Prediction of outcome in whiplash-associated disorders using West Haven-Yale Multidimensional Pain Inventory

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.

Do expectations of recovery improve risk assessment for people with whiplash-associated disorders? Secondary analysis of a prospective cohort study

Background

WhipPredict, which includes prognostic factors of pain-related disability, age and hyperarousal symptoms, was developed and validated for prediction of outcome in people with whiplash associated disorders (WAD). Patient expectations of recovery was not an included factor, though is known to mediate outcomes. The aim of this study was to determine whether the addition of expectations of recovery could improve the accuracy of WhipPredict.

Methods

Two hundred twenty-eight participants with acute WAD completed questionnaires (WhipPredict and expectations of recovery) at baseline. Health outcomes (neck disability index (NDI) and Global Perceived Recovery (GPR)) were assessed at 6- and 12-months post injury. Cut-off points for expectations of recovery predictive of both full recovery (NDI ≤10 % , GPR ≥ 4) and poor outcome (NDI ≥30 % , GPR ≤  − 3) were determined, and multivariate logistic regression analyses were used to compare models with and without this variable.

Results

Expectations of recovery improved or maintained the accuracy of predictions of poor outcome (6-months: sensitivity 78 to 83%, specificity maintained at 79.5%; 12-months: sensitivity maintained at 80%, specificity 69 to 73%). The sensitivity of predictions of full recovery improved (6-months: 68 to 76%; 12-months: 57 to 81%), though specificity did not change appreciably at 6 months (80 to 81%) and declined at 12 (83 to 76%). ROC curves indicated a larger and more consistent improvement in model performance when expectations of recovery were added to the pathway predictive of full recovery.

Conclusions

The addition of expectations of recovery may improve the accuracy of WhipPredict, though further validation is required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05242-8.

Effects of a preoperative neuromobilization program offered to individuals with carpal tunnel syndrome awaiting carpal tunnel decompression surgery: A pilot randomized controlled study

STUDY DESIGN

Pilot randomized controlled trial with parallel groups.

INTRODUCTION

Engaging individuals with carpal tunnel syndrome (CTS) awaiting carpal tunnel decompression surgery in a preoperative rehabilitation program may mitigate pain and sensorimotor impairments, enhance functional abilities before surgery, and improve postoperative outcomes.

PURPOSE OF THE STUDY

To assess the feasibility and the efficacy of a novel preoperative neuromobilization exercise program (NEP).

METHODS

Thirty individuals with CTS were randomly allocated into a four-week home-based neuromobilization exercise group or a standard care group while awaiting surgery. Outcome measures included feasibility (ie, recruitment, attrition, adherence, satisfaction, and safety) and efficacy metrics (ie, median nerve integrity and neurodynamics, tip pinch grip, pain, and upper limb functional abilities) collected before (ie, at the baseline and about four weeks later) and four weeks after surgery.

RESULTS

Thirty individuals with CTS were recruited (recruitment rate = 11.8%) and 25 completed the study (attrition rate = 16.7%). Adherence (94%) and satisfaction with the program (eg, enjoy the exercises and likeliness to repeat the NEP (≥4.2/5) were high and no serious adverse event was reported. NEP-related immediate pre- and post-surgery beneficial effects on pain interference were documented (P = .05, η² = .10), whereas an overall increased neurodynamics (P = .04, η² = .11) and decreased pain severity (P = .01, η² = .21) were observed.

DISCUSSION

Engaging in the proposed NEP has limited beneficial effect as a stand-alone intervention on pre- and post-surgery outcomes for individuals with CTS. Expanding the program's content and attribute by adding other components including desensitization maneuvers and novel therapies promoting corticospinal plasticity is recommended.

CONCLUSION

A preoperative NEP completed by individuals with CTS awaiting surgery is feasible, acceptable, and safe. However, given the limited beneficial effectsof the program, revision of its content and attributes is recommended before proceeding to large-scale trials.

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.

Assessment of Patient-Reported Outcome Instruments to Assess Chronic Low Back Pain

Objective

To identify patient-reported outcome (PRO) instruments that assess chronic low back pain (cLBP) symptoms (specifically pain qualities) and/or impacts for potential use in cLBP clinical trials to demonstrate treatment benefit and support labeling claims.

Design

Literature review of existing PRO measures.

Methods

Publications detailing existing PRO measures for cLBP were identified, reviewed, and summarized. As recommended by the US Food & Drug Administration (FDA) PRO development guidance, standard measurement characteristics were reviewed, including development history, psychometric properties (validity and reliability), ability to detect change, and interpretation of observed changes.

Results

Thirteen instruments were selected and reviewed: Low Back Pain Bothersomeness Scale, Neuropathic Pain Symptom Inventory, PainDETECT, Pain Quality Assessment Scale Revised, Revised Short Form McGill Pain Questionnaire, Low Back Pain Impact Questionnaire, Oswestry Disability Index, Pain Disability Index, Roland-Morris Disability Questionnaire, Brief Pain Inventory and Brief Pain Inventory Short Form, Musculoskeletal Outcomes Data Evaluation and Management System Spine Module, Orebro Musculoskeletal Pain Questionnaire, and the West Haven-Yale Multidimensional Pain Inventory Interference Scale. The instruments varied in the aspects of pain and/or impacts that they assessed, and none of the instruments fulfilled all criteria for use in clinical trials to support labeling claims based on recommendations outlined in the FDA PRO guidance.

Conclusions

There is an unmet need for a validated PRO instrument to evaluate cLBP-related symptoms and impacts for use in clinical trials.

Recovery Pathways and Prognosis After Whiplash Injury

Synopsis Recovery from a whiplash injury is varied and complex. Some individuals recover quickly and fully, while others experience ongoing pain and disability. Three distinct patterns of predicted recovery (trajectories) have been identified using disability and psychological outcome measures. These trajectories are not linear, and show that recovery, if it is going to occur, tends to happen within the first 3 months of the injury, with little improvement after this period. Identification of factors associated with poor recovery is accumulating, and since 2000 there have been at least 10 published systematic reviews on prognostic factors for whiplash-associated disorder. Poor recovery has been consistently reported to be associated with high initial neck pain intensity and neck-related disability, posttraumatic stress symptoms, pain catastrophizing, and, to a lesser extent, low self-efficacy and cold hyperalgesia. Evidence regarding factors, including compensation status, psychological factors, structural pathology, and preinjury health status, remains equivocal. Given the huge number of predictive factors and various interpretations of recovery, adapting these data for use in clinical practice is difficult. Tools such as clinical prediction rules (CPRs), by statistically quantifying relevant data, may help to predict the probability of diagnosis, prognosis, or response to treatment. Numerous CPRs have been derived for individuals with whiplash; however, to date, only 3 prognostic CPRs have undergone external validation, and none have yet undergone impact analysis, a necessary step in providing information about the rules' ability to improve clinically relevant outcomes. J Orthop Sports Phys Ther 2016;46(10):851-861. Epub 3 Sep 2016. doi:10.2519/jospt.2016.6918.

Comparing 2 Whiplash Grading Systems to Predict Clinical Outcomes

OBJECTIVE

Two whiplash severity grading systems have been developed: Quebec Task Force on Whiplash-Associated Disorders (QTF-WAD) and the Croft grading system. The majority of clinical studies to date have used the modified grading system published by the QTF-WAD in 1995 and have demonstrated some ability to predict outcome. But most studies include only injuries of lower severity (grades 1 and 2), preventing a broader interpretation. The purpose of this study was assess the ability of these grading systems to predict clinical outcome within the context of a broader injury spectrum.

METHODS

This study evaluated both grading systems for their ability to predict the bivalent outcome, recovery, within a sample of 118 whiplash patients who were part of a previous case-control designed study. Of these, 36% (controls) had recovered, and 64% (cases) had not recovered. The discrete bivariate distribution between recovery status and whiplash grade was analyzed using the 2-tailed cross-tabulation statistics.

RESULTS

Applying the criteria of the original 1993 Croft grading system, the subset comprised 1 grade 1 injury, 32 grade 2 injuries, 53 grade 3 injuries, and 32 grade 4 injuries. Applying the criteria of the modified (QTF-WAD) grading system, there were 1 grade 1 injury, 89 grade 2 injuries, and 28 grade 3 injuries. Both whiplash grading systems correlated negatively with recovery; that is, higher severity grades predicted a lower probability of recovery, and statistically significant correlations were observed in both, but the Croft grading system substantially outperformed the QTF-WAD system on this measure.

CONCLUSIONS

The Croft grading system for whiplash injury severity showed a better predictive measure for recovery status from whiplash injuries as compared with the QTF-WAD grading system.

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.

An Overview of Systematic Reviews on Prognostic Factors in Neck Pain: Results from the International Collaboration on Neck Pain (ICON) Project

Given the challenges of chronic musculoskeletal pain and disability, establishing a clear prognosis in the acute stage has become increasingly recognized as a valuable approach to mitigate chronic problems. Neck pain represents a condition that is common, potentially disabling, and has a high rate of transition to chronic or persistent problems. As a field of research, prognosis in neck pain has stimulated several empirical primary research papers, and a number of systematic reviews. As part of the International Consensus on Neck (ICON) project, we sought to establish the general state of knowledge in the area through a structured, systematic review of systematic reviews (overview).

An exhaustive search strategy was created and employed to identify the 13 systematic reviews (SRs) that served as the primary data sources for this overview. A decision algorithm for data synthesis, which incorporated currency of the SR, risk of bias assessment of the SRs using AMSTAR scoring and consistency of findings across SRs, determined the level of confidence in the risk profile of 133 different variables. The results provide high confidence that baseline neck pain intensity and baseline disability have a strong association with outcome, while angular deformities of the neck and parameters of the initiating trauma have no effect on outcome. A vast number of predictors provide low or very low confidence or inconclusive results, suggesting there is still much work to be done in this field. Despite the presence of multiple SR and this overview, there is insufficient evidence to make firm conclusions on many potential prognostic variables. This study demonstrates the challenges in conducting overviews on prognosis where clear synthesis critieria and a lack of specifics of primary data in SR are barriers.

The clinical utility of the Multidimensional Pain Inventory (MPI) in characterizing chronic disabling occupational musculoskeletal disorders

PURPOSE

The Multidimensional Pain Inventory (MPI) was designed to help capture unique characteristics of chronic pain patients. The present study examined the proportion of subgroups classified by the MPI in a chronic disabling occupational musculoskeletal disorder (CDOMD) patient cohort, and described characteristics of MPI profile groups in terms of other psychosocial variables.

METHODS

A cohort of 1,270 CDOMD patients undergoing an interdisciplinary functional restoration program was studied. Before the start of the program, all patients received a standard psychosocial assessment battery. A MPI computer program scored and identified pre-defined MPI subgroups: Adaptive Coper (AC); Interpersonally Distressed (ID); and Dysfunctional (DYS).

RESULTS

The distribution of MPI profiles for CDOMD patients was similar with those of highly disabled patients, with the largest proportion of patients having the DYS profile (44 %), followed by AC (33 %) and ID (23 %). The DYS profile group showed the highest level of pain severity, and psychosocial distress; the ID group had a moderate level; and the AC profile group had the lowest level. Higher rates of psychiatric disorders were also found in the DYS and ID groups. The DYS profile group was less likely to complete the treatment program.

CONCLUSION

The present study further demonstrated the clinical utility of the MPI classification in a large cohort of CDOMD patients, indicating that the MPI profiles successfully distinguish among patients who may require extra psychosocial attention to achieve successful treatment gains and program completion.

Effects of pain controllability and discrepancy in social support on depressed mood among patients with chronic pain

BACKGROUND

Preference of types of social support may vary across recipients, and social support that is less than the amount preferred may be associated with depressed mood.

PURPOSE

This study aimed to investigate the interaction effects between pain controllability and discrepancy in social support and the additive utility of discrepancy in social support over perceived social support in predicting depressed mood among patients with chronic pain.

METHOD

A total of 173 patients seeking treatment at two outpatient pain management clinics in Hawaii participated.

RESULTS

The results indicated that (1) patients with low pain controllability preferred significantly more social support than those with high pain controllability, for all types of social support; (2) patients preferred significantly more informational and emotional support than instrumental support for both pain controllability levels; (3) discrepancy in informational or instrumental support was not associated with depressed mood, whereas discrepancy in emotional support was significantly associated with more depressed mood for low pain controllability, but not for high pain controllability; and (4) discrepancy in emotional support added a significant increment of variance in predicting depressed mood over and above perceived emotional support, whereas discrepancy in informational or instrumental support did not.

CONCLUSION

Findings suggest the relative importance of discrepancy in emotional support from a significant other, especially for patients with low pain controllability.

Pain coping but not readiness to change is associated with pretreatment pain-related functioning

OBJECTIVE

The purpose of the present study was to determine if readiness to use adaptive and avoid maladaptive pain-coping skills before initiation of psychosocial treatment for chronic pain was related to reports of present coping, and whether those variables, together or separately, explained variance in pain, pain interference, and symptoms of depression.

METHODS

A total of 132 patients with chronic low back pain completed measures of readiness, coping, and pain-related functioning before participation in a clinical trial of cognitive-behavioral therapy for pain.

RESULTS

Pearson correlations indicated that the content-matched subscales of readiness and coping were moderately correlated (rs between 0.30 and 0.60), and "mismatched" subscales were generally more weakly related or unrelated. None of the readiness subscales were significantly associated with variance in any of the functioning variables. However, several aspects of coping were significantly associated with functioning. Task persistence was associated with lower pain interference and symptoms of depression; asking for assistance was associated with higher pain interference; and pain-contingent rest was associated with higher pain interference.

DISCUSSION

Overall, the results indicate that adaptive coping is associated with better pain-related functioning and maladaptive coping is associated with poorer functioning, whereas readiness appears to not play a significant role in patient functioning before psychosocial pain treatment. The findings support the discriminant validity of the coping and readiness measures and inform treatment conceptualization.

The Relationship between Beliefs about Pain and Functioning with Rheumatologic Conditions

Pain beliefs influence understanding of pain mechanisms and outcomes. This study in rheumatologic conditions sought to determine a relationship between beliefs about pain and functioning. Participants in Arthritis New Zealand's (ANZ) exercise and education programmes were used. Demographic data and validated instruments used included the Arthritis Impact Measurement Scale 2nd version-Short Form (AIMS2-SF) to measure functioning, and two scales of organic and psychological beliefs in Pain Beliefs Questionnaires (PBQ) to measure pain beliefs. 236 Members of ANZ were surveyed anonymously with AIMS2-SF and PBQ, with a 61% response rate; 144 responses were entered into the database. This study used α of 0.05 and a 1-β of 0.8 to detect for significant effect size estimated to be r = 0.25. Analysis revealed a significant relationship between organic beliefs scale of PBQ and functioning of AIMS2-SF, with an r value of 0.32 and P value of 0.00008. No relationship was found between psychological beliefs scale of PBQ and AIMS2-SF. Organic pain beliefs are associated with poorer functioning. Psychological pain beliefs are not. Beliefs might have been modified by ANZ programmes. Clinicians should address organic pain beliefs early in consultation. Causal links between organic pain beliefs and functioning should be clarified.

Use of a modified Comprehensive Pain Evaluation Questionnaire (CPEQ): characteristics and functional status of patients on entry to a tertiary care pain clinic

BACKGROUND

With increasing knowledge of chronic pain, clinicians have attempted to assess chronic pain patients with lengthy assessment tools.

OBJECTIVES

To describe the functional and emotional status of patients presenting to a tertiary care pain clinic; to assess the reliability and validity of a diagnostic classification system for chronic pain patients modelled after the Multidimensional Pain Inventory; to provide psychometric data on a modified Comprehensive Pain Evaluation Questionnaire (CPEQ); and to evaluate the relationship between the modified CPEQ construct scores and clusters with Diagnostic and Statistical Manual, Fourth Edition - Text Revision Pain Disorder diagnoses.

METHODS

Data on 300 new patients over the course of nine months were collected using standardized assessment procedures plus a modified CPEQ at the Comprehensive Pain Program, Toronto Western Hospital, Toronto, Ontario.

RESULTS

Cluster analysis of the modified CPEQ revealed three patient profiles, labelled Adaptive Copers, Dysfunctional, and Interpersonally Distressed, which closely resembled those previously reported. The distribution of modified CPEQ construct T scores across profile subtypes was similar to that previously reported for the original CPEQ. A novel finding was that of a strong relationship between the modified CPEQ clusters and constructs with Diagnostic and Statistical Manual, Fourth Edition - Text Revision Pain Disorder diagnoses.

DISCUSSION AND CONCLUSIONS

The CPEQ, either the original or modified version, yields reproducible results consistent with the results of other studies. This technique may usefully classify chronic pain patients, but more work is needed to determine the meaning of the CPEQ clusters, what psychological or biomedical variables are associated with CPEQ constructs or clusters, and whether this instrument may assist in treatment planning or predict response to treatment.

Readiness for change predicts outcomes of functional rehabilitation following motor vehicle accident

INTRODUCTION

Previous research has found pre-treatment motivational readiness to engage in pain self-management to be associated with completion of a rehabilitation program. This preliminary study examined this relationship, as well as the ability of pre-treatment readiness to change to predict clinical decisions of post-treatment functional work capacity.

METHODS

The sample consisted of 106 individuals involved in a tertiary functional rehabilitation program for motor vehicle accident (MVA) survivors. The Multidimensional Pain Inventory (MPI) and Pain Stages of Change Questionnaire (PSOCQ) were completed prior to treatment.

RESULTS

Hierarchical logistic regression analyses revealed that PSOCQ profile scores (P = 0.008), including higher individual PSOCQ contemplation (OR = 5.30; P = 0.017) and action (OR = 5.16; P = 0.049) scores, significantly increased the likelihood of completing the functional rehabilitation program. Clinical decisions about functional work capacity were predicted by MPI profile scores (P = 0.001), and this model was significantly improved by the addition of PSOCQ scores (P = 0.037). Lower MPI interference (OR = 5.41; P = 0.002), and higher MPI affective distress (OR = 2.81; P = 0.010), MPI support (OR = 1.72; P = 0.027), and PSOCQ action (OR = 5.35; P = 0.038) scores were significant predictors of clinicians' decisions regarding functional work capacity in the final model that identified 88% of those judged capable of returning to work and 63% of those who were judged not capable of returning to work.

CONCLUSIONS

This preliminary study suggests that readiness to self-manage pain is an important predictor of both completion of functional rehabilitation program and clinicians' decisions regarding functional work capacity after an MVA. The latter outcome appears to be more complex, influenced both by motivational readiness to engage in pain self-management and cognitive-behavioral adaptation to pain.

Beliefs and expectations for recovery, coping, and depression in whiplash-associated disorders: lessening the transition to chronicity

STUDY DESIGN

Literature review and discussion.

OBJECTIVE

To discuss the role played by beliefs, expectations, coping, and depression in the transition to chronicity in whiplash-associated disorders (WAD), and to discuss their clinical and research implications.

SUMMARY OF BACKGROUND DATA

Psychological factors are important in musculoskeletal pain problems. Recently, there has been attention paid to their role in the transition from acute to chronic WAD. However, most of this attention has focused on identifying and addressing the personal and behavioral aspects of psychological factors, and little focus on the social and societal influences shaping these factors in WAD patients.

METHODS

A literature review was conducted to describe the evidence regarding the roles of beliefs, expectations, pain coping, and depression in WAD recovery. These psychological constructs and research findings were discussed in the context of efforts to improve beliefs, coping, and psychological well-being in WAD.

RESULTS

There is consistent evidence negative beliefs about WAD are common in the general population and that poor expectations for recovery are associated with poor recovery. Pain coping and depression also appear to predict WAD recovery. The conceptual frameworks (such as social learning theory) for understanding these psychological constructs highlight the roles of interpersonal and societal factors. However, most research and clinical interventions related to these factors focuses on the individual, rather than also addressing the social context.

CONCLUSION

Beliefs, expectations, coping, and depression all predict WAD recovery. Efforts to address these factors should take a broad-based approach. These psychological constructs should be viewed as being developed and maintained within the broader social context of family, social networks, employment, and societal processes in general. There is need for a research and clinical paradigm, which acknowledges the interrelationships between internal processes and the social context in attempts to optimize recovery and functioning in those with WAD.

A review of the definitions of 'recovery' used in prognostic studies on whiplash using an ICF framework

PURPOSE

The purpose of this article is to review the various definitions of recovery used in the prognostic whiplash literature to date, and to evaluate them from the framework of the International Classification of Functioning, Disability and Health (ICF).

METHODS

Reference lists of previous systematic reviews and meta-analyses on the topic were reviewed and citations were retrieved. An updated Medline search was performed. Recovery rates and the method for operationalising recovery were extracted and evaluated for their fit within the ICF model of health. Descriptive statistics were calculated and presented.

RESULTS

Thirty-one independent cohorts were identified. In total, 30 different primary methods for defining recovery were described in the sample of literature. Eighty-three percent of the primary outcomes fit within the body structure and function domain of the ICF. Restricted participation was the second most common domain represented, followed by activity limitations. Even within each domain, there is wide variability in the cut-off values for dichotomising a group as recovered or not.

CONCLUSIONS

The wide range of recovery rates reported in the literature can be at least partly accounted for by the lack of a standardised definition of recovery after acute whiplash. The emphasis on symptoms in the current literature neglects other important aspects of health as described by the ICF.

Psychosocial and socio-demographic factors associated with outcomes for patients undergoing rehabilitation for chronic whiplash associated disorders: a pilot study

PURPOSE

Identify psychosocial and socio-demographic factors (measured prior to treatment) that were associated with post-treatment self-perceived pain and disability and two secondary outcomes: psychological distress, and return to work in patients undergoing multidisciplinary rehabilitation for chronic whiplash associated disorders (WAD).

METHOD

Interviews were conducted with 28 patients with chronic WAD at entry to and completion of an intensive rehabilitation program, and a telephone interview was carried out three months later. Participants completed pain and disability, and psychological distress questionnaires, at baseline and at both follow-ups. They also completed psychosocial questionnaires and provided socio-demographic information. The effect of each of the independent variables on the outcomes was first evaluated by simple regressions, and then subsequently by multiple regression analysis.

RESULTS

Higher baseline pain and disability predicted higher pain and disability at both follow-ups (p < 0.001), and higher psychological distress at program completion (p = 0.003). Younger age (p = 0.028) and higher baseline psychological distress (p = 0.002) were associated with higher psychological distress three months post-rehabilitation. Greater social support at work was prognostic of return to work at program completion (p = 0.04).

CONCLUSIONS

Baseline pain and disability was the only factor that affected pain and disability post-rehabilitation. Psychosocial factors played a role in the prognosis of psychological distress and return to work.

French translation of the Multidimensional Pain Inventory: L'inventaire multidimensionnel de la douleur

BACKGROUND

The Multidimensional Pain Inventory (MPI) is a widely used tool in the evaluation of pain conditions. This questionnaire has been translated and validated in multiple languages. However, there is no validated French-language version available for clinicians and researchers interested in evaluating people living with pain.

OBJECTIVES

The main objective of the present project was to make available a validated French-language evaluation tool for the cognitive, behavioural and emotional aspects of pain.

METHODS

Following a reverse translation of the MPI, a French-language version of the questionnaire, the Inventaire multidimensionnel de la douleur, that was presented to 227 participants living with chronic pain, was obtained. These participants were all involved in a rehabilitation program in four different settings. A series of exploratory and confirmatory factor analyses was executed.

RESULTS AND CONCLUSIONS

Although three items were removed from the original version of the MPI, the three sections of the Inventaire multidimensionnel de la douleur had good psychometric properties. The results concerning the questionnaire's structure were very similar to those obtained with the original tool and during its translation into other languages. People wishing to evaluate pain in French-speaking populations now have access to a French-language version of the MPI.

Life satisfaction in patients with long-term non-malignant pain - relating LiSat-11 to the Multidimensional Pain Inventory (MPI)

BACKGROUND

The West-Haven Multidimensional Pain Inventory (MPI) can be used to describe behavioural and psychosocial consequences of long-term pain but little is known about how MPI items and MPI subgroups relate to goals that patients find important in rehabilitation. Life satisfaction measured by the LiSat-11 checklist can be defined as an individual's perception of the difference between his reality and his needs or wants. This difference can be considered a "goal achievement gap". This study investigates the relation of MPI to LiSat-11 with the aim to explore the possibility that LiSat-11 can be used to measure pain rehabilitation outcomes that are important from the patients' view.

METHODS

Participators were patients (n = 294) referred to the Pain and Rehabilitation Clinic in Uppsala, Sweden. Measures used were LiSat-11, MPI and its Swedish version MPI-S. LiSat-11 domains were correlated to MPI scales. Cluster analysis was used to demonstrate MPI-S subgroups. Analysis of variance followed by post-hoc analysis was used to investigate life satisfaction in the three MPI-S subgroups.

RESULTS

The strongest positive correlation were found for the LiSat-11 domains/MPI scales: psychological health/life control and contacts/social activities, and the strongest negative correlation for: psychological health/affective distress, partner relationship/punishing responses, somatic health/interference and leisure/interference. None or only little correlation was found between MPI scale pain severity and most LiSat-11 domains and satisfaction with life as a whole. Among the MPI-S subgroups, adaptive copers generally had better life satisfaction than the dysfunctional and the interpersonally distressed.

CONCLUSION

Pain severity alone is a rather poor predictor of low life satisfaction. MPI and LiSat-11 partly supplement each other as tools to describe how functional impairments relate to life satisfaction domains, which may be relevant for identifying domains which the patients find important to improve. Furthermore, differences in life satisfaction between the MPI-S subgroups may help to identify functional domains that may be of particular importance in specialised rehabilitation programs.

Clinical assessment of prognostic factors for long-term pain and handicap after whiplash injury: a 1-year prospective study

BACKGROUND AND PURPOSE

Physical mechanisms are the possible factors involved in the development and maintenance of long-term handicaps after acute whiplash injury. This study prospectively examined the role of active neck mobility, cervical and extra-cervical pains, as well as non-painful complaints after a whiplash injury as predictors for subsequent handicap.

METHODS

Consecutive acute whiplash patients (n = 688) were interviewed and examined by a study nurse after the median of 5 days after injury, and divided into a high- or a low-risk group by an algorithm based on pain intensity, number of non-painful complaints and active neck mobility [active cervical range of motion (CROM)]. All 458 high-risk patients and 230 low-risk patients received mailed questionnaires after 3, 6 and 12 months. Two examiners examined all high-risk patients (n = 458) and 41 consecutive low-risk patients at median 11, 109, 380 days after injury. The main outcome measures were: handicaps, severe headaches, neck pain and neck disability.

RESULTS

The relative risk for a 1-year disability increased by 3.5 with initial intense neck pain and headaches, by 4.6 times with reduced CROM and by four times with multiple non-painful complaints.

CONCLUSION

Reduced active neck mobility, immediate intense neck pain and headaches and the presence of multiple non-painful complaints are the important prognostic factors for a 1-year handicap after acute whiplash.

[Whiplash-associated disorders: a challenge for the expert in compensation claims and litigation]

In the literature, the association between chronic complaints of the cervical spine and sustained"whiplash trauma" is a matter of controversy. Whiplash trauma is identified as contusion, compression, and/or sprain without definite imaging proof of injury to the bone, disk, or ligaments.However, complex chronic complaints leading to permanent and significant functional limitations in daily living and work may develop. Besides the diagnostic and therapeutic challenges for the treating physician, the expert confronted with compensation claims very often must decide whether whiplash trauma of the spine may lead to significant and permanent functional limitations or loss with chronic disorders. The data from the literature dealing with this topic are contradictory and deficient. In this article, based on the present available data from the literature, we critically examine the causality between spinal whiplash trauma and possible permanent chronic complaints in order to support the process of decision making in cases of litigation and controversial compensation claims.

Course and prognostic factors of whiplash: a systematic review and meta-analysis

We conducted a systematic review and meta-analysis of prospective cohort studies of subjects with acute whiplash injuries. The aim was to describe the course of recovery, pain and disability symptoms and also to assess the influence of different prognostic factors on outcome. Studies were selected for inclusion if they enrolled subjects with neck pain within six weeks of a car accident and measured pain and/or disability outcomes. Studies were located via a sensitive search of electronic databases; Medline, Embase, CINAHL, Cochrane database, ACP Journal club, DARE and Psychinfo and through hand-searches of relevant previous reviews. Methodological quality of all studies was assessed using a six item checklist. Sixty-seven articles, describing 38 separate cohorts were included. Recovery rates were extremely variable across studies but homogeneity was improved when only data from studies of more robust methodological quality were considered. These data suggest that recovery occurs for a substantial proportion of subjects in the initial 3 months after the accident but after this time recovery rates level off. Pain and disability symptoms also reduce rapidly in the initial months after the accident but show little improvement after 3 months have elapsed. Data regarding the prognostic factors associated with poor recovery were difficult to interpret due to heterogeneity of the techniques used to assess such associations and the way in which they are reported. There was also wide variation in the measurement of outcome and the use of validated measures would improve interpretability and comparability of future studies.

A systematic literature review of psychological factors and the development of late whiplash syndrome

This systematic literature review aims to assess the prognostic value of psychological factors in the development of late whiplash syndrome (LWS). We included prospective cohort studies that provided a baseline measure of at least one psychological variable and used outcome measures relating to LWS (i.e. pain or disability persisting 6 months post injury). A search of electronic databases (Pubmed, Medline, Cinahl, Embase and Psychinfo) up to August 2006 was done using a predetermined search strategy. Methodological quality was assessed independently by two assessors. Data extraction were carried out using a standardised data extraction form. Twenty-five articles representing data from 17 cohorts were included. Fourteen articles were rated as low quality with 11 rated as adequate quality. Meta-analysis was not undertaken due to the heterogeneity of prognostic factors, outcome measures and methods used. Results were tabulated and predefined criterion applied to rate the overall strength of evidence for associations between psychological factors and LWS. Data on 21 possible psychological risk factors were included. The majority of findings were inconclusive. Limited evidence was found to support an association between lower self-efficacy and greater post-traumatic stress with the development of LWS. No association was found between the development of LWS and personality traits, general psychological distress, wellbeing, social support, life control and psychosocial work factors. The lack of conclusive findings and poor methodological quality of the studies reviewed highlights the need for better quality research. Self-efficacy and post-traumatic distress may be associated with the development of LWS but this needs further investigation.

A systematic literature review of physical prognostic factors for the development of Late Whiplash Syndrome

STUDY DESIGN

Systematic Review.

OBJECTIVE

To summarize evidence concerning physical prognostic factors for development of Late Whiplash Syndrome (LWS).

SUMMARY OF BACKGROUND DATA

There have been 3 previous systematic reviews of prognosis of whiplash with conflicting findings. The Quebec Task Force concluded that high priority should be given to determining prognostic factors. Subsequently their review was updated by Cote et al (Spine 2001;26:E445-58) and most recently by Scholten-Peeters et al (Pain 2003;104:303-22).

METHODS

We searched electronic databases from their inception to August 2006 using a prespecified search strategy. We included prospective cohort and case control studies that studied physical prognostic factors at baseline. Two independent reviewers selected articles, extracted data, and assessed quality. Meta-analysis was not performed due to the heterogeneity between studies. Instead, levels of evidence were generated by grouping similar findings from cohorts.

RESULTS

Thirty-eight articles from 26 cohorts were reviewed. The majority of articles (25 of 38) were rated as low quality. No studies were rated as high quality. Only a minority of studies used validated prognostic measures and/or outcome measures. High initial neck pain intensity, neck pain related disability, and cold hyperalgesia all had moderate evidence for an association with the development of LWS. No factor was rated as having strong evidence.

CONCLUSION

Pain has a central role to play as a prognostic factor for the development of LWS. Other physical factors commonly used in the clinical setting showed inconclusive evidence for their influence on prognosis. There is a need for improved quality of studies with consistent use of validated measures of all categories of prognostic factors and outcome. This may then provide a clearer understanding of prognosis of Whiplash Associated Disorders and therefore facilitate effective management of this costly problem.

Neck collar, "act-as-usual" or active mobilization for whiplash injury? A randomized parallel-group trial

STUDY DESIGN

Randomized, parallel-group trial.

OBJECTIVE

To compare the effect of 3 early intervention strategies following whiplash injury.

SUMMARY OF BACKGROUND DATA

Long-lasting pain and disability, known as chronic whiplash-associated disorder (WAD), may develop after a forced flexion-extension trauma to the cervical spine. It is unclear whether this, in some cases disabling, condition can be prevented by early intervention. Active interventions have been recommended but have not been compared with information only.

METHODS

Participants were recruited from emergency units and general practitioners within 10 days after a whiplash injury and randomized to: 1) immobilization of the cervical spine in a rigid collar followed by active mobilization, 2) advice to "act-as-usual," or 3) an active mobilization program (Mechanical Diagnosis and Therapy). Follow-up was carried out after 3, 6, and 12 months postinjury. Treatment effect was measured in terms of headache and neck pain intensity (0-10), disability, and work capability.

RESULTS

A total of 458 participants were included. At the 1-year follow-up, 48% of participants reported considerable neck pain, 53% disability, and 14% were still sick listed at 1 year follow-up. No significant differences were observed between the 3 interventions group.

CONCLUSION

Immobilization, "act-as-usual," and mobilization had similar effects regarding prevention of pain, disability, and work capability 1 year after a whiplash injury.

Prognostic factors for chronic neck pain in persons with minor or moderate injuries in traffic accidents

Prognostic factors for chronic neck pain were identified in a prospective Norwegian insurance cohort comprising 636 persons with minor or moderate traffic injuries. One questionnaire was used at baseline and another at 3 years post-injury. Daily severe or very severe neck pain at three years follow up was defined as chronic neck pain. Eight significant independent prognostic factors for chronic neck pain were identified: (1) rear-end or frontal and rear-end collision, odds ratio (OR): 4.10 (95% confidence interval (CI): 1.72-10.82); (2) neck and/or shoulder pain before the accident, OR: 2.38 (95% CI: 1.07-5.37); (3) post-accident (a) memory and concentration problems, OR: 4.62 (95% CI: 1.99-11.20), (b) bodily tension, OR: 3.43 (95% CI: 1.49-8.42), (c) difficulties to climb stairs, OR: 5.03 (95% CI: 1.77-14.95), (d) difficulties to bend forward, OR: 4.85 (95% CI: 2.06-11.79), (e) difficulties to do heavy labour, OR: 3.70 (95% CI: 1.24-11.64); (4) beliefs in future work disability, OR: 2.64 (95% CI: 1.11-6.48). The results indicate that development of chronic neck pain is influenced by pre-accident neck and/or shoulder pain, the impact of the collision, as well as post-accident symptoms, perceived impaired function and pessimism for the future ability to work.

An examination of the psychometric structure of the Multidimensional Pain Inventory in temporomandibular disorder patients: a confirmatory factor analysis

Background

This paper seeks to analyse the psychometric and structural properties of the Multidimensional Pain Inventory (MPI) in a sample of temporomandibular disorder patients.

Methods

The internal consistency of the scales was obtained. Confirmatory Factor Analysis was carried out to test the MPI structure section by section in a sample of 114 temporomandibular disorder patients.

Results

Nearly all scales obtained good reliability indexes. The original structure could not be totally confirmed. However, with a few adjustments we obtained a satisfactory structural model of the MPI which was slightly different from the original: certain items and the Self control scale were eliminated; in two cases, two original scales were grouped in one factor, Solicitous and Distracting responses on the one hand, and Social activities and Away from home activities, on the other.

Conclusion

The MPI has been demonstrated to be a reliable tool for the assessment of pain in temporomandibular disorder patients. Some divergences to be taken into account have been clarified.

The influence of prognostic factors on neck pain intensity, disability, anxiety and depression over a 2-year period in subjects with acute whiplash injury

The influence of potential prognostic factors (occupant- and crash-related factors, initial neck pain intensity and headache, whiplash injury severity, helplessness, locus of control, socioeconomic status) on neck pain intensity (VAS), disability (DRI), anxiety and depression (HADS) was estimated in a cohort of 3704 subjects with whiplash injury following a motor vehicle crash. Questionnaires were administered (baseline, 1-, 6-, 12-, 24-month follow-ups). VAS was trichotomized; "low" (0-30), "moderate" (31-54), "severe" (55-100). A cumulative logit model with a proportional odds assumption was applied. Results regarding depression differed somewhat from the other outcomes. Overall, initial neck pain intensity was an important prognostic factor, but acted also as an evident effect modifier. Females had slightly increased odds for all outcomes but depression, for which no gender differences were shown. Injury severity was associated with all outcomes, but was most pronounced regarding disability among those who perceived numbness/pain in arms/hands and also had severe initial neck pain (proportional odds ratio [OR] 6.5; 95% confidence interval [CI] 2.5-17.0). Initial headache influenced all outcomes. Income was not related to any of the outcomes, whereas a lower level of education was associated with all outcomes but depression. Locus of control was not a factor of importance. In contrast, helplessness was related to all outcomes, but was most pronounced regarding neck pain intensity and depression for subjects with severe initial neck pain (OR 4.8; 95% CI 2.9-7.8; OR 6.6; 95% CI 2.6-17.0). Associations seem to be established early, and then to be relatively constant over time.

Predictors of persistent neck pain after whiplash injury

OBJECTIVE

To establish the aetiological influences of persistent neck pain following a motor vehicle collision and to construct a model for use in the emergency department for identifying patients at high risk of persistent symptoms.

DESIGN

Prospective cohort study. Patients recruited from hospital emergency departments were sent a questionnaire to gather information on various exposures. They were followed up at 1, 3, and 12 months to identify those with persistent symptoms.

MAIN OUTCOME MEASURE

Persistent neck pain (pain at 1, 3, and 12 months after collision).

RESULTS

The baseline survey included 765 patients. Subsequently, 480 completed a questionnaire at each follow up time point, of whom 128 (27%) reported neck pain on each occasion. Few collision specific factors predicted persistent neck pain. In contrast, a high level of general psychological distress, pre-collision history of widespread body pain, type of vehicle, whiplash associated symptoms, and initial neck disability best predicted the persistence of symptoms. Furthermore, these factors, in combination, accounted for more than a fivefold increase in the risk of persistent neck pain.

CONCLUSION

The greatest predictors of persistent neck pain following a motor vehicle collision relate to psychological distress and aspects of pre-collision health rather than to various attributes of the collision itself. With these factors, and those relating to initial injury severity, it is possible to identify a subgroup of patients presenting with neck pain with the highest risk of persistent symptoms. Thus, it is possible to identify whiplash patients with a poor prognosis and to provide closer follow up and specific attention to management in these individuals.

Internal Consistency, Stability, and Validity of the Spinal Cord Injury Version of the Multidimensional Pain Inventory

OBJECTIVE

To evaluate the internal consistency, stability, and construct validity of a spinal cord injury (SCI) version of the Multidimensional Pain Inventory (MPI-SCI).

DESIGN

Interview.

SETTING

Veterans Affairs medical center and university-based institute.

PARTICIPANTS

Community sample of persons with SCI and chronic pain (N=161).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The MPI-SCI.

RESULTS

The internal consistency of the MPI-SCI subscales ranged from fair (.60) for affective distress to substantial (.94) for pain interference with activities. The subscales of the MPI-SCI (ie, life interference [r=.81], affective distress [r=.71], solicitous responses [r=.86], distracting responses [r=.85], general activity [r=.69], pain interference with activities [r=.78], pain severity [r=.69], negative responses [r=.69]) showed adequate stability. In contrast, the stability of the support (r=.59) and the life control subscales (r=.31) was unacceptably low. All MPI-SCI subscales with the exception of the perceived responses by significant others subscales showed good convergent, discriminant, and concurrent validity.

CONCLUSIONS

The MPI-SCI appears to be a reasonable measure for evaluating chronic pain impact after SCI. In clinical trials, however, supplementary instruments should be included to assess changes in affect, social support, and perceptions of life control.

The development of persistent pain and psychological morbidity after motor vehicle collision: integrating the potential role of stress response systems into a biopsychosocial model

OBJECTIVES

Persistent pain and psychological sequelae are common after motor vehicle collision (MVC), but their etiology remains poorly understood. Such common sequelae include whiplash-associated disorders (WAD), fibromyalgia, and posttraumatic stress disorder (PTSD). Increasing evidence suggests that these disorders share overlapping epidemiologic and clinical features. A model is proposed in which central neurobiological systems, including physiologic systems and neuroanatomical structures involved in the stress response, are an important substrate for the development of all 3 disorders and interact with psychosocial and other factors to influence chronic symptom development.

METHODS

Epidemiologic and clinical characteristics regarding the development of these disorders after MVC are reviewed. Evidence suggesting a role for stress response systems in the development of these disorders is presented.

RESULTS

Contemporary evidence supports a model of chronic symptom development that incorporates the potential for interactions between past experience, acute stress responses to trauma, post-MVC behavior, and cognitive/psychosocial consequences to alter activity within brain regions which process pain and to result in persistent pain, as well as psychological sequelae, after MVC. Such a model incorporates factors identified in prior biopsychosocial theories and places them in the landscape of our rapidly developing understanding of stress systems and CNS pain-modulating pathways.

CONCLUSION

New models are needed to stimulate deeper examination of the interacting influences of initial tissue damage, acute pain, psychosocial contingencies, and central stress pathways during chronic symptom development after MVC. Deeper understanding could contribute to improved treatment approaches to reduce the immense personal and societal burdens of common trauma-related disorders.

Fibromyalgia after motor vehicle collision: evidence and implications

OBJECTIVE

Assess currently available evidence regarding the ability of a motor vehicle collision (MVC) to trigger the development of fibromyalgia (FM).

METHODS

Consensus standards developed by the American College of Rheumatology Environmental Disease Study Group were used to assess the ability of an MVC to trigger FM.

RESULTS

Increasing evidence suggests that FM and related disorders are characterized by abnormalities in central nervous system function related to sensory processing, autonomic regulation, and neuroendocrine function. MVC trauma appears capable of triggering FM, but generally not through direct biomechanical injury. Instead, the evidence suggests that MVC trauma can act as a "stressor," which in concert with other factors, such as an individual's biologic vulnerability, psychosocial factors, cultural factors, and so on, may result in the development of chronic widespread pain and other somatic symptoms. MVC trauma is only one of many stressors which can trigger such disorders, and the environment within which the stressor is experienced (biological and psychosocial) may largely determine whether there is an adverse physiologic result or not.

CONCLUSIONS

The evidence that MVC trauma may trigger FM meets established criteria for determining causality, and has a number of important implications, both for patient care, and for research into the pathophysiology and treatment of these disorders.

Physical and psychological factors predict outcome following whiplash injury

Predictors of outcome following whiplash injury are limited to socio-demographic and symptomatic factors, which are not readily amenable to secondary and tertiary intervention. This prospective study investigated the predictive capacity of early measures of physical and psychological impairment on pain and disability 6 months following whiplash injury. Motor function (ROM; kinaesthetic sense; activity of the superficial neck flexors (EMG) during cranio-cervical flexion), quantitative sensory testing (pressure, thermal pain thresholds, brachial plexus provocation test), sympathetic vasoconstrictor responses and psychological distress (GHQ-28, TSK, IES) were measured in 76 acute whiplash participants. The outcome measure was Neck Disability Index scores at 6 months. Stepwise regression analysis was used to predict the final NDI score. Logistic regression analyses predicted membership to one of the three groups based on final NDI scores (<8 recovered, 10-28 mild pain and disability, >30 moderate/severe pain and disability). Higher initial NDI score (1.007-1.12), older age (1.03-1.23), cold hyperalgesia (1.05-1.58), and acute post-traumatic stress (1.03-1.2) predicted membership to the moderate/severe group. Additional variables associated with higher NDI scores at 6 months on stepwise regression analysis were: ROM loss and diminished sympathetic reactivity. Higher initial NDI score (1.03-1.28), greater psychological distress (GHQ-28) (1.04-1.28) and decreased ROM (1.03-1.25) predicted subjects with persistent milder symptoms from those who fully recovered. These results demonstrate that both physical and psychological factors play a role in recovery or non-recovery from whiplash injury. This may assist in the development of more relevant treatment methods for acute whiplash.

The Potential of Treatment Matching for Subgroups of Patients With Chronic Pain

A large and diverse number of treatments have been shown to be effective in reducing pain and other symptoms for a minority but statistically significant number of patients in different chronic pain syndromes. The means by which such different treatments achieve similar outcomes is not well understood. In this paper, the importance of considering patient heterogeneity for those who may be diagnosed with the same medical syndrome is discussed. The author suggests that the lack of satisfactory treatment outcomes for the treatments of chronic pain syndromes may be accounted for by the patient homogeneity myth--the assumption that all patients with the same medical diagnosis are similar on all important variables. The importance of subdividing (splitting) patients into meaningful groups is described. Studies presenting data on the identification of patient subgroups based on psychosocial and behavioral characteristics and the reliability and validity of this approach are presented. Some initial attempts to demonstrate the potential for matching treatments to patient subgroups are described.

Exacerbation of Chronic Pain following Spinal Cord Injury

Because of the high prevalence and the refractory nature of pain following spinal cord injury (SCI), it is important to increase the understanding of what factors aggravate different types of pain. This information is related to pain generating mechanisms and may thus be useful in the diagnosis and management of these difficult pain conditions. The aims of the present study were to (1) identify variables (factors) that exacerbate chronic pain associated with SCI and (2) define the relationships among these patterns of pain exacerbation, specific pain characteristics, and psychological features. A sample out of 159 (75.5%) people with SCI and chronic pain, volunteered to participate in a mail survey. Over 50% of the sample indicated that prolonged sitting, infections, fatigue, muscle spasms, cold weather, and sudden movements exacerbated their pain. A principal components analysis detected five sets of factors that were reported to magnify pain: negative mood, prolonged afferent activity (bowel, bladder, somatic), weather, voluntary physical activity, and transient somatic afferent activity. Negative mood and prolonged afferent activity were frequently and significantly associated with both pain characteristics and psychosocial issues. A multiple regression analysis revealed that a combination of decreased activity levels due to pain (t = 3.54; p < 0.001), pain located in the frontal aspects of torso (including genitals) (t = 2.29; p < 0.05), "burning" (t = 2.26; p < 0.05), or "electric" (t = 2.09; p < 0.05) pain, and a limited perception of life control (t = -2.16; p < 0.05) was significantly associated with a high extent of pain aggravation (R2 = 0.39; p < 0.000).

Catastrophizing and perceived partner responses to pain

This study examined the relationship between catastrophizing and patient-perceived partner responses to pain behaviors. The Catastrophizing subscale of the Cognitive Coping Strategy Inventory and the West Haven-Yale Multidimensional Pain Inventory were completed by 62 adult chronic pain patients. Consistent with past research, catastrophizing and patient-perceived solicitous partner behaviors were positively correlated with negative pain outcomes. The communal coping theory of catastrophizing suggests that catastrophizing might be undertaken to solicit support and empathy from others. However, catastrophizing was not related to perceived solicitous partner behavior in this study. Rather, catastrophizing was associated with perceived punishing partner responses. Implications are that catastrophizing and perceived solicitous partner behaviors are independently associated with pain and that catastrophizing may not be reinforced by empathy from significant others.

Stability of patient adaptation classifications on the multidimensional pain inventory

This study examined the adaptational classification stability of the multidimensional pain inventory (MPI) in two samples of female fibromyalgia syndrome patients. Retest resulted in one-third of patients being assigned to a different classification. Twenty patients had four repeated MPI assessments over a 10-month period; 85% of them changed classification at least once. Prediction of classification stability using demographic variables and measures of pain, depression, anxiety, impression management, and self-deception was unsuccessful. Examination of the MPI Variable Response Scale and an index of the goodness of fit of the cluster for each patient did not yield sufficient predictive power. The implication of this study is that for a sizable number of chronic pain patients, MPI classifications may not be stable, trait-like characterizations. As such, caution must be applied when treatment is tailored to MPI clusters and when classification change is used as an outcome measure.

Comparison of the Redundancy, Reliability, and Responsiveness to Change Among SF-36, Oswestry Disability Index, and Multidimensional Pain Inventory

OBJECTIVE

To compare the Medical Outcomes Trust Short-Form-36 (SF-36), the Multidimensional Pain Inventory (MPI), and the Oswestry Disability Index (ODI) measures on internal consistency, domain overlap, and responsiveness in detecting changes following multidisciplinary pain treatment.

METHODS

424 patients with chronic pain referred to a multidisciplinary pain center were assessed. Of these, 87 patients were assessed prior to and following treatment. Cronbach's alphas were calculated for each SF-36 and MPI domain, and for the ODI. Canonical correlation and regression analyses (R2) described overlap. Responsiveness to change was computed from treatment effect size and significance.

RESULTS

Cronbach's alpha ranged from 0.69-0.92 for MPI domains, from 0.79-0.91 for SF-36 domains, and was 0.86 for the ODI. Three domains overlapped but several were unique (eg, the MPI "significant other" domains; R2 range 0.03-0.16). Significant changes following treatment were observed for the MPI Pain Severity, Interference and Outdoor Work Activities, the SF-36 Physical and Social Functioning, Bodily Pain, and the ODI.

CONCLUSION

The MPI, SF-36, and ODI each have good psychometric properties. Three domains overlapped between the MPI and the SF-36: pain, Interference/Social functioning, and mental health. The MPI and the SF-36 each contributed unique domains such as the SF-36 General Health and Vitality domains and the MPI "significant other" and physical activity domains. Several of the MPI domains were among the most sensitive to change. Because of its large normative sample and samples of patients with diverse medical disorders, the SF-36 may be particularly useful to compare chronic pain patients to those with other medical conditions. The ODI has the lowest respondent burden. The MPI and SF-36, although containing much overlapping information, both make unique and complementary contributions to assessing patients with chronic pain.

The possibility to use simple validated questionnaires to predict long-term health problems after whiplash injury

STUDY DESIGN

A prospective follow-up study.

OBJECTIVES

To evaluate the relation of the state of health before the accident and the significance of the symptoms reported soon after the injury to the situation 3 years after the injury. To evaluate the possibility of using simple validated questionnaires to predict long-term health problems after the injury.

SUMMARY OF BACKGROUND DATA

A whiplash injury is generally benign in its natural course. However, some of the patients have diverse and prolonged symptoms. Although several prognostic factors have been suggested for the poor recovery, in most cases the factors leading to prolonged disability remain unclear.

METHODS

In collaboration with traffic insurance companies, we gathered information of neck injuries that occurred in traffic accidents in Finland in 1998. After the insurance company received a notification of a neck injury and consent from the injured party to participate in the study, they sent the information to the research team. The first inquiry was sent to the patients as soon as possible. One- and three-year follow-up questionnaires were posted to those who responded to the first inquiry. A total of 144 persons returned the 3-year follow-up questionnaires and form the material of this study. RESULTS A poor state of health or frequent neck pain or headache before the accident did not have any significant relation to the poor outcome 3 years after the accident. The extent of neck pain and lower back pain reported soon after the accident was significantly associated to a poor outcome in the follow-up. The Neck Disability Index questionnaire was significantly related to the poor outcome after 3 years.

CONCLUSIONS

The subjective experience of a notably decreased level of activity because of the neck pain when supplemented by the enhanced score of Neck Disability Index questionnaire predicts well poor outcome in long-term follow-up and can be used as a tool to identify persons who are at risk to suffer long-term health problems after whiplash injury.

Psychosocial Profiles of People With Pain Associated With Spinal Cord Injury

OBJECTIVES

The objectives of the study were to: (1) identify psychosocial profiles of people with pain associated with spinal cord injuries (SCI), and (2) compare the psychosocial profiles with other chronic pain syndromes.

METHODS

History questionnaires and the Multidimensional Pain Inventory (MPI) were mailed to 159 persons with chronic pain and SCIs (SCICP) and 120 (75.5%) agreed to participate.

RESULTS

Cluster analysis of MPI scores identified 2 subgroups of SCICP. One (42.5%) was characterized by high Pain Severity (PS), Affective Distress (AD), Life Interference (LI), and low Life Control (LC) similar to a previously identified cluster labeled Dysfunctional. The second (57.5%) was characterized by low PS, AD, LI, and high levels of LC and activity (GA), similar to the Adaptive Copers (AC) cluster identified in previous studies with the exception that the scores were lower on Support (S), Solicitous Responses (SR), and Negative Responses (NR) and higher on Distracting Responses (DR). Both subgroups were similar to those observed in other chronic pain syndromes (CPSs). People with SCIs differed significantly from heterogeneous chronic pain and chronic headaches in that they indicated less inference of pain with activities. They also scored lower on S. SCICP reported comparable levels of LI, LC, AD, S, SR, but greater levels of PS compared with a group of people with post-polio syndrome.

DISCUSSION

The similarities and differences between SCI and other CPSs suggest that although a general measure assessing psychosocial impact can be used across pain syndromes, it is important to use different norms for comparison of particular pain syndromes. The failure to identify a subgroup of patients characterized by low levels of S and high levels of NR, and the low SR and DR for SCICP compared with other CPSs warrants examination.