Whiplash in Australia: illness or injury?

Why Are Women with Fibromyalgia so Stigmatized?

INTRODUCTION

Many female pain sufferers with medically unexplained pain are at risk of being stigmatized in our Western society. Fibromyalgia is offered as the exemplar condition.

AIM

To understand why these women are being stigmatized.

METHODS

A review of the recent literature was conducted with a focus on the perceptions of women with a diagnosis of fibromyalgia who have been stigmatized.

RESULTS

Three intertwined themes emerged as contributing to their stigmatization: moralizing attitudes, disbelief as to the reality of pain, and pain's invisibility.

CONCLUSION

Given how embedded the factors responsible for the stigmatization of women with fibromyalgia in Western society are, the realistic prospects for addressing this issue are poor.

The notion of a "whiplash culture": a review of the evidence

OBJECTIVE

Most whiplash patients eventually recover, although some are left with ongoing pain and impairment. Why some develop long-term symptoms after whiplash, whereas others do not, is largely unknown. One explanation blames the cultural expectations of the population wherein the injury occurred, engendering the moniker whiplash culture. The purpose of this review was to locate and discuss studies that were used as a basis for developing the whiplash culture concept and to evaluate its plausibility.

METHODS

The PubMed database was searched using combinations of the terms whiplash culture, whiplash OR WAD, and chronic OR late OR long term. Search dates spanned from 1950 to June 2008. Filters were set to only retrieve English-language citations. Articles that dealt with the whiplash culture were selected and examined to determine which studies had been used to create the concept.

RESULTS

Nineteen articles discussed the cultural aspects of whiplash and were explored to determine which were used as a basis for the whiplash culture. Eight studies were found that met this final criterion.

CONCLUSION

There are many unanswered questions about the basis of chronic whiplash, and the notion of a whiplash culture is controversial. Chronic whiplash symptoms are surely not caused entirely by cultural issues, yet they are probably not entirely physical. Presumably, a tissue injury component exists in most chronic whiplash-associated disorder victims that becomes aggravated in those who are susceptible to biopsychosocial factors. As with many other controversial health care topics, the answer to the debate probably lies somewhere in the middle.

Cervicogenic headache: a review comparison with migraine, tension-type headache, and whiplash

Cervicogenic headache (CEH) is a well-recognized syndrome. Proposed diagnostic criteria differentiate CEH from migraine and tension-type headache (TTH) in most of the cases. The best differentiating factors include side-locked unilateral pain irradiating from the back and evidence of neck involvement--attacks may be precipitated by digital pressure over trigger spots in the cervical/nuchal areas or sustained awkward neck positions. Migrainous traits may be present in some cases. Cervical lesions are not necessarily seen, and most common cervical lesions do not produce CEH. Whiplash may occasionally induce headaches. This is suspected when the pain onset and the whiplash trauma are close in time. Whiplash-related headaches tend to be short-lasting, admitting mostly a TTH or a CEH-like phenotype. Neuroimaging abnormalities are not necessarily expected in CEH. Whiplash patients must undergo cervical imaging mostly in connection with the trauma, as no abnormalities are pathognomonic in chronic cases.

The immigrant patient having widespread pain. Clinical findings by physicians in Swedish primary care

AIM

Do the clinical findings explain the complaints of longstanding demonstrated widespread pain (DWP) in a group of immigrant patients, or not?

SUBJECTS

Consecutive immigrant patients, on long-term sick leave, aged 18 - 45, at a primary healthcare centre in Stockholm, Sweden.

METHODS

Interpreters were available. Two primary care physicians jointly, made a somatic status and diagnosed tender-structure locations (> or =3 tender-structure locations or less) and depression (yes or no), and assessed psychosocial stressors (little or much) and pain-related anxiety (yes or no). The patients pointed at their pain parts. This was transferred by one of the doctors to a pain drawing with 18 fields. Five or more fields were defined as DWP. Non-parametric tests were used to detect significant differences between the DWP and non-DWP groups. Cumulative frequencies of the following four categories of explanatory variables of DWP were counted: > or =3 tender-structure locations (could also include the other variables), much psychosocial stress (could include depression and pain-related anxiety), depression (could include pain-related anxiety), or pain-related anxiety alone.

RESULTS

Many of the 49 men and 100 women, on average 38 years, spoke little or no Swedish. A fifth of the men (n = 10) and half (n = 56) of the women had DWP. These men often had much stress (p < 0.01) while the women had > or =3 tender-structure locations (p < 0.001). DWP among men was explained to 100% by: > or =3 tender-structure locations (30%), much psychosocial stress (60%), or depression alone (10%). DWP among the women was explained to 96 cum. % by: > or =3 tender-structure locations (59%), much psychosocial stress (25%), or pain-related anxiety alone (13%).

CONCLUSION

Demonstrated widespread pain was nearly always explained by clinical findings, and especially by numerous tender-structure locations in women. There is a need for more studies among men.

Whiplash injury

This review discusses the causes, outcome and prevention of whiplash injury, which costs the economy of the United Kingdom approximately £3.64 billion per annum. Most cases occur as the result of rear-end vehicle collisions at speeds of less than 14 mph. Patients present with neck pain and stiffness, occipital headache, thoracolumbar back pain and upper-limb pain and paraesthesia. Over 66% make a full recovery and 2% are permanently disabled. The outcome can be predicted in 70% after three months.

[Problems involved in expert opinions on acceleration injuries of the cervical spine]

Reasons for problems in stating an expert opinion on acceleration injuries of the cervical spine are numerous. The presence of unexpected or the absence of expected symptoms, the lack of objective proof for alterations or the presence of complaints that are difficult to prove, the discrepancy between recognizable force of the impact versus the resulting damage to the injured as well as the chance of being completely incapable of rendering proof that unquestionably a potentially damage-causing event is--beyond any reasonable doubt--the origin of an observed alteration in an injured individual are some of the problems a medical expert has to face when dealing with the analysis of injuries of the cervical spine. Unsatisfactory documentation in the patient's records, discussions about the reliability of diagnostic means or the interpretation of their results, difficult to procure evidence of accident-specific biomechanics and their direct or indirect impact on the body or neck of the injured person as well as distinguishing cervical sprain from mild brain damage, post-traumatic distress syndrome, cognitive disorder, psychiatric disease, aggravation, or malingering makes it hard for an expert to state an expert opinion.

Stabilizing effect of precontracted neck musculature in whiplash

STUDY DESIGN

This study investigated the effect of neck muscle precontraction in aware occupants in whiplash. Head angulation relative to T1 and facet joint capsular ligament distractions were compared between aware and unaware occupants.

OBJECTIVE

To quantify changes in facet joint capsular ligament distractions between aware occupants with precontracted neck muscles and unaware occupants with reflex muscle contraction.

SUMMARY OF BACKGROUND DATA

Clinical studies have reported that patients aware of the impending impact had decreased symptom intensity and faster recovery after whiplash. To date, no study has investigated the effects of precontracted neck musculature on localized spinal soft tissue distortions in whiplash.

METHODS

Aware occupants with precontracted neck muscles and unaware occupants with reflex muscle contraction in whiplash were simulated using a validated computational model. Muscle contraction attained maximum levels before impact in the aware occupant and implemented reflex delay, electromechanical delay, and finite muscle rise time in the unaware occupant.

RESULTS

Precontraction of neck muscles in aware occupants resulted in 63% decreased maximum head angles, elimination of cervical S-curvature, and up to 75% decrease in maximum facet joint capsular ligament distractions.

CONCLUSIONS

Occupants aware of an impending whiplash impact with precontracted neck muscles can markedly reduce overall head-neck and spinal motions. It is our theory that this would reduce whiplash injury likelihood.

Persistent myalgia following whiplash

Persistent myalgia following whiplash is commonly considered the result of poor psychosocial status, illness behavior, or failing coping skills. However, there is much evidence that persistent myalgia may be due to neurophysiologic mechanisms involving peripheral and central sensitization. Myofascial trigger points may play a crucial role in maintaining sensitization. Recent research suggests that the chemical environment of myofascial trigger points is an important factor. Several consequences are reviewed when central pain mechanisms and myofascial trigger points are included in the differential diagnosis and in the management of patients with persistent pain following whiplash.

In vivo study of nerve movement and mechanosensitivity of the median nerve in whiplash and non-specific arm pain patients

Chronic pain following whiplash injury and non-specific arm pain (NSAP, previously termed diffuse repetitive strain injury) present clinicians with problems of diagnosis and management. In both patient groups there are clinical signs of altered nerve movement and increased nerve trunk mechanosensitivity. Previous studies of NSAP patients have identified altered median nerve movement at the wrist. The present study uses high frequency ultrasound imaging to examine changes to median nerve movement and clinical examination to assess altered mechanosensitivity of the median nerve. Longitudinal median nerve movement was measured in the forearm during maximal inspiration in nine post-whiplash patients with chronic neck and arm pain and eight controls subjects. Eight NSAP patients and seven controls were also studied. Transverse median nerve movement at the proximal carpal tunnel during 30 degrees wrist extension to 30 degrees flexion was also measured. A clinical examination of nerve trunk allodynia was performed in all subjects. Longitudinal nerve movement in the forearm was reduced by 71% in the post-whiplash patients and by 68% in NSAP patients compared to controls. In the whiplash patients the pattern of transverse median nerve movement at the proximal carpal tunnel was significantly different to controls (patient mean=2.57+/-0.80 mm (SEM) in a radial direction; control mean=0.39+/-0.52 mm in an ulnar direction). Signs of neural mechanosensitivity (i.e. painful responses to median nerve trunk and brachial plexus pressure and stretch) were apparent in both patients groups. Change in nerve tension and neural mechanosensitivity may contribute to symptoms in whiplash and NSAP patients.

Chronic Post-Traumatic Neck and Head Pain

OBJECTIVE

This is a review of current concepts of chronic post-traumatic neck and head pain. In this article, I will emphasize the physiological and sociological aspects of these disorders.

BACKGROUND

The pathophysiology of chronic post-traumatic neck and head pain has not been well understood. Some have emphasized the organic factors and others the psychogenic aspects of these conditions. Only in recent years have this dichotomy been integrated with sociocultural concepts.

METHODS

The history of chronic post-traumatic head and neck pain is reviewed. Paradoxes are discussed, ie, the great differences in prevalence around the world, the inconsistent relationship of symptoms to degree of trauma, the curious phenomena of structural disease without symptoms, and symptoms without structural disease. The organic and pathophysiologic factors are reviewed, then those factors that modulate pain in these conditions are discussed.

CONCLUSION

Chronic post-traumatic neck and head pain is rarely either organic or psychogenic. Rather physiological, social, and cultural factors play major roles in modulating pain and either perpetuate or ameliorate these chronic pain conditions.

Clinical Research. Effect of whiplash injury on accommodation

BACKGROUND

Accommodative disturbance has been cited as one of the causes of visual disturbance following whiplash injury but to date, with one exception, none of the studies have incorporated a group of control subjects; none of the results have been statistically analysed. The aim of the present study was to examine the amplitude of accommodation in a group of whiplash subjects, the majority of whom had specifically complained of visual/ocular symptoms.

METHODS

The whiplash group consisted of 19 subjects and the control group consisted of 43 subjects. The amplitude of accommodation of the right and left eyes of the whiplash and control group subjects was measured and the results of the two groups compared.

RESULTS

There was reduced amplitude of accommodation of the right (P = 0.02) and left (P = 0.02) eyes in the whiplash group subjects compared to the control group subjects.

CONCLUSION

These results indicate that whiplash was associated with defective accommodation in the present select group of whiplash subjects.

Whiplash associated disorders: a review of the literature to guide patient information and advice

OBJECTIVES

To review the literature and provide an evidence based framework for patient centred information and advice on whiplash associated disorders.

METHODS

A systematic literature search was conducted, which included both clinical and non-clinical articles to encompass the wide range of patients' informational needs. From the studies and previous reviews retrieved, 163 were selected for detailed review. The review process considered the quantity, consistency, and relevance of all selected articles. These were categorised under a grading system to reflect the quality of the evidence, and then linked to derived evidence statements.

RESULTS

The main messages that emerged were: physical serious injury is rare; reassurance about good prognosis is important; over-medicalisation is detrimental; recovery is improved by early return to normal pre-accident activities, self exercise, and manual therapy; positive attitudes and beliefs are helpful in regaining activity levels; collars, rest, and negative attitudes and beliefs delay recovery and contribute to chronicity. These findings were synthesised into patient centred messages with the potential to reduce the risk of chronicity.

CONCLUSIONS

The scientific evidence on whiplash associated disorders is of variable quality, but sufficiently robust and consistent for the purpose of guiding patient information and advice. While the delivery of appropriate messages can be both oral and written, consistency is imperative, so an innovative patient educational booklet, The Whiplash Book, has been developed and published.

Pain management in the opioid-dependent patient

The opioid-dependent patient presents great challenges for pain management. These challenges are not limited to potential addictive behaviors. In contrast to the profound pain relieving effects of acute opioid intake, chronic opioid intake can promote a counterintuitive state of enhanced pain sensitivity. Multiple biologic mechanisms inducing opioid tolerance and hyperalgesia have recently been elucidated. The potential hyperalgesic state accompanying opioid dependence complicates pain management somewhat for acute pain and cancer pain, but it especially does so for chronic pain. Guidelines for treatment of opioid dependence in the pain patient are proposed. Treatment oriented toward the long term requires limit setting and psychologic support that go beyond simple medication management.

Biomechanics of the cervical spine Part 3: minor injuries

Minor injuries of the cervical spine are essentially defined as injuries that do not involve a fracture. Archetypical of minor cervical injury is the whiplash injury. Among other reasons, neck pain after whiplash has been controversial because critics do not credit that an injury to the neck can occur in a whiplash accident. In pursuit of the injury mechanism, bioengineers have used mathematical modelling, cadaver studies, and human volunteers to study the kinematics of the neck under the conditions of whiplash. Particularly illuminating have been cinephotographic and cineradiographic studies of cadavers and of normal volunteers. They demonstrate that externally, the head and neck do not exceed normal physiological limits. However, the cervical spine undergoes a sigmoid deformation very early after impact. During this deformation, lower cervical segments undergo posterior rotation around an abnormally high axis of rotation, resulting in abnormal separation of the anterior elements of the cervical spine, and impaction of the zygapophysial joints. The demonstration of a mechanism for injury of the zygapophysial joints complements postmortem studies that reveal lesions in these joints, and clinical studies that have demonstrated that zygapophysial joint pain is the single most common basis for chronic neck pain after injury.

Chronic pain disorder following physical injury

Pain disorders that are primarily associated with psychological factors are of great clinical concern, but they are difficult to study because of the inability to make valid or reliable diagnoses by structured interview alone. The authors confront this difficulty by using an injured subject population that had extensive psychiatric and medical evaluations. Those who developed somatoform pain disorder (SPD) were compared with a control group who did not. The SPD group had distinctive associated factors: more sites of pain, spread of pain beyond area of original injury, and substantially more opiate and benzodiazepine use. Compensation/litigation influenced symptoms more in the SPD group. Psychotherapists often supported the patient's viewpoint that the pain was physical and to be endured.

Cervicogenic headache: a comparison with migraine and tension-type headache

Cervicogenic headache (CEH) is a neck-generated headache syndrome. Attacks may be similar to migraine (M) or tension-type headache (TTH). In order to test the accuracy of the IHS diagnostic criteria for M and episodic TTH and of the criteria for CEH of Sjaastad et al., 33 CEH, 65 M, and 29 TTH were evaluated according to the CEH criteria, and CEH patients were tested for M and TTH according to the IHS criteria. Only 30% of the CEH patients met the criteria for M, 3% met the criteria for TTH, and 66% were neither M nor TTH. The mean number of criteria met, sex, age, and age of onset were also analysed, and the results indicate an inequality among these three headache types. The most important differentiating aspects were the site and radiation of the pain, the temporal pattern, and the induction of attacks from neck posture, movements, and/or digital pressure. CEH clearly differs from M and TTH. Existing criteria adequately distinguish the three headaches.

A comparison of economic and social reward in patients with chronic nonmalignant back pain

OBJECTIVE

Patients with chronic nonmalignant back pain are often exposed to multiple sources of economic and social reward. At issue in the present study was whether these rewards are 1) correlated with similar or dissimilar outcome variables and 2) able to account for unique variance in regression models of illness behavior.

METHODS

A 2 x 2 factorial design was used in which patients were retrospectively assigned to one of four independent groups: low economic/low social reward, low economic/high social reward, high economic/low social reward, and high economic/high social reward. Of 265 consecutive patients enrolled at a tertiary pain service, 75 met eligibility criteria and had chronic nonmalignant back pain.

RESULTS

Preexisting differences in health status were not associated with differences in illness behavior or pain ratings. With social reward held constant, patients in the high economic reward group missed more days from work (p < .005), had more domestic disability (p < .05), and were more depressed (p < .05) than patients in the low economic reward group. With economic reward held constant, patients in the high social reward group missed more days from work (p < .05), had more domestic disability (p < .01), and were more depressed (p < .01) than patients in the low social reward group. Unlike patients in the high economic reward group, however, patients in the high social reward group had higher levels of pain (p < .05) and more nonspecific medical complaints (p < .01).

CONCLUSIONS

Economic and social rewards were both associated with increased disability and depression, but only social rewards were associated with increased symptom reporting. Exposure to economic and social rewards may account for unique variance in illness behavior that cannot be explained by differences in medical diagnosis, symptom duration, pain intensity, depression, or somatization.

Chronic neck syndromes: an update

Chronic neck pain syndromes are recognized as myofascial disorders in the main. Often such syndromes follow trauma, and there are significant psychological and secondary gain issues that impact on the outcome of therapy. Comparison with cervical radicular syndromes is discussed.

A review and methodologic critique of the literature refuting whiplash syndrome

The validity of whiplash syndrome has been a source of debate in the medical literature for many years. Some authors have published articles suggesting that whiplash injuries are impossible at certain collision speeds; others have stated that the problem is psychological, or is feigned as a means to obtain secondary financial gain. These articles contradict the majority of the literature, which shows that whiplash injuries and their sequelae are a highly prevalent problem that affects a significant proportion of the population. The authors of the current literature critique reviewed the biomedical and engineering literature relating to whiplash syndrome, searching for articles that refuted the validity of whiplash injuries. Twenty articles containing nine distinct statements refuting the validity of whiplash syndrome were found that fit the inclusion criteria. The methodology described in these articles was evaluated critically to determine if the authors' observations regarding the validity of whiplash syndrome were scientifically sound. The authors of the current critique found that all of the articles contained significant methodologic flaws with regard to their respective authors' statements refuting the validity of whiplash syndrome. The most frequently found flaws were inadequate study size, nonrepresentative study sample, nonrepresentative crash conditions (for crash tests), and inappropriate study design. As a result of the current literature review, it was determined that there is no epidemiologic or scientific basis in the literature for the following statements: whiplash injuries do not lead to chronic pain, rear impact collisions that do not result in vehicle damage are unlikely to cause injury, and whiplash trauma is biomechanically comparable with common movements of daily living.

Sick leave and disability pension among passenger car occupants injured in urban traffic

STUDY DESIGN

A follow-up cohort study of passenger car occupants injured in car crashes in an urban area in Sweden.

OBJECTIVES

To analyze the injuries, injury events, and long-term consequences of injuries in car crashes.

SUMMARY OF BACKGROUND DATA

The consequences of car crashes usually are described in terms of the number of people injured, the severity of injuries, or the number of inpatient days. Certain types of crash injuries can results in long-term sick leave and granting of disability pension. The increased socioeconomic significance of these outcomes is not always indicated by analysis of commonly used variables.

METHODS

Two hundred fifty-five passenger car occupants aged 16-64 years who were injured in car crashes in urban traffic were analyzed in terms of length of sick leave and receipt of disability pension.

RESULTS

Strain of the cervical spine was the most common type of injury (55%, 141 injuries), and these injuries accounted for 82% of all sick leave taken within 2.5 years after the injury event. Injury to the cervical spine in 16 of 18 cases resulted in long-term sick leave or dependence on disability pension. The most common injury mechanism was rear-end collisions (39%). This type of crash resulted in 64% of all sick-leave days within 2.5 years after the injury event. Twelve out of 18 injured people on long-term sick leave or receiving disability pension had been in cars struck from behind.

CONCLUSIONS

It is important to include long-term consequences in the form of sick leave and disability pension when describing the consequences of different types of car crashes and injuries.

Cervicogenic headache. Josey's cases revisited

Before Sjaastad coined the term cervicogenic headache (CR) 15 years ago, neck-related headaches have been considered by different authors for many years. Even after the publication of diagnostic criteria, dispute on the clinical picture, differential diagnosis, pathophysiology and treatment of CR still persists. A paper published in 1949 by Josey reports on 6 "illustrative" cases of cervical-related headaches. Indeed, looked from a more recent perspective, those cases could eventually correspond to CH. Important topics such as the relatively high frequency, fixed unilaterality of the pain, relation to previous trauma, irradiation from the back to the forehead, normal or slightly abnormal roentgenograms, and the mechanical precipitation of attacks are some of the topics considered by Josey. The female gender was not prevalent in Josey's series. Traction and analgesics were basically the recommended treatment. CR is probably a common disorder, an idea already considered by a clinician in 1949. This syndrome was not adequately described before Sjaastad's group papers in the 80's.

Natural evolution of late whiplash syndrome outside the medicolegal context

BACKGROUND

In Lithuania, few car drivers and passengers are covered by insurance and there is little awareness among the general public about the potentially disabling consequences of a whiplash injury. We took this opportunity to study the natural course of head and neck symptoms after rear-end car collisions.

METHODS

In a retrospective questionnaire-based cohort study, 202 individuals (157 men; 45 women) were identified from the records of the traffic police department in Kaunas, Lithuania. These individuals were interviewed 1-3 years after experiencing a rear-end car collision. Neck pain, headache, subjective cognitive dysfunction, psychological disorders, and low back pain in this group were compared with the same complaints in a sex-matched and age-matched control group of uninjured individuals selected randomly from the population register of the same geographic area.

FINDINGS

Neck pain was reported by 71 (35% [95% CI 29-42]) accident victims and 67 (33% [27-40]) controls. Headache was reported by 107 (53% [46-60]) accident victims and 100 (50% [42-57]) controls. Chronic neck pain and chronic headache (more than 7 days per month) were also reported in similar proportions (17 [8.4%; 5-13] vs 14 [6.9%; 4-12] and 19 [9.4%; 6-15] vs 12 [5.9%; 3-10]) by the two groups. Of those who reported chronic neck pain or daily headache after the accident, substantial proportions had had similar symptoms before the accident (7/17 for chronic neck pain; 10/12 for daily headache). There was no significant difference found. No one in the study group had disabling or persistent symptoms as a result of the car accident. There was no relation between the impact severity and degree of pain. A family history of neck pain was the most important risk factor for current neck symptoms in logistic regression analyses.

INTERPRETATION

Our results suggest that chronic symptoms were not usually caused by the car accident. Expectation of disability, a family history, and attribution of pre-existing symptoms to the trauma may be more important determinants for the evolution of the late whiplash syndrome.

Cervicogenic headache: a personal view

Cervicogenic headache describes pain referred along the upper three cervical roots and is a common source of headache in the over fifties. A review of clinical features, anatomy, and investigations using neural blockade shows several clinical pictures. Diseases of the cranio-vertebral junction, e.g. syringomyelia, and tonsilar descent, can produce mechanical or hydrodynamic head and neck pain. Pre-existent migraine and tension headache may be precipitated or aggravated by cervical spondylosis, but the anatomical mechanism is unclear. Headaches which arise from and are primarily caused by disorders in the cervical spine are exemplified by spondylosis and acute whiplash injury, but are usually transient. Evidence for a cervicogenic mechanism of chronic whiplash headache is, however, lacking.

Neck strain in car occupants: injury status after 6 months and crash-related factors

In this study, 29 individuals who sustained a neck strain as a result of a car crash were drawn from a group of physiotherapy and general practices and were followed up after 6 months. The aim was to examine relationships between the state of the neck injury at the time of follow up and crash-related factors, notably crash severity and occupant awareness. Crash severity was assessed by measurement of damage to the involved vehicles, while 6-month injury status was established through physical examinations and interviews. No statistically significant associations between crash severity and 6-month injury status were found, but subjects who were unaware of the impending collision had a greatly increased likelihood of experiencing persisting symptoms of and/or signs of neck strain, compared with those who were aware (odds ratio = 15.0; 95 per cent confidence limits: 1.8, 178). While the role of crash severity in the production and duration of neck strains remains unclear, awareness appears to have a strong protective influence and may prove to be a useful prognostic indicator in clinical settings.