Doubtful nosological validity of the chronic whiplash syndrome
From: Orthopade. 2011 Nov 30. [Epub ahead of print]
Since the 1980s, victims of traffic accidents in western countries increasingly report chronic symptoms which they attribute to a whiplash injury of the cervical spine. In an extensive review article published in 1996, it was, however, concluded that this so-called chronic whiplash syndrome has little nosological validity. It was now investigated whether this conclusion could be upheld by the results of later published studies.
Extensive evaluation was carried out of all the whiplash literature listed in Pubmed since 1996 with the question whether research over the last 15 years has achieved a better validation of this syndrome. Of the over 1,600 publications about whiplash since 1996, no study could be identified which confirmed the nosological validity of the chronic whiplash syndrome.
As a positive consequence of the results of this study, accident victims suffering whiplash can be informed about the very good prognosis after whiplash in a more trustworthy way. Many iatrogenic injuries can thus be avoided. The expert opinion after whiplash without radiologically documented and/or neurologically confirmed significant acute traumatic injury which can cause chronic symptoms, should generally not be in favor of insurance benefits. The authors propose that all of a set of minimal criteria should be fulfilled if in exceptional cases a probable relationship between the trauma and chronic symptoms can be assumed.
Reflecting on whiplash associated disorder through a QoL lens: an option to advance practice and research
From: Disabil Rehabil. 2011 Nov 23. [Epub ahead of print]
The purpose of this study was to examine the constructs of quality of life as applied to whiplash associated disorder, its current state of measurement and suggestions for future application in a narrative literature review.
The burden of whiplash associated disorder on the healthcare system is substantive. Assessment of quality of life issues for people with whiplash associated disorder may provide a broader understanding of the patient experience. No consistent framework for quality of life in whiplash associated disorder has been adopted, nor has preference for any quality of life instrument been established. Inconsistent use of terminology for what is being measured, and the measures themselves hamper clarity on the issue. Options for assessing quality of life currently include a meaningful condition-specific scale that has not undergone sufficient psychometric evaluation (Whiplash Disability Questionnaire (WDQ), or generic scales with strong psychometric properties that have not undergone sufficient relevancy evaluation (e.g. SF-36, WHOQOL BREF). Generic measures can measure overlapping constructs including heath status, utility, health-related quality of life or generic quality of life. The inter-relationships between these in whiplash associated disorder have not been defined.
Given the impact of whiplash associated disorder on quality of life, additional clarity on tools and approaches are needed. There is a need for research on the relevance and clinical measurement properties of available condition-specific and generic tools to define a preferred measurement approach in whiplash associated disorder
Physiotherapy rehabilitation for whiplash associated disorder II: a systematic review and meta-analysis of randomised controlled trials.
From: BMJ Open. 2011 Nov 14;1(2)
Road traffic accidents are the primary cause of whiplash, a soft tissue injury to the neck following an acceleration–deceleration mechanism of injury. The cumulative incidence of patients seeking healthcare post-whiplash from a road traffic accident has increased during the last 30 years to recent estimates of >3/1000 inhabitants in North America and Western Europe and 1.0–3.2/1000 inhabitants in Sweden. In the UK, insurance statistics indicate that 300 000 patients present per annum with whiplash associated disorders. Whiplash associated disorders are the resulting clinical presentations following the injury and can range in severity, clinical symptoms and physical findings. Many patients with whiplash associated disorders experience persistent pain and disability, with reports suggesting that 40–60% of those injured have chronic symptoms. The annual economic cost associated with management of whiplash associated disorders and associated time off work is estimated as $3.9 billion in the USA, and €10 billion in Europe.
Patients experiencing whiplash associated disorders may be regarded as a distinct group within the broader non-specific neck pain population, although following review of trial data (n=4 trials), recent evidence questions this distinction for a primary care population and has identified a need for further research. Whiplash associated disorders can be categorised as grades 0–IV, where a higher grade indicates increased severity. The classification system is widely used in clinical practice and guidelines. Patients with whiplash associated disorder II who experience neck pain accompanied by stiffness or tenderness, and musculoskeletal signs, for example a reduced range of available movement, form the major group of patients (93.4%) who might benefit from conservative management, commonly involving physiotherapy intervention. A recent best evidence synthesis recommended a focus of research to the most common whiplash associated disorder I and II classifications, excluding classification III and above (ie, patients with neurological signs and fracture and/or dislocation) and classification 0 (no complaint at the neck, and no physical signs) However, a classification of whiplash associated disorder I is less commonly seen by physiotherapists as there are no accompanying physical findings (neck pain, stiffness or tenderness but with no physical findings) and patients are known to recover within 6 months post-injury.
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Does fear of movement mediate the relationship between pain intensity and disability in patients following whiplash injury? A prospective longitudinal study.
From: Pain. 2011 Nov 2. [Epub ahead of print]
The aim of this study was to test the capacity of the Fear Avoidance Model to explain the relationship between pain and disability in patients with whiplash associated disorders. Using the method of Baron and Kenny [1], we assessed the mediating effect of fear of movement on the cross-sectional and longitudinal relationships between pain and disability. Two hundred and five subjects with neck pain due to a motor vehicle accident provided pain intensity (0 to 10 numerical rating scale), fear of movement (Tampa Scale of Kinesiophobia and Pictorial Fear of Activity Scale) and disability (Neck Disability Index) scores within 4weeks of their accident, after 3months, and after 6months.
The analyses were consistent with the Fear Avoidance Model mediating approximately 20% to 40% of the relationship between pain and disability. Contrary to the authors initial hypothesis, the proportion of the total effect of pain on disability that was mediated by fear of movement did not substantially change as increasing time elapsed after the accident. The proportion mediated was slightly higher when fear of movement was measured by Tampa Scale of Kinesiophobia as compared with Pictorial Fear of Activity Scale. The findings of this study suggest that the Fear Avoidance Model plays a role in explaining a moderate proportion of the relationship between pain and disability after whiplash injury.
Related Source: Assessing Fear in Patients with Cervical Pain: Development and Validation of the Pictorial Fear of Activity Scale – Cervical
Vehicle head restraint positioning knowledge and behaviours in a sample of Irish drivers
From: Int J Inj Contr Saf Promot. 2011 Nov 2. [Epub ahead of print]
A correctly positioned vehicle head restraint can reduce whiplash injury risk in collisions, however, head restraints are often sub-optimally positioned. The primary aim of this study was to investigate vehicle head restraint position and driver knowledge of correct head restraint positioning in an Irish population. Secondary aims were to investigate the associations with driver age, gender and vehicle age.
Data collection involved head restraint measurement and a driver questionnaire (n = 110). Just 27% of drivers had optimal head restraint positioning, while 30% had poor or marginal positioning. Newer vehicles (<5 years old) had better positioned head restraint in the horizontal plane, than older vehicles. Younger drivers (<30 years) were more likely to have poorer positioning of head restraint than the 30 years or over group. Females were more likely to have better vertical positioning of their head restraint than males. Driver knowledge of correct position was variable, and not associated with actual head restraint position, with 65% knowing the correct vertical positioning standard but only 27% identifying the correct horizontal position. Many drivers have inadequately positioned head restraint, which needs to be addressed by improved vehicle design and public education.
More information about head restraint positioning and whiplash at Add On Headrest
Dynamic and functional balance tasks in subjects with persistent whiplash: a pilot trial
Man Ther. 2011 Aug;16(4):394-8.
Static balance tests using posturography and force plates have been used to identify and evaluate postural stability in subjects with persistent whiplash and postural stability deficits in various stance and visual conditions have been found in these patients. Subjects with persistent whiplash also commonly report dizziness and or unsteadiness (70%) and complain of episodes of loss of standing balance (48%) and of actual falls (21%). Subjects who report these symptoms have also demonstrated greater deficits in static standing balance when compared to those who don’t report these symptoms. It is thought that these symptoms are a direct result of the cervical injury although vestibular damage is also possible.
The disturbances in static standing balance seen in patients with trauma induced persistent neck pain, may contribute to consequent difficulties in the completion of dynamic and functional balance tasks but to date there has only been one other study to look at some functional and dynamic measures and they demonstrated altered trunk angular velocity and sway angle during the tests in a whiplash compared to a control group. Simple and easy to conduct dynamic and functional balance tests using clinical measures with minimal equipment are thought to more adequately evaluate performance on the types of tasks in which falls may potentially occur.
Such clinical measures of dynamic and functional tests have been used in the assessment of balance in subjects with neurological and vestibular conditions and recently some tests have been measured in an elderly population with neck pain, where the dynamic balance measures were found to be impaired in addition to force plate evaluations of static balance. The findings suggested that neck pain in the elderly contributes to disturbance in balance and gait parameters over and above that which occurs with normal ageing. Specifically, a slower self-selected gait speed and cadence when walking with side to side head turning, and a significantly longer gait cycle duration when walking both without and with head turns was observed when compared to healthy control subjects. Dynamic balance deficits have also been found in subjects with unilateral vestibular loss in the step test, tandem walk and Dynamic Gait Index.
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On cervical Zygapophysial Joint Pain After Whiplash
From: Spine (Phila Pa 1976). 2011 Oct 20. [Epub ahead of print]
This was a narrative review to summarise the evidence that implicates the cervical zygapophysial joints as the leading source of chronic neck pain after whiplash. Reputedly a patho-anatomic basis for neck pain after whiplash has been elusive. However, studies conducted in a variety of disparate disciplines indicate that this is not necessarily the case. Data were retrieved from studies that addressed the post-mortem features and biomechanics of injury to the cervical zygapophysial joints, and from clinical studies of the diagnosis and treatment of zygapophysial joint pain, to illustrate convergent validity.
Post-mortem studies show that a spectrum of injuries can befall the zygapophysial joints in motor vehicle accidents. Biomechanics studies of normal volunteers and of cadavers reveal the mechanisms by which such injuries can be sustained. Studies in cadavers and in laboratory animals have produced these injuries. Clinical studies have shown that zygapophysial joint pain is very common amongst patients with chronic neck pain after whiplash, and that this pain can be successfully eliminated by radiofrequency neurotomy.
The fact that multiple lines of evidence, using independent techniques, consistently implicate the cervical zygapophysial joints as a site of injury and source of pain, strongly implicates injury to these joints as a common basis for chronic neck pain after whiplash.
The relationship between self-rated disability, fear-avoidance beliefs, and nonorganic signs in patients with chronic whiplash-associated disorder.
J Manipulative Physiol Ther. 2011 Oct;34(8):506-13.
The purpose of this study was to determine the role of standard and novel (cervical) nonorganic signs in patients with chronic whiplash associated disorder.
Chronic whiplash associated disorder I to III patients (>3 months) were recruited from private chiropractic practice in Canada. Subjects completed a Neck Disability Index, Tampa Scale for Kinesiophobia, pain visual analog scale, and pain diagram. Clinical and demographic data were also obtained. Nine standard nonorganic pain behavior tests and 4 novel cervical nonorganic simulation signs tests were applied. Bivariate correlations were obtained with the Pearson correlation coefficient. Items achieving statistical significance on univariate analysis were loaded in a sequential linear regression analysis. Post hoc analyses were conducted with analysis of variance tests of Neck Disability Index and Tampa Scale for Kinesiophobia scores.
Ninety-one subjects were investigated (49 males and 42 females), with a mean age of 41.7 (SD, 14.7) years and a mean duration of 9.4 (SD, 11.2) months. Because mean Neck Disability Index scores were 57.5 (SD, 17.8) and mean pain scores were 68.3 (SD, 21.0), this sample represents moderate to severe whiplash associated disorder. Fair to moderately strong correlations were obtained between the Neck Disability Index and the Tampa Scale for Kinesiophobia, pain visual analog scale and nonorganic symptoms and signs and cervical nonorganic simulation signs scores, but not with “age,” “sex,” or “duration.” The nonorganic symptoms and signs and cervical nonorganic simulation signs scores correlated most strongly at 0.70. A multivariate model accounting for 53% of the variance of the Neck Disability Index scores was obtained with the Tampa Scale for Kinesiophobia, pain severity, and nonorganic symptoms and signs scores. There was no significant correlation between cervical nonorganic simulation signs and Tampa Scale for Kinesiophobia scores. At least 25% of subjects scored either 5 of 9 or 2 of 4 on the nonorganic symptoms and signs and cervical nonorganic simulation signs tests, respectively.
Based on the findings of this study, nonorganic signs should be considered in the interpretation of self-rated disability in patients with moderate to severe chronic whiplash associated disorder.
Pain-Related Emotions in Early Stages of Recovery in Whiplash-Associated Disorders: Their Presence, Intensity, and Association With Pain Recovery
From: Psychosom Med. 2011 Sep 23. [Epub ahead of print]
Psychological factors such as depression affect recovery after whiplash associated disorders. This study examined the prevalence of pain related emotions, such as frustration, anger, and anxiety, and their predictive value for postcrash pain recovery during a 1-year follow-up.
A population-based prospective cohort study design was used. Self reported pain related depression, anxiety, fear, anger, and frustration were assessed using 100-mm visual analog scales at 6 weeks after crash in 2986 persons with traffic related whiplash associated disorder. Multivariable logistic regression was used to assess the relationship between the intensity of these pain related emotions and pain recovery at 4 and 12 months after crash. Pain was measured at all time points on a 100-mm visual analog scales, and pain recovery was defined as a score of 10 or lower.
Pain related frustration was the most intense, with a mean score of 52. Only 3% of the cohort reported having no pain related frustration, and 4% reported no pain related anxiety. Multivariable logistic regression models revealed that each pain related emotion increased the risk of failing to recover. Specifically, with each 10-point increase in pain-related emotion, the odds of failing to achieve pain recovery at 4 months was increased by 14% for depression, 15% for anxiety, 11% for fear, 12% for anger, and 11% for frustration.
These findings suggest that it may be beneficial for health care providers to address emotional status related to pain in the first few weeks after a whiplash injury.
How well are you recovering? The association between a simple question about recovery and patient reports of pain intensity and pain disability in whiplash-associated disorders.
From: Disabil Rehabil. 2011 Sep 22. [Epub ahead of print]
There is potential value in developing a brief assessment tool for assessing recovery after musculoskeletal injuries. Our goal was to investigate the association between a one-item global self-assessment of recovery and commonly used measures of recovery status. The authors followed a cohort of 6,021 adults with acute whiplash associated disorders for six months. Pain, depression, work status and physical health were assessed at baseline and follow-up. The question “How do you feel you are recovering from your injury?” (six response options from “all better” to “getting much worse”) and functional limitations were administered at follow-up.
Responses to the recovery question was associated with our other indices of recovery. Those “all better” had the lowest pain intensity, pain-related limitations, depression and work disability, and the best general physical health. Incrementally poorer recovery ratings on the recovery question were associated with greater pain, functional limitations and depression, poorer physical health and being off work, although “no improvement” and “getting a little worse” were similar. Recovery categories also reflected different degrees of actual improvements over the preceding follow-up period.
The findings suggest that a single recovery question is a useful tool for conducting brief global assessments of recovery of musculoskeletal injuries.
