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Differential predictors of pain and disability in patients with whiplash injuries.

The psychological predictors of pain and disability were examined in a sample of people who sustained whiplash injuries during rear-end motor vehicle accidents. Sixty-five patients referred to a specialty pain clinic with a diagnosis of whiplash injury completed measures of depression, anxiety, catastrophizing, pain and perceived disability. Regression analysis revealed that psychological variables accounted for 18% of the variance in pain ratings. The magnification subscale of the Pain Catastrophizing Scale was the only variable that contributed significant, unique variance to the prediction of pain. Psychological variables accounted for 37% of the variance in perceived disability scores. In the latter analysis, however, none of the independent variables contributed significant, unique variance to the prediction of perceived disability. Psychological variables accounted for significant variance in disability ratings, even when controlling for pain intensity. Discussion focuses on the need to draw clearer distinctions between determinants of pain and disability, and directions for interventions aimed at minimizing disability following whiplash injury are suggested.

Adult↗

Symptom characteristics in TMD patients reporting blunt trauma and/or whiplash injury.

Descriptive data are presented for 100 patients reporting facial pain and temporomandibular dysfunction (TMD) precipitated by (1) overt facial/head trauma, (2) "whiplash" injury, and (3) "whiplash" injury with overt trauma. Analysis of the data suggests that these TMD trauma subsets are significantly different in terms of total number of pain sites, presence of concomitant neck pain, range of opening, and report of sleep disturbance and involvement in litigation. They also varied with respect to reducing and nonreducing disc displacement. However, significant differences were not observed for initial pain at presentation; muscle pressure pain threshold; McGill affective or HSCL-90 depression, anxiety, and somatization scores; prior pain duration; or time post-trauma before pain onset. These findings suggest that patients within these trauma categories share some common characteristics but may differ in important demographic, pain, and temporomandibular joint dysfunction variables.

Adult↗

[Street traffic accident--whiplash injury of the cervical spine from the viewpoint of insurance medicine].

The Swiss Accident Insurance Institute (SUVA), as the largest mandatory insurer against accidents in Switzerland, handles approximately 3000 cases of injury to the cervical spine every year, half of which are the result of traffic accidents. A considerable proportion of these involve whiplash injuries to the cervical spine. Epidemiological and statistical results according to this medical definition and based on material collected over a period of several years are presented. The assessment of these cases from the medical insurance point of view is discussed. Mild whiplash injuries are very common and as a rule they heal without sequelae. Severe whiplash injuries with massive soft-tissue damage and fractures are rare and present few problems for the causality assessment. Problemtical, on the other hand, are the not infrequent cases of whiplash injuries which initially seem to be ordinary sprains but which subsequently develop into lasting clinical syndromes that are very difficult to objectify. Further, the assessment and care of these problem cases in particular are discussed from the medical insurance point of view. In these patients, who suffer severe pain and discomfort, it is in most cases not possible to obtain any objective findings with the classical diagnostic measures of radiology, orthopaedics and neurology. They can very soon be suspected of malingering, exaggeration or pension neurosis. Only with the very sophisticated, modern diagnostic methods of neuropsychology, chiropraxis and functional computed tomography is it sometimes possible to objectify these syndromes in a reproducible manner and possibly to establish a post-traumatic instability as the cause. This then again opens up promising possibilities for the treatment of these patients. The SUVA supports research aimed at developing and testing such promising new methods of examination. However, it at the same time warns against the uncritical use of these expensive methods of examination, the informative value and the scientific validity of which are in some respects still not sufficiently well established.

Accidents, Traffic↗

Whiplash injury associated with acute bilateral internal carotid arterial dissection.

Internal carotid arterial occlusion, being a rare occurrence following whiplash injury, is frequently missed. We report an unusual case of a 41-year-old woman driver who was involved in a head-on collision with a truck. On admission she was noted to have sustained closed head and neck trauma with a severe whiplash injury and lower limb paraparesis. Subsequent investigations showed a right parietal lobe infarct and bilateral internal carotid arterial dissection. We conclude that acute whiplash injury can result in bilateral internal carotid arterial dissection and that clinicians treating these patients should be aware of this complication.

Acute Disease↗

[Results of a 1-year follow-up study of whiplash injury].

Based on a strict definition of whiplash injury, a sample of 117 non-selected patients was examined 7.2 +/- 4.2 days and at 3, 6 and 12 months after trauma. Initially all patients underwent a neurological examination, cognitive and psychosocial factor assessment and cervical spine x-rays. 56%, 70% and 76% of patients had completely recovered at 3, 6 and 12 months respectively. The results indicated that impairment of patients' well-being and cognitive ability was closely associated with somatic symptoms. No major impairment of attentional functioning was found, but some change in cognitive equilibrium was observed which may be related to the type of medication utilized. Delayed recovery at 12 months could be predicted by the following initial variables: higher age, intensity of initial neck pain and headache, symptoms of radicular irritation, sleep disturbances, pretraumatic headache, history of head trauma, nervousness score and--significantly inversely proportional--initial concentration problems and neuroticism score. These results suggest that a more severe neck injury may in particular account for delayed recovery from whiplash.

Adult↗

The cervical facet capsule and its role in whiplash injury: a biomechanical investigation.

STUDY DESIGN: Cervical facet capsular strains were determined during bending and at failure in the human cadaver. OBJECTIVE: To determine the effect of an axial pretorque on facet capsular strains and estimate the risk for subcatastrophic capsular injury during normal bending motions. SUMMARY OF BACKGROUND DATA: Epidemiologic and clinical studies have identified the facet capsule as a potential site of injury and prerotation as a risk factor for whiplash injury. Unfortunately, biomechanical data on the cervical facet capsule and its role in whiplash injury are not available. METHODS: Cervical spine motion segments were tested in a pure-moment test frame and the full-field strains determined throughout the facet capsule. Motion segments were tested with and without a pretorque in pure bending. The isolated facet was then elongated to failure. Maximum principal strains during bending were compared with failure strains, by paired t test. RESULTS: Statistically significant increases in principal capsular strains during flexion-extension loading were observed when a pretorque was applied. All measured strains during bending were significantly less than strains at catastrophic joint failure. The same was true for subcatastrophic ligament failure strains, except in the presence of a pretorque. CONCLUSIONS: Pretorque of the head and neck increases facet capsular strains, supporting its role in the whiplash mechanism. Although the facet capsule does not appear to be at risk for gross injury during normal bending motions, a small portion of the population may be at risk for subcatastrophic injury.

Cadaver↗

Cerebral symptoms following whiplash injury.

Fifty-two patients suffering from various chronic disturbances after whiplash injury were studied retrospectively. Frequencies and coincidences of the complaints and symptoms were calculated. From those 26 patients who had reported cognitive disturbances 18 were examined with an extensive neuropsychological test battery. The results showed deficits mainly in the attention and concentration tests, to a lesser extent in the memory tests and least in the tests of higher cognitive functions. The findings were discussed as being compatible with damage to frontobasal cerebral structures and the upper brainstem as a consequence of the whiplash injury.

Adult↗

[Whiplash injuries of the cervical spine and Swiss insurance against accidents (author's transl)].

The indemnity for the consequences of a whiplash injury on the cervical spine by the Swiss Insurance against Accidents is discussed. The number of these cases can be only roughly extimated. We can calculate yearly with about 600 distortions of the cervical spine resulting from motoring accidents. The definition of the whiplash injury is defined on the base of recent German literature. The supposed mechanical assumptions for a lesion of the cervical spine are based mainly on the works of Erdmann (Frandfurt). The relations between the lesion of the cervical spine an the rebound injuries of the skull are discussed. The significance of the preexistent degenerative alterations of the cervical spine in the whiplash injury and the problem of the psychogenic superposition are presented by means of 46 observed cases.

Cervical Vertebrae↗

The incidence of TMJ dysfunction in patients who have suffered a cervical whiplash injury following a traffic accident.

Forty consecutive patients with a cervical whiplash injury were examined and compared with 40 matched controls. The incidence of signs and symptoms was high in both groups. Temporomandibular joint pain (P < .001), limitation of mouth opening (P < .01), and masticatory muscle tenderness (P > .01) were found significantly more frequently in the patient group, while the presence of joint sounds, deviation during mouth opening, and the overall presence of a symptom were not significantly different between groups. When asked whether they would seek treatment for the observed signs and symptoms, a significantly higher number of the whiplash group responded positively when compared to the control group. These findings warrant further study and suggest the benefit of a routine examination of the temporomandibular joint and masticatory system in patients with cervical whiplash injury.

Accidents, Traffic↗

[A case of abducens nerve palsy after whiplash injury].

We report a patient who developed abducens nerve palsy after whiplash injury. The patient was a 61-year-old man who was involved in a traffic accident on May 15, 1993. After the accident, he developed severe neck pain. Four days later, he still had neck pain and vertigo. On the fifth day after the accident, he noted diplopia on left gaze and visited our hospital. Neurologic examination revealed an isolated abduction deficit of the left eye. Head magnetic resonance imaging and angiography showed no abnormal findings. Ten days later, the ocular movements of the patient were full and the diplopia disappeared. About two months later, his neck pain and vertigo also resolved. In this patient, the abducens nerve palsy was caused by whiplash injury and was in full recovery.

Abducens Nerve↗

[Episodes of amnesia following whiplash injury to the cervical spine].

A so-called conscious post-traumatic twilight state ("besonnener Dämmerzustand") after a whiplash injury is described here, showing up its similarities with a classic post-traumatic conscious twilight state on the one hand and a classic transient global amnesia on the other hand. The term "conscious twilight state" is analysed and found inappropriate for the state it is meant to describe, and hence the term "post-traumatic transient global amnesia" is proposed instead. A post-traumatic transient global amnesia after whiplash injury is considered to be caused by a concussion.

Adult↗

A review and methodologic critique of the literature supporting 'chronic whiplash injury': part I - research articles.

The existence of a 'chronic whiplash injury' has been a source of debate in the medical literature for many years. Some authors have published articles suggesting that chronic whiplash syndrome is the result of chronic pathology (injury), and that this injury may occur at any collision speed; others have stated that any psychological factors are secondary rather than primary (etiologic) to the problem of chronic pain, or that secondary gain is a rare or uncommon phenomenon. These articles contradict scientific measures and efforts which show that for Quebec Task Force Grade 1 and 2 whiplash-associated disorders, the highly prevalent problem of chronic pain may be a culturally and psychosocially determined phenomenon, in which confounding psychosocial variables determine the behaviour and outcome following an otherwise benign acute injury. The authors of the current literature critique reviewed the biomedical and engineering literature relating to whiplash syndrome, searching for articles that supported the construct of 'chronic whiplash injuries'. Thirty seven articles containing fourteen distinct statements supporting the construct of 'chronic whiplash injuries' were found that fit the inclusion criteria. The methodology described in these articles was evaluated critically to determine if the authors' conclusions regarding 'chronic whiplash injuries' were scientifically sound. The authors of the current critique found that all of the articles contained significant methodologic errors relative to their respective authors' statements regarding chronic whiplash. The most frequent concerns reside with sampling, experimental design and interpretation of data.

Accidents, Traffic↗

The classification of outcome following whiplash injury--a comparison of methods.

There are many definitions and classifications of chronic neck pain and of neck pain following whiplash injury, many of them developed for a single study. This study compares three different outcome measures (neck disability index, Gargan and Bannister grade, general health questionnaire) in 277 patients who were examined for medicolegal reporting following isolated whiplash injury. There is significant correlation between the physical outcome scales and also between the physical and psychological outcome scales examined (both p <0.01). Definitions of chronic neck pain (with or without whiplash injury) and measures to assess and classify patients with chronic symptoms are reviewed. We recommend the use of a simple self-administered questionnaire that does not require physical measurement as the most useful tool in the evaluation of these patients and the most accurate method of classifying outcome.

Disability Evaluation↗

[Quantification of acute muscle pain after whiplash injury using computer-aided pressure algesimetry].

OBJECTIVE AND METHOD: The present study utilised the PC-interactive pressure algesimetry to quantify cervical pain after whiplash injury. Pressure painfulness of the splenius and trapezius muscles was investigated in patients with an acute cervical syndrome after whiplash injury and compared to that of healthy subjects. RESULTS: Pressure painfulness of neck and shoulder muscles was significantly increased in whiplash patients. The trapezius muscles were more painful left than right, probably due to the seat belt position. CONCLUSIONS: The computer-interactive pressure algesimetry enables a standardised, rater-independent quantification of cervical pain due to whiplash injury.

Acute Disease↗

Low energy high frequency pulsed electromagnetic therapy for acute whiplash injuries. A double blind randomized controlled study.

The standard treatment of acute whiplash injuries (soft collar and analgesia) is frequently unsuccessful. Pulsed electromagnetic therapy PEMT (as pulsed 27 MHz) has been shown to have pro-healing and anti-inflammatory effects. This study examines the effect of PEMT on the acute whiplash syndrome. One half of the 40 patients entering the study received active PEMT collars: the other half facsimile (placebo). All patients were given instructions to wear the collar for eight hours a day at home and advised to mobilise their necks. At 2 and 4 weeks the actively treated group had significantly improved (p less than 0.05) in terms of pain (visual analogue scale). By chance movement scores for the PEMT group were significantly worse at entry to the study than the control group (p less than 0.05). At 12 weeks they had become significantly better (p less than 0.05). PEMT as described is safe for domiciliary use and this study suggests that PEMT has a beneficial effect in the management of the acute whiplash injury.

Accidents, Traffic↗

Evidence, mechanisms, and clinical implications of central hypersensitivity in chronic pain after whiplash injury.

OBJECTIVES: To provide insights into the mechanisms underlying central hypersensitivity, review the evidence on central hypersensitivity in chronic pain after whiplash injury, highlight reflections on the clinical relevance of central hypersensitivity, and offer a perspective of treatment of central hypersensitivity. METHODS: A review of animal and human studies focusing on the mechanisms of postinjury central sensitization, an analysis of psychophysical investigations on central hypersensitivity in patients with chronic pain after whiplash injury, and a review of possible treatment modalities. RESULTS: Animal data show that tissue damage produces plasticity changes at different neuronal structures that are responsible for amplification of nociception and exaggerated pain responses. Some of these changes are potentially irreversible. There is consistent psychophysical 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. Psychologic distress could contribute to central hypersensitivity via imbalance of supraspinal and descending modulatory mechanisms. Although specific treatment strategies are limited, they are largely unexplored. IMPLICATIONS: Central hypersensitivity may explain exaggerated pain in the presence of minimal nociceptive input arising from minimally damaged tissues. This could account for pain and disability in the absence of objective signs of tissue damage in patients with whiplash. Central hypersensitivity may provide a common neurobiological framework for the integration of peripheral and supraspinal mechanisms in the pathophysiology of chronic pain after whiplash. Therapy studies are needed.

Animals↗

Whiplash injuries in Finland--the possibility of some sociodemographic and psychosocial factors to predict the outcome after one year.

PURPOSE: The aim of our study was to evaluate if there was any relation between the change experienced in the condition of health or the length of the reported sick leaves after one year of whiplash injury and different sociodemographic and psychosocial factors. METHOD: Our study design is a prospective 1-year-follow-up study. The material was collected in the year 1998 from neck injuries that had been caused by traffic accidents. The insurance companies sent a notice of the accident with medical certificate to the research team. After this we sent questionnaires to the injured and after one year of the accident a new inquiry was done. One hundred and eighty-two persons returned the 1-year-follow-up questionnaire which formed the material of this study. RESULTS: The persons who had the lowest basic education and people over 60 years of age had more health problems after one year of the accident. The other sociodemographic and psychosocial factors had only limited prognostic value when we evaluated the experienced change of health one year after the whiplash injury. Only 71 persons reported that they had been on sick leave because of the whiplash injury and of them only 21 reported sick leave over 1 month. CONCLUSIONS: Several sociodemographic and psychosocial factors can have relation to the deterioration of health experienced after whiplash injury but in this prospective study they proved to have only limited prognostic value in the long term symptoms with the exception of the education.

Accidents, Traffic↗

Management of chronic pain in whiplash injury.

We investigated the response of chronic neck and shoulder pain to decompression of the carpal tunnel in 38 patients with whiplash injury. We also determined the plasma levels of substance P (SP) and calcitonin gene-related peptide (CGRP), which are inflammatory peptides that sensitise nociceptors. Compared with normal control subjects, the mean concentrations of SP (220 v 28 ng/l; p < 0.0001) and CGRP (400 v 85 ng/l; p < 0.0005) were high in patients with chronic shoulder and neck pain before surgery. After operation their levels fell to normal. There was resolution of neurological symptoms with improvement of pain in 90% of patients. Only two of the 30 with chronic neck and shoulder pain who had been treated conservatively showed improvement when followed up at two years. In spite of having neuropathic pain arising from the median nerve, all these patients had normal electromyographic and nerve-conduction studies. Chronic pain in whiplash injury may be caused by 'atypical' carpal tunnel syndrome and responds favourably to surgery which is indicated in patients with neck, shoulder and arm pain but not in those with mild symptoms in the hand. Previously, the presence of persistent neurological symptoms has been accepted as a sign of a poor outcome after a whiplash injury, but our study suggests that it may be possible to treat chronic pain by carpal tunnel decompression.

Adult↗