Relationship between symptoms and psychological factors five years after whiplash injury
From: J Rehabil Med. 2009 Apr;41(5):353-9
Whiplash injuries have become a major health problem because of their high frequency and increasing economic costs. In Western countries, the incidence is 1.0–3.2/1000 per year. The term whiplash describes a mechanism of energy caused by acceleration being transferred to the neck, which results in soft tissue injury/distortion of the neck. Most whiplash trauma is the result of traffic accidents, but other trauma mechanisms have also been described. The distortion of the neck usually decreases over subsequent days or weeks, but the injury may lead to a number of clinical symptoms known as whiplash associated disorder. The dominating complaints after the injury are neck pain and headache. Other symptoms commonly associated with whiplash associated disorder are fatigue, dizziness, irritability, concentration and memory disturbances, sleep disturbance and anxiety. Although many patients with whiplash trauma recover within a few months after the accident, a significant proportion experiences prolonged symptoms. The frequency of long-term symptoms after whiplash injuries varies. Mayou et al. reported that 35% of subjects had physical problems 5 years after the injury, and persistent neck pain has been demonstrated in 84–90% of patients 1–2 years after the injury and in as much as 50% of whiplash patients 17 years after the injury. Moreover, patients may also have psychological issues after the injury, such as post-traumatic stress or depression, which can influence recovery.
Although studies have identified risk factors such as increased age, gender and initial neck pain intensity, the literature is inconsistent, making it unclear which factors lead to the development of persistent symptoms and related disability after whiplash injuries. During the last years some studies have looked at both physical and psychological aspects as causes of prolonged recovery. However, most studies of long-term outcome after whiplash associated disorder have focused on neck pain after the injury, while the persistence of other symptoms, together with psychosocial and psychological aspects, is less well investigated. Recently, Williamson et al., in a systematic review, identified the need for further research with respect to psychological factors in the development of late symptoms after whiplash injury. Moreover, in several studies attention has been paid to the influence of gender as a potential prognostic factor after whiplash injuries, and female gender has been identified as a factor related to poor recovery. In contrast, some studies have failed to show any gender differences regarding long-term symptoms after the injury. The inconsistent results may be due to differences in study populations and the investigated variables.
The conditions after whiplash injury may often affect several aspects of daily life, such as work, leisure and the total experience of satisfaction with life. Since people live in a social context with social relationships, the influence of social support after the trauma seems to be important for the injured persons. However, few studies have focused on these factors. The consequences of the injury may also be reflected in difficulties with return to usual occupation. In a previous study Bylund & Björnstig. found that most people on sick leave due to traffic accidents were injured by whiplash trauma and, recently, Berglund et al. reported increased sick leave several years after motor vehicle injuries. Moreover, attempts have been made to find factors related to sick leave and time off work following a whiplash injury, but the underlying causes remain unclear. However, since the follow-up time after whiplash injury differs between studies, and the length of time after injury in most studies has been rather short, it is difficult to compare the long-term outcome.
The present study therefore investigates persons with whiplash injuries in a defined population and geographical area 5 years after the trauma in order to address the following aims: (1) to describe the frequency of whiplash related symptoms and psychological factors; (2) to study the relationship between symptoms and psychological factors; (3) to examine gender differences in these frequencies and relationships; and (4) to investigate the cause of sick leave.
The present study shows that 5 years after whiplash injury persistent symptoms, post-traumatic stress and depression reactions were frequently reported, together with low levels of life satisfaction and reduced social support. Both the total score of pain intensity and of whiplash related symptoms were significantly related to depression and post-traumatic stress scores. Although some previous studies have reported pain and some psychological factors a shorter time after whiplash injury, this study is the first to demonstrate high frequencies of physical symptoms and psychological factors that also include different aspects of social support many years after a whiplash event.
In the present study, physical symptoms were assessed using the RPQ. In total, 76% of the participants reported some symptom related to the whiplash injury, which is clearly higher than previously reported 1 year after injury. In agreement with other studies neck pain was the most common symptom, reported by 59%. Pain intensity was rated on the VAS, almost 63% reported VAS-scores higher than 10 mm and were considered symptomatic. The percentage of symptomatic persons was somewhat lower than previously reported by Kyhlback et al. (84%) one year after the trauma. Yet, since their study was based on patients referred to an orthopaedic clinic and the time leading up to follow-up was shorter, the results are not strictly comparable. Although the participants were not asked to refer their pain intensity to any specific pain location, it can be assumed that pain intensity in most participants referred to neck pain, since that was the most common symptom. Other participants, however, probably reported their VAS scores of headache or of neck pain and headache together, as many persons experienced both of the symptoms. Moreover, the frequency of cognitive symptoms according to the RPQ was surprisingly high with presence of memory and concentration difficulties in more than half of the participants. The relevance of cognitive impairments in patients with whiplash has been discussed. Some studies have demonstrated neuropsychological dysfunction in persons with chronic symptoms, whereas other studies have suggested preexistent psychological distress or a neurotic development as the underlying cause of cognitive disturbances. However, since cognitive symptoms might be influenced by pain, depression and post-traumatic stress, these factors may have contributed to the explanation for the present findings.
Among the psychological consequences after whiplash injuries, symptoms of depression are commonly reported, but the level of depression is seldom classified. In the present study mild to severe depression was found in 22% of the participants. These findings are in accordance with the previous results reported by Miettinen et al. 3 years after a whiplash injury (23.7% rated their BDI scores as abnormal) and indicate that a considerable proportion suffers depression long after whiplash injury and that the level of depression might persist. Psychological problems may also include posttraumatic stress reactions. In the present study the levels of post-traumatic stress (mild stress in 85% and distinct stress in 15%) were similar to the results documented in the acute phase after whiplash injuries (mild stress in 87%, distinct stress in 13%) by Kongsted et al. who likewise used the IES for assessment. Even though the severity levels of post-traumatic stress have not previously been assessed in persons long after whiplash injury, post-traumatic stress reactions are described several years after traffic accidents. However, since the rate of post-traumatic stress reactions after whiplash injuries might be underestimated, the fairly high post-traumatic stress levels in the present study support the recommendation by the Swedish Society of Medicine and the Whiplash Commission Task Force of diagnosis and treatment of post-traumatic stress early after a whiplash injury in order to reduce the risk of long-lasting symptoms.
In the present study, relationships between physical symptoms and psychological factors were investigated and strong correlations were demonstrated both between pain intensity, whiplash related symptoms, and the total depression and posttraumatic stress scores. Although there are few studies of the long-term outcome, there are some results of psychological and psychosocial complications in victims up to 2–5 years after motor vehicle accidents and several authors have pointed out that psychological problems should be seen as a consequence of somatic complaints.
Social contacts and personal relationships may have influenced perceived health and well-being. Thus, the quantity of social support, (AVSI) and the quality of social support (AVAT) were assessed. These results revealed a significant gender difference on the AVAT; men reported a lower score than women, indicating that they perceived lower quality of support. On the other hand, pain intensity and total score of whiplash related symptoms were negatively correlated with the AVAT in women but not in men. This finding might suggest that close relationships with strong supportive networks are of greater importance for decreasing pain intensity and symptoms in women. In men, whiplash related symptoms were weakly negatively correlated with the AVSI, which implies that the size of the social support network may play a role for their experience of symptoms. Although, few studies have focused on the different aspects of social support after whiplash injury, Buitenhuis et al. have shown a negative association between the duration of neck complaints and social support. The authors proposed that the persons who seek social comfort and share their concerns with others have a shorter duration of neck complaints, but they did not report any gender differences. In the present study, no difference was shown in the frequency of neck pain between men and women, and there was no association between neck pain and social support. Thus, satisfaction with the quality of support might be of importance for the pain intensity experienced in women, but not for the presence of neck pain.
Consequences in some aspect of quality of life have been described after whiplash injury. In the present study only 38% of subjects were either very satisfied or satisfied with somatic health; other items with low ratings of satisfaction were also economy, leisure, vocation and psychological health. These ratings of life satisfaction were generally lower than those of a large population-based Swedish reference group) and seem to correspond with the LiSat-11 scores reported for a group of patients with chronic whiplash seeking hospital care. Moreover, the level of life satisfaction was significantly negatively correlated with the total scores of VAS and RPQ, which seem to depict the fact that decreased life satisfaction reflects increased pain intensity and the level of symptoms experienced.
Some persons might experience difficulties with return to usual occupation after whiplash injury and increased sick leave several years after the accident has been reported. The proportion of injury-related sick leave in the present study was somewhat lower than previously reported 2 years after road traffic accidents; nevertheless, the number of persons on sick leave had increased in comparison with the sick leave at the time of the injury. Since depression was the only single factor in the multivariate logistic regression model that was associated with being on sick leave 5 years after the injury, symptoms of depression may have influenced the recovery and contributed to lower well-being in the injured persons.
This study has implications for clinicians, since the results indicate that it is of great importance to be aware that various symptoms might be frequent and associated with depression and post-traumatic stress reactions long after a whiplash injury. To optimize the management of persons with long-term problems after whiplash injury, it is crucial to assess possible relationships and to treat existing symptoms, especially depression. The treatment of depression might positively affect other symptoms and could improve the injured person’s general well-being. Questionnaires could be used as a brief screening and as a complement to the assessment. Moreover, since social support may play a role (positive or negative) in recovery, the injured person’s social relationships should also be examined.
In conclusion, this study demonstrated long-lasting symptoms and psychological consequences, reduced life satisfaction, decline in social support, and difficulties with resuming work after whiplash injury. These aspects should be taken into consideration in the management of persons with whiplash associated disorder.
