects with chronic WAD who did not respond to any of the drugs tested scored badly in some aspects of the psychometric instruments. Implications The present study confirms one aspect of the heterogeneity in the population with chronic WAD. The study does not elucidate precise pain mechanisms but taken together with other studies exploring other aspects, it stresses the importance of individualizing the assessment and treatment of subjects with chronic WAD. A common clinical experience is that depression, anxiety and maladaptive coping strategies often are obstacles for successful medical treatment of chronic pain. The present study supports this experience and emphasizes the need for assessment of psychometric variables when planning the treatment of chronic WAD.

Predictors of neck pain after motor vehicle collisions: a prospective survey

PURPOSE

To identify possible predictors (psychosocial) of neck pain in patients with acute injuries following motor vehicle trauma.

METHODS

221 male and 85 female patients aged 18 to 85 (mean, 38) years who had acute fractures of the humerus, radius, ulna, pelvis, femur, patella, tibia, talus or calcaneus following motor vehicle trauma were prospectively recruited. No patient sustained a cervical spine injury. Patients sustaining minor trauma were excluded. As putative predictors of neck pain, data relating to demographics, injury, socio-economic status, and compensation were collected at the time of presentation and at month 6. Neck pain was measured by adapting the bodily pain questions from the SF-36 general health survey. Simple unadjusted and multiple regression analyses were conducted. RESULTS; 232 (76%) of the 306 patients completed the 6-month questionnaire. In multiple regression analysis, neck pain at 6 months was significantly associated with female gender, having a primary level of education only, and use of a lawyer.

CONCLUSION

Adversarial legal and compensation involvement may attribute to the development and continuation of neck pain after motor vehicle trauma.

Potential processes involved in the initiation and maintenance of whiplash-associated disorders: discussion paper 3

STUDY DESIGN

Nonsystematic review and discussion of the etiological processes involved in whiplash-associated disorders (WAD).

OBJECTIVE

To summarize the research and identify priorities for future research.

SUMMARY OF BACKGROUND DATA

Although there is convergent evidence of a peripheral lesion in some individuals after whiplash injury, in the majority of injured people, a lesion cannot be established with current imaging technology. Therefore, it is important to consider processes that underlie the initiation and maintenance of whiplash pain as this may allow for the development and testing of interventions to target these processes and improve outcomes.

METHODS

A nonsystematic review was performed to summarize current knowledge regarding potential etiological processes involved in the initiation and maintenance of WAD and to identify future research priorities.

RESULTS

There are several etiological processes potentially involved in the initiation and maintenance of WAD. These include augmented nociceptive processing, stress system responses, and psychosocial and sociocultural factors. Recent findings also indicate that morphological changes in the neck muscles of injured people show some association with poor recovery, but the mechanisms underlying these changes are not clear. Preliminary evidence indicates associations between these processes. Future research priorities include the following: more sophisticated investigation and analysis of interactions between the various processes; whether the modification of these processes is achievable and if modification can improve health outcomes; and to clarify factors involved in the initiation of whiplash pain versus those involved in symptom maintenance.

CONCLUSION

Research to date indicates that there are several physiological and psychological etiological processes that may underlie the initiation and maintenance of whiplash-related pain and disability. Further research is required to determine relationships and interactions between these factors and to determine whether their modification is possible and will improve outcomes after injury.

Fear avoidance and illness beliefs in post-traumatic neck pain

STUDY DESIGN

A descriptive overview of the relevant literature and the introduction of a new psychological model.

OBJECTIVE

The fear-avoidance (FA) model and the potential importance of illness beliefs in post-traumatic neck pain are discussed. The causal beliefs-anxiety model is introduced as an adaptation of the FA model, emphasizing the critical role of illness beliefs.

SUMMARY OF BACKGROUND DATA

Although the FA model is most thoroughly used to investigate chronic low back pain, it seems also highly relevant as a starting point for other chronic pain conditions like whiplash. Kinesophobia and pain catastrophizing form critical components of the FA model. It has been shown that breaking the FA cycle by affecting the critical components of the model may be an effective method to prevent the development of chronicity.

METHODS

By using the FA model as a starting point, we present the causal beliefs-anxiety model and argue how this might help explain chronic whiplash symptoms and might provide clues for preventive interventions.

RESULTS

On experiencing muscular neck pain, catastrophizing may give rise to dysfunctional illness beliefs regarding the cause of this pain. The illness identity and other beliefs feed symptom expectation and attribution, as well as expectations regarding the course of muscular neck pain. These negative expectations can contribute to a less favorable outcome or may even cause symptoms. Therefore, it seems important to integrate the alleged role of illness beliefs in an adapted FA model, the "causal beliefs-anxiety model."

CONCLUSION

In clinical practice, it seems important to have insight into the patient's illness beliefs about the cause of the experienced symptoms. Health care professionals should be aware of the possible detrimental influence of dysfunctional illness beliefs. In the early stage, adequate explanation and information about the probable course may be sufficient to prevent the generation of dysfunctional illness beliefs thereby preventing the development of a chronic course. At the population level, educational campaigns that inform people about probable causes and realistic expectations regarding post-traumatic neck pain could provide an effective strategy for preventing chronic whiplash symptoms.

Trunk sway in patients with and without, mild traumatic brain injury after whiplash injury

OBJECTIVE

This study assessed the addition effect of mild traumatic brain injury (MTBI) on the balance control of patients who simultaneously suffered a whiplash associated disorder (WAD).

BACKGROUND

Dizziness is common in patients suffering from whiplash injury with or without a MTBI, but data is lacking about the additional balance problems and dizziness caused by MTBI.

METHODS

44 patients with WAD and MTBI and 36 WAD patients without MTBI participated in the study. A dizziness handicap index (DHI) was used to quantify self-perceived handicap. Balance control was assessed using measures of trunk sway for a battery of stance and gait tests.

RESULTS

Patients with WAD and MTBI perceived significantly higher dizziness and unsteadiness (higher score in DHI Emotional category) and had greater trunk sway than WAD patients without MTBI for stance tasks and complex gait tasks (e.g. walking up and down stairs). Both groups had greater sway than controls for these tasks. Both groups of patients showed equal reductions in trunk sway with respect to controls for simple gait tasks (e.g. walking while rotating the head).

CONCLUSIONS

A similar pattern of balance impairment was present in patients with whiplash injury with and without MTBI. However, the impairment was greater for stance and complex gait tasks in WAD patients with MTBI.

The association of compensation on longer term health status for people with musculoskeletal injuries following road traffic crashes: emergency department inception cohort study

OBJECTIVE

To compare the health status of people claiming compensation for injuries sustained in road traffic crashes (RTC), with people who do not claim compensation.

DESIGN

Prospective cohort study.

SETTING

Australian Capital Territory, Australia and a fault based common law compensation scheme.

SUBJECTS

People presenting to the emergency department with mild to moderate musculoskeletal injury following RTC.

MAIN OUTCOME MEASURES

Physical Component Score (PCS) and Mental Component Score (MCS) of the Short Form 36 (SF-36) health status measure, Hospital Anxiety and Depression Scale (HADS) and the Functional Rating Index (FRI). These measures are recorded immediately post crash, at 6 and 12 months post crash.

RESULTS

95 people participated in the study and were enrolled a mean of 8.6 (median 8) days following the crash. 86% were followed up to 12 months after injury. Mean age was 37 years, 61% were female and 91% were employed at the time of their injury.33%ultimately claimed compensation, and 25% engaged a lawyer. There were no major differences in baseline personal characteristics or injury related factors between the groups. As expected, involvement as a passenger and in multiple vehicle crashes, were more frequent in the group claiming compensation. Over the duration of the study claiming compensation was associated with lower SF-36 PCS (5.5 (95%CI 8.6 to 2.4), p = 0.001), greater HADS-Anxiety (1.7 (95%CI 0.2–3.3), p = 0.048), and worse FRI (11.2 (95%CI 3.9–18.5), p = 0.003). There was a highly significant improvement in health status between baseline and 6 months after injury, but no further significant change between 6 and 12 months after injury. There was no difference in rate of improvement between the groups. Claiming compensation and psychological factors were independent predictors of worse health status at 12 months.

CONCLUSION

In this study the group claiming compensation had overall worse health status following mild to moderate musculoskeletal injuries over the course of the study. There was no difference in rate of improvement between the groups. However, it is not possible to determine whether this negative effect was due to claiming compensation itself or the presence of other unmeasured factors.

Reverse causality in the association between whiplash and symptoms of anxiety and depression: the HUNT study

STUDY DESIGN

Longitudinal population-based cohort study.

OBJECTIVE

The aim of this study was to examine the possibility of reverse causality, that is, if symptoms of anxiety and depression are associated with incident self-reported whiplash injury. The clinical relevance of self-reported whiplash injury was evaluated by its association with subsequent disability pension award.

SUMMARY OF BACKGROUND DATA

Whiplash is associated with an increased level of anxiety and depressive symptoms. This increase in psychological distress is generally understood as the consequence of the accident and related whiplash.

METHODS

Longitudinal data from the HUNT study was used. Baseline measures of symptoms of anxiety and depression were used in prediction of incident whiplash injury self-reported at follow-up 11 years later. Incident disability pension award was obtained from a comprehensive national registry during 2-year follow-up after self-reported whiplash injury.

RESULTS

Case-level symptom load of anxiety and depression at baseline increased the likelihood of reporting incident whiplash at follow-up (odds ratio [OR] = 1.60, 95% confidence interval = 1.22-2.11). Self-reported whiplash increased the chances of a subsequent disability pension award (OR = 6.54), even in the absence of neck pain (OR = 3.48).

CONCLUSION

This is the first published study with a prewhiplash prospective evaluation of psychological status. Our findings are in conflict with previous research suggesting whiplash to be the cause of associated psychological symptoms rather than their consequence. Self-reported whiplash injury was clinically relevant as it independently increased subsequent disability pension award. The strength of this effect, even in the absence of neck pain, suggests the ascertainment of this diagnostic label, or factors associated with this, are important predictors of disability.