Whiplash Injuries. Current State of Knowledge

Due to the rapid development of transport and a significant increase in the number of road users, whiplash injuries are a global health problem and a significant financial burden for both health care systems and insurance systems. The rich symptomatology of whiplash injuries with their impact on the somatic and emotional-behavioral sphere prompts us to define a new disease entity, namely Whiplash Associated Disorders (WAD). The mechanism of whiplash injury is still under debate and theories explaining the pathogenesis of WAD are very diverse, ranging from purely biomechanical and hydrostatic to neurophysiological, emphasizing sensitization and dysfunctional neuromodulation of pain after whiplash injuries. WAD syndrome should be understood more broadly than just cervical trauma, as problems specific to local legal cultures often determine both epidemiological indicators, the course of treatment and prognosis of the disease. There is a need for further research on the issue of whiplash considering inconsistent literature data about optimal rehabilitation after such injuries.

[Expert evidence in whiplash injury: interdisciplinary orthopaedic and biomechanical approach]

Considering the controversially discussed issue of whiplash injury a pragmatic approach based on our own experience in the area of forensic expert opinion is presented. Findings of accident analysis and biomechanics are correlated with the individual situation after the accident (initial clinical appearance), the course of the ailment and the indispensable physical examination. The latter leads to determination of the individual vulnerability (not increased/increased) which is important for the evaluation of the physical condition and estimation of the physical stress limit. These limits vary widely between individuals and must be considered carefully when relating dose and effect of accident severity to a possible physical injury. Determination of the accident severity is especially important when there are no objective signs of injury and the existence of a minor whiplash injury (Quebec Task Force degree 1 or 2) is in question.

[About the Geserick sign--a literature study]

Fractures of the medial and basal orbital wall as well as the petrous part of the temporal bone were described first in 1980 by a Berlin-based study group led by Geserick as new cranium findings resulting from a contrecoup mechanism. Experimental and comparative examinations revealed that indirect fractures of the orbital walls are caused by a coup action of the eyeballs, whereas the mechanogenesis of the petrous bone fractures continues to be unclear. The frequently combined occurrence with the orbital sign nonetheless permits an allocation to the contrecoup mechanism. Both signs are important criteria for forensic and clinical assessment of craniocerebral injuries.

[Definition, classification and epidemiology of whiplash]

A whiplash trauma is caused by an acceleration-deceleration force transferring its energy to the cervical spine. Whiplash-associated disorder (WAD) refers to the symptoms that develop after a whiplash injury. The prognosis is favorable with recovery in over 90% of the injured subjects. In a fraction of patients, long-term symptoms with pain and cognitive and emotional symptoms may occur, causing long-term disability. The pathophysiology is unclear. Most research groups favor a multifactorial pathophysiology similar to that observed for other chronic pain conditions without a clear nociceptive or neuropathic component.

[Using the term "whiplash" has no decisive influence for the prognosis: statistical misinterpretation]

A recent thesis that received much media attention recommended that the term "whiplash" be avoided, because causal beliefs connected to this term would have a major and detrimental effect on prognosis. Indeed, Buitenhuis et al. found a larger odds ratio for the causal belief scale compared with a measure of physical disability. However, their conclusion is based on a misinterpreted logistic regression analysis including continuous variables that differed in range. After correction, disability appeared to be more important for prognosis than the whiplash causal belief scale. This statistical misinterpretation illustrates that odds ratios and relative risks are not easily understood and therefore often misinterpreted.

[Whiplash injury--an update]

Whiplash injuries of the cervical spine are of paramount clinical and socioeconomic importance. To date, many problems in regard to diagnosis, classification, treatment and assessment have not been sufficiently solved. Diagnosis is often made subjectively and the ideal mode of treatment is still the subject of controversy. Scientific progress has lead to the development of a prognostic classification system, objective diagnostic tests, different treatment modalities and, perhaps most importantly, the production of more secure automobiles. Current scientific evidence of the assessment and treatment of whiplash injuries is only partially integrated into clinical routine, although modern strategies of combining medicamentous therapy with early physiotherapy has shown good results. Clear dignostic criteria and treatment guidelines would conquer the cost explosion associated with whiplash injuries largely evident in the Swiss-German population.

A comparison of Christiana Spine Center's whiplash patients' course of illness to the guidelines set forth by the Quebec Task Force for Whiplash Associated Disorders

In 1995, the Quebec Task Force on Whiplash Associated Disorders came out with guidelines for diagnosis and management of automobile related "whiplash" injuries to the neck. The task force reviewed the available literature and found it quite lacking, but nonetheless came up with a "best evidence synthesis" and based their recommendations on this. The purpose of this paper was to determine how frequently these guidelines were followed in a group of patients with whiplash who were referred to a spine specialist clinic in New Castle County, Delaware.

MRI study of the cross-sectional area for the cervical extensor musculature in patients with persistent whiplash associated disorders (WAD)

Cervical muscle function is disturbed in patients with persistent pain related to a whiplash associated disorder (WAD) but little is known about neck extensor muscle morphometry in this group. This study used magnetic resonance imaging to measure relative cross-sectional area (rCSA) of the rectus capitis posterior minor and major, multifidus, semispinalis cervicis and capitis, splenius capitis and upper trapezius muscles bilaterally at each cervical segment. In total, 113 female subjects (79 WAD, 34 healthy control; 18-45 years, 3 months-3 years post-injury) were recruited for the study. Significant main effects for differences in muscle and segmental level were found between the two groups (P < 0.0001) as well as a significant group * muscle * level interaction (P < 0.0001). The cervical multifidus muscle in the WAD group had significantly larger rCSA at all spinal levels and in contrast, there were variable differences in rCSA measures across levels in the intermediate and superficial extensor muscles when compared to the healthy controls (P < 0.0001). There were occasional weak, although statistically significant relationships between age, body mass index (BMI), duration of symptoms and the size of some muscles in both healthy control and WAD subjects (P < 0.01). It is possible that the consistent pattern of larger rCSA in multifidus at all levels and the variable pattern of rCSA values in the intermediate and superficial muscles in patients with WAD may reflect morphometric change due to fatty infiltrate in the WAD muscles. Future clinical studies are required to investigate the relationships between muscular morphometry, symptoms and function in patients with persistent WAD.

Classification of patients with whiplash associated disorders (WAD): reliable and valid subgroups based on the Multidimensional Pain Inventory (MPI-S)

BACKGROUND

Classification of patients with chronic whiplash associated disorders (WAD) into homogenous subgroups is an important objective in order to tailor interventions and to control for subgroup differences when evaluating treatment outcome.

AIMS

The aims of this study were to investigate if it was possible to replicate and describe the three cluster solution and profiles found in other pain groups and describe cluster profiles based on self-reported Multidimensional Pain Inventory-scores for patients with WAD three months after the injury, describe characteristics of the clusters in relation to disability, self-efficacy and coping at the same point in time and to validate the cluster solution by comparing clusters in disability, self-efficacy and coping over time.

METHODS

Ninety-one WAD-patients three months after the accident took part in the study. The measures used were the Multidimensional Pain Inventory-Swedish version (MPI-S), The Self-Efficacy Scale, The Coping Strategies Questionnaire and The Pain Disability Index. Cluster analysis was conducted for the total sample MPI-S subscale scores.

RESULTS

The adaptive copers cluster represented 42% of the sample, dysfunctional 34% of the sample, and interpersonally distressed 24% of the sample. The external validation of cluster solution showed that there were several significant differences between clusters in self-efficacy, disability and coping measures. There was also a significant interaction effect (clusterxtime) in disability (PDI). Patients in dysfunctional cluster reported a decreased disability over time.

CONCLUSIONS

These results support the presence of different subgroups among patients with whiplash associated disorders. This classification can be seen as a complement to a classification based on medical condition.

Whiplash injury. TOS and double crush syndrome. Forensic medical aspects

In this article the author wants to specify that the whiplash syndrome is underestimated, even by the specialists. In particular the complications aren't taken into correct consideration, above all if they concern the brachial plexus, especially regarding the TOS syndrome and double-crush syndrome. This is a problem also among the experts who have to make an evaluation in the field of insurance.

Classification of neck movement patterns related to whiplash-associated disorders using neural networks

This paper presents a new method for classification of neck movement patterns related to Whiplash-associated disorders (WAD) using a resilient backpropagation neural network (BPNN). WAD are a common diagnosis after neck trauma, typically caused by rear-end car accidents. Since physical injuries seldom are found with present imaging techniques, the diagnosis can be difficult to make. The active range of the neck is often visually inspected in patients with neck pain, but this is a subjective measure, and a more objective decision support system, that gives a reliable and more detailed analysis of neck movement pattern, is needed. The objective of this study was to evaluate the predictive ability of a BPNN, using neck movement variables as input. Three-dimensional (3-D) neck movement data from 59 subjects with WAD and 56 control subjects were collected with a ProReflex system. Rotation angle and angle velocity were calculated using the instantaneous helical axis method and motion variables were extracted. A principal component analysis was performed in order to reduce data and improve the BPNN performance. BPNNs with six hidden nodes had a predictivity of 0.89, a sensitivity of 0.90 and a specificity of 0.88, which are very promising results. This shows that neck movement analysis combined with a neural network could build the basis of a decision support system for classifying suspected WAD, even though further evaluation of the method is needed.

A proposed new classification system for whiplash associated disorders—implications for assessment and management

The development of chronic symptoms following whiplash injury is common and contributes substantially to costs associated with this condition. The currently used Quebec Task Force classification system of whiplash associated disorders is primarily based on the severity of signs and symptoms following injury and its usefulness has been questioned. Recent evidence is emerging that demonstrates differences in physical and psychological impairments between individuals who recover from the injury and those who develop persistent pain and disability. Motor dysfunction, local cervical mechanical hyperalgesia and psychological distress are present soon after injury in all whiplash injured persons irrespective of recovery. In contrast those individuals who develop persistent moderate/severe pain and disability show a more complex picture, characterized by additional impairments of widespread sensory hypersensitivity indicative of underlying disturbances in central pain processing as well as acute posttraumatic stress reaction, with these changes present from soon after injury. Based on this heterogeneity a new classification system is proposed that takes into account measurable disturbances in motor, sensory and psychological dysfunction. The implications for the management of this condition are discussed.

Diagnostik und Therapie akuter Beschwerden nach ?HWS-Distorsion? in Deutschland

Whiplash injury of the cervical spine is a relevant medical and socioeconomic problem, which is still the subject of controversy. We performed a survey to evaluate the current status of diagnostics, classification, treatment, and doctors' subjective opinions at surgical and trauma departments in Germany. A total of 1568 hospitals were addressed to answer a standardized questionnaire on their proceedings and opinions concerning whiplash injury. We received 540 (34.44%) completed questionnaires. There was overall agreement concerning the need for physical examination. The radiological assessment included an a.p. and a lateral plain X-ray of the cervical spine in 82.6%. The indication for functional X-rays in flexion/extension was inconsistent. On average they were performed in 39.1% of all patients. In most cases (68.9%) whiplash injury was not classified; 13.2% of doctors used the classification according to the Quebec Task Force and 13.9% according to Erdmann. A cervical collar was prescribed in 85%. While 30% of patients received only a cervical collar, 55.6% underwent additional physiotherapy. Only 8.3% were treated by physiotherapy without immobilization. The doctors' subjective opinions indicated psychological factors to be important for long-lasting problems, but not for the acute period of complaints. There is no homogeneous concept for diagnostics, classification, and treatment of patients who suffered a whiplash injury in Germany. This situation reflects the current problems in management of this condition. Scientific evidence for functional treatment to avoid adverse influence of immobilization by cervical collars has not yet been transferred to our daily routine in Germany.

Cervical whiplash syndrome. Hyperextension-hyperflexion injury

Cervical whiplash syndrome, or hyperextension-hyperflexion injury, is a common traumatic injury to the soft tissue structures around the cervical spine. The mechanisms of injury that cause cervical whiplash syndrome vary, yet they may be sufficient enough to cause cervical spine fracture, resulting in partial or complete neurologic deficit. The pathogenesis of cervical whiplash syndrome are presented.

[Occupational disease 2108. Degenerative changes of the cervical spine as a causality criterion in the assessment of discogenic diseases according to BeKV 2108]

With the second amendment to the Ordinance on Occupational Diseases (BeKV) of 18 December 1992, discogenic diseases of the spine are included in the disease register of occupational diseases for the first time. If occupations that impose stress on the spine have been practised for many years, the possibility exists of recognizing degenerative diseases as an occupational disease. In assessment practice, the radiological data on the spine exposed to stress is compared with that of regions which are remote from the stress (cervical/thoracic spine). This pattern of the distribution of degenerative disease is then used as the basis for determining a causal relationship between the occupation causing the stress and disease of the axial skeleton. The pattern of degeneration of the cervical spine was investigated in two groups, one with ( n =153) and one without ( n =333) occupations that impose stress on the lumbar spine. A cumulative score of degenerative changes was elaborated and presented as a new classification. No differences were found between the groups with regard to either the frequency of occurrence, segmental distribution or severity of disease. In both groups, degenerative changes correlated with age. The prevailing assessment practice is discussed on the basis of these data.

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

OBJECTIVE

To investigate the predictive capacity of the West Haven-Yale Multidimensional Pain Inventory (MPI) with regard to prolonged pain, using car occupants who had sustained a neck sprain in a traffic accident.

DESIGN

A prospective cohort study including a one-year follow-up.

PATIENTS

One hundred thirty adults were examined by a specialized neck-injury team after a first visit to an accident and emergency department. The subjects answered the MPI questionnaire within one month of the accident.

OUTCOME MEASURES

One year later, the patients answered a questionnaire about residual neck pain. The main outcome was determined by the question, "Do you have residual pain which you relate to the accident?"

RESULTS

One hundred twenty-three (95%) of the subjects completed the study. Ninety-seven reported pain of some degree that they related to the accident. All but one of the MPI variables differed significantly between the group with residual pain and the group without pain. The variable interference had the strongest correlation with the outcome. Its discriminative capacity was 81% for those with pain and 94% for those without pain one year later.

CONCLUSIONS

The MPI may be used at an early stage to identify patients who may develop chronic neck-pain after a traffic accident, at least in those who want a follow-up session after an initial visit to an accident and emergency department.

The Quebec classification and a new Swedish classification for whiplash-associated disorders in relation to life satisfaction in patients at high risk of chronic functional impairment and disability

Unlike the Quebec classification system, which is based primarily on pathoanatomy, a new Swedish classification system is based on the site of functional impairment and disability. A prospective study was performed on 85 patients with whiplash-associated disorders grade II according to the Quebec classification. The patients were examined 3-36 months following trauma. A team of professionals with different training performed the diagnostic procedure. An independent assessor classified these patients according to a Swedish classification system. All patients answered questionnaire regarding life satisfaction. Logistic regression demonstrated significant differences in 6 of 10 specific dimensions of life satisfaction between the classification categories C and D (presence of arm symptoms) in a Swedish classification. Patients with whiplash-associated disorders grade II and neuropsychological symptoms seem to have a worse prognosis for spontaneous recovery than those without. A new Swedish classification system seems to be an important complement to the Quebec classification.

Clinical practice guideline for the physiotherapy of patients with whiplash-associated disorders

STUDY DESIGN

A clinical practice guideline.

OBJECTIVES

To assist physiotherapists in decision making and to improve the efficacy and uniformity of care for patients with whiplash-associated disorders Grades I and II.

SUMMARY OF BACKGROUND DATA

Whiplash constitutes a considerable problem in health care. Many interventions are used in physiotherapy practice, despite increasing evidence for the use of active interventions. There is still no clinical practice guideline for the management of patients with whiplash-associated disorders. METHOD OF DEVELOPMENT: A computerized literature search of Medline, Cinahl, Cochrane Controlled Trial Register, Cochrane Database of Systematic Reviews, and the Database of the Dutch National Institute of Allied Health Professions was performed to search for information about the diagnostic process and the therapeutic process in whiplash patients. When no evidence was available, consensus between experts was achieved to develop the guideline. Practicing physiotherapists reviewed the clinical applicability and feasibility of the guideline, and their comments were used to improve it.

RECOMMENDATIONS

The diagnostic process consists of systematic history taking and a physical examination supported by reliable and valid assessment tools to document symptoms and functional disabilities. The primary goals of treatment are a quick return to normal activities and the prevention of chronicity. Active interventions such as education, exercise therapy, training of functions, and activities are recommended according to the length of time since the accident and the rate of recovery. The biopsychosocial model is used to address the consequences of whiplash trauma.

CONCLUSIONS

Scientific evidence for the diagnosis and physiotherapeutic management of whiplash is sparse; therefore, consensus is used in different parts of the guideline. The guideline reflects the current state of knowledge of the effective and appropriate physiotherapy in whiplash patients. More and better research is necessary to validate this guideline in the future.

Prognostic value of the Quebec Classification of Whiplash-Associated Disorders

STUDY DESIGN

Retrospective cohort.

OBJECTIVES

1) Evaluate the utility of the Québec Classification of Whiplash-Associated Disorders as an initial assessment tool; 2) assess its ability to predict persistence of symptoms at 6, 12, 18, and 24 months postcollision; 3) examine one potential modification to the Classification.

SUMMARY OF BACKGROUND DATA

In 1995, a task force from Québec, Canada, developed the Québec Classification of Whiplash-Associated Disorders to assist health care workers in making therapeutic decisions. The Classification was applied to an inception cohort of patients presenting for emergency medical care following their involvement in a rear-end motor vehicle collision.

METHODS

All patients (n = 446) presenting to the only two emergency departments serving Kingston, Ontario, between October 1, 1995 and March 31, 1998 were considered for inclusion in the study. Eligible patients (n = 380) were categorized according to the Classification based on signs and symptoms documented in their emergency medical chart. Attempts were made to interview all patients shortly following and again 6 months after their collision. Patients were contacted at 12, 18, and 24 months postinjury only if sufficient time had elapsed between recruitment into and cessation of the study. Data were gathered regarding symptoms, treatments received, effects on usual activities, crash circumstances, and personal factors. Associations between initial Classification grade and the frequency/intensity of follow-up symptoms were quantified via multivariable analyses.

RESULTS

The Classification was prognostic in that risk for Whiplash-Associated Disorders at 6, 12, 18, and 24 months increased with increasing grade. Analyses supported modification of the Classification to distinguish between Grade II cases of Whiplash-Associated Disorders with normal or limited range of motion. The greatest risk for long-term symptoms was seen among the group of patients with both point tenderness and limited range of motion.

CONCLUSION

The analyses of this study support the use of the Québec Classification of Whiplash-Associated Disorders as a prognostic tool for emergency department settings, and the authors propose a modification of the Classification using a subdivision of the Grade II category.

Whiplash injuries from car accidents in a Swedish middle-sized town during 1993-95

OBJECTIVE

To assess the incidence of whiplash associated disorders (WAD) after minor whiplash injuries in car accidents.

DESIGN

A cohort defined by means of a health-care-based registration of traffic injuries and followed up by postal questionnaire after 12 months.

SETTING

Primary and hospital care in a Swedish middle-sized town (approx. 80,000 inhabitants) during 2 years in the period 1993-1995.

MAIN OUTCOME MEASURES

Incidence of WAD, duration of symptoms and sick leave.

RESULTS

A total of 485 injured car occupants were identified; 158 had a WAD with no difference between the sexes. The incidence was estimated to be 1/1000 inhabitants and year. The response rate to the questionnaire was 79% (125/158). In 64 cases, symptoms lasted 6 weeks and in 30 cases more than 6 months. Forty individuals (32%) reported sick leave exceeding 4 weeks in 15 cases. Seven persons (5.6%) were still on sick leave at follow-up. The duration of symptoms and sick leave was similar for men and women.

CONCLUSION

Relatively few cases of WAD reported long-term sick leave. More cases reported chronic symptoms.

Late whiplash syndrome: a clinical and magnetic resonance imaging study

Cervical hyperextension injuries are common and are associated with significant morbidity. Clinically two syndromes are described: "acute" whiplash syndrome and "late" whiplash syndrome (in which the patients are still symptomatic after six months despite normal physical and radiological examination). In order to clarify the pathology of the persistent pain in late whiplash syndrome we performed a cervical spine magnetic resonance imaging (MRI) in 33 consecutive patients suffering from this condition. Twenty-six patients (78.8%) showed MRI abnormalities, the most common MRI finding (57.6%) was pre-existent spondylosis. Indeed, the group of patients with spondylosis and other MRI changes had higher clinical scores than those without MRI abnormalities as measured by a three-point grading system based upon the symptoms and signs shown. Several MRI changes, most of them already demonstrable by standard X-ray were seen among 33 patients suffering from late whiplash syndrome. Although no one of these findings appears to be specific and certainly related to the previous neck injury, they could represent a risk factor for a longer pain duration.

[Whiplash-associated disorders]

Whiplash-associated disorders (WAD) represent a class of clinical complaints which commonly result from rear-end car accidents. An automobile collision can generate major forces which are transferred to the neck by an acceleration-deceleration mechanism (whiplash), resulting in bony or soft-tissue injuries (whiplash injury). Incidence of WAD is estimated to be 0.1 to 3.8/1000/year; WAD cost $29 billion a year in the USA. They can be classified clinically into 5 degrees of severity, namely WAD grades 0 to IV. Signs and symptoms typically crescendo during the first few days after an accident. Pathological findings (especially of musculo-skeletal or neurological types) must often be sought actively and should be documented at the earliest stage. Prevention of possible chronicity is the most important goal in clinical management of WAD. WAD grade IV patients are treated in the way their fracture or dislocation demands. Therapy of WAD grades I to III has three main aspects: non-narcotic analgesics, early active mobilisation (to the extent possible consistent with pain) and education of the patient. Soft collars should not be used (or only temporarily and sparingly). Most patients with WAD grades I-III feel well again relatively soon. Symptoms and signs that persist for longer than two months are important warning signs for imminent chronicity, which occurs at rates of 14-42%. In such cases, an interdisciplinary approach is recommended. Risk factors are accident severity, head position at the time of accident, age and pretraumatic existence of headache. Patients with chronic complaints can develop additional psychic and cognitive problems, which are caused by--and not the cause of--their chronic disorder. Therapy of chronic whiplash-associated disorders involves all the problems inherent in therapies of chronic pain. There are many therapeutic concepts, but little evidence that anything helps. Prevention of whiplash injuries is therefore very important in view of the lack of powerful treatment options. Although there is a substantial body of scientific literature about WAD, many unanswered questions remain. In particular the most important questions (how can patients with acute and chronic disorders be helped best) have no clear answer yet. Furthermore, there are many opinions and prejudices (especially concerning psycho-social factors of WAD) which have no scientific basis. Therefore, an intensive exchange of information between health care professionals, patients and the general public appears to be very important.

Long-term functional and psychological problems in whiplash associated disorders

In recent years, Whiplash Associated Disorders (WAD) have been recognized as an increasing problem and up to 35% of patients have been reported to suffer from persisting symptoms. The aim of this study was to describe the consequences of pain and impairment of movement for everyday activities and dysfunction, in a sample of 104 chronic WAD patients. It was hypothesized that predictors such as initial grade of injury, self-efficacy and optimism, as well as mediating coping strategies, would influence the patients' quality of life in terms of dysfunction, disability, anxiety, depression and pain intensity. The results showed that chronic WAD patients differ from other groups in quality-of-life related indicators. Psychosocial problems were more pronounced than physical, while there were no gender differences. There was some evidence that use of specific coping strategies is a significant predictor of psychological well-being.

Efficacy of home cervical traction therapy

Cervical traction is administered by various techniques ranging from supine mechanical motorized cervical traction to seated cervical traction using an over-the-door pulley support with attached weights. Duration of cervical traction can range from a few minutes to 20 to 30 min, once or twice weekly to several times per day. Anecdotal evidence suggests efficacy and safety, but there is no documentation of efficacy of cervical traction beyond short-term pain reduction. Because of a clinical impression that a simplified, inexpensive, over-the-door home cervical traction method of treatment requiring 5 min of cervical traction twice daily was efficacious for both cervical pain and radiculopathic syndromes, we undertook a retrospective study of 58 outpatients treated between 1994 and 1996. Age range was 29 to 84 (mean, 56) yr. Twenty-three males and 35 females were classified as Grade 1 to Grade 3 according to the Quebec Task Force of Whiplash-Associated Disorders Cohort Study. Outcomes were as follows: Grade 1 (mild)--4 of 4 (100%) patients improved; Grade 2 (moderate)--34 of 44 (77%) patients improved (P < 0.01), 5 were unchanged, and 5 felt their symptoms were aggravated by cervical traction; Grade 3 (patients with radiculopathy)--9 of 10 (90%) patients improved (P < 0.01). In a retrospective study, a brief (3-5 min), over-the-door home cervical traction modality provided symptomatic relief in 81% of the patients with mild to moderately severe (Grade 3) cervical spondylosis syndromes. Prospective, randomized assessment of cervical traction for this and other methods is needed.

Prevention of minor neck injuries in F-16 pilots

INTRODUCTION

F-16 pilots have a high incidence of minor neck injuries. It was hypothesized that pilots who did neck strengthening exercises and pilots who used other preventive strategies would have fewer injuries.

METHOD

We surveyed 268 U.S. Air Force F-16 pilots. Subjects were divided into two groups. Group I, the Early Intervention Group, performed an intervention, or not, from the start of their F-16 careers. Outcomes were measured as a percent of pilots reporting an injury during their F-16 careers. Group II, the Midstream Intervention Group, initiated an intervention after sustaining an injury. Injuries before and after the intervention were compared as a median injury rate per 100 h F-16 time.

RESULTS

The 1 -yr prevalence of neck injury was 56.6% and for an F-16 career was 85.4%. For every 100 h in the F-16, the risk of injury increased by 6.9%. Only 26.9% of the pilots routinely did neck strengthening exercises. For the Early Intervention Group, fewer injuries were associated with neck strengthening exercises and placing the head against the seat prior to loading +Gz. For the Midstream Intervention Group, a lower median injury rate was associated with neck strengthening exercises, placing the head against the seat prior to loading, warming up with stretching or isometrics, prepositioning the head prior to loading, and unloading prior to moving the head. Interventions not associated with fewer injuries included body exercises and placing the head against the canopy.

CONCLUSION

Certain strategies may prevent neck injuries. Prospective research is needed to confirm these results.

The Whiplash Shaken Infant Syndrome: has Caffey's syndrome changed or have we changed his syndrome?

OBJECTIVE

The aim of this study is to examine the data used by John Caffey in his description of the Whiplash Shaken Infant Syndrome and compare it with recent data in an attempt to determine whether the syndrome that he described has changed, or if we have changed his syndrome into what we now call The Shaken Infant Syndrome.

METHOD

This study examined recent literature describing the Shaken Infant Syndrome, and compared it to Caffey's descriptions. In addition, a retrospective review of 71 children under the age of 3 years identified as having a subdural hematoma caused by other than accidental means during 54 months was done. This data was compared to data from the 27 case examples offered by Caffey in 1972 and his other descriptions in 1974 and 1946.

RESULTS

A review of recent literature shows that our definition of Shaken Infant Syndrome today includes cases where impact trauma was involved. In contrast to Caffey's descriptions, we found the perpetrator to be more often male, fractures to be more often to ribs rather than long bones, and admissions of shaking and other trauma more often made.

CONCLUSIONS

Our findings demonstrate that not only have we changed the diagnostic parameters from Caffey's original Whiplash Shaken Infant Syndrome, but the syndrome has also changed to reflect changes in medical diagnosis and in our society.

The nosologic status of the whiplash syndrome: a critical review based on a methodological approach

STUDY DESIGN

Empirical studies concerning the whiplash syndrome are reviewed from the point of view of epidemiologic methodology.

OBJECTIVE

To assess the nosologic status of the whiplash syndrome.

SUMMARY OF BACKGROUND DATA

Although a large number of studies concerning the syndrome exist, there is still controversy concerning the existence of the syndrome.

METHODS

The manner in which each study contributes to the validity of the syndrome is determined on the basis of the methodologic design (descriptive, case-control, cohort, and intervention/experimental) of the study.

RESULTS

Whereas the face validity of the syndrome is excellent, the descriptive, construct, and predictive validity are rather poor. In particular, convincing empirical evidence for a causal link (construct validity) between the trauma mechanism and chronic symptoms is sparse.

CONCLUSIONS

Carefully conducted studies designed to assess the degree to which head and nec trauma contribute to the development of chronic pain, particularly head and neck pain, are urgently needed.

Chronic neck pain

The disorders most commonly seen in rheumatologic practice are acute to chronic cervical disc-related strains, radiculopathies, and degenerative spondylosis. Inflammatory disorders including ankylosing spondylitis and rheumatoid arthritis, although generally rare, are not uncommonly seen in a rheumatologic practice. The pertinent anatomic and pathologic features of cervical disorders are examined in the context of their implications for the hierarchy of specific therapeutic interventions. The basis for the usually favorable prognosis for these conditions, particularly in response to a rational, structured, and phased conservative regimen, is delineated.

[Clinical aspects and neurologic expert assessment in sequelae of whiplash injury to the cervical spine]

Whiplash injury to the cervical spine and its possible long-term sequelae, the late (or chronic) whiplash syndrome, are analysed based on a clearly defined accident mechanism and an initial battery of investigations to exclude lesions other than those affecting the soft tissue of the neck region (i.e. the consequences of strain and sprain). Predictors are discussed that may point to a delayed and complicated recovery, with development of a complex array of symptoms. The pattern of this symptomatology, as reviewed on the basis of different neuropsychological investigations, appears inhomogeneous. Comparison with other non-traumatic conditions, such as the chronic fatigue syndrome, the fibromyalgia syndrome and chronic daily headache, as well as with chronic disturbances of cervical origin, reveals striking similarities. In cases of litigation, these circumstances require careful assessment of the patient's previous history and an extensive differential diagnosis. Whiplash injury to the cervical spine rarely results in disability and, if so, is only minor.

Soft-tissue injuries of the cervical spine

Cervical sprain syndrome is usually the result of a hyperextension injury of the neck; symptoms include neck, intrascapular and arm pain, and headache. Associated complaints of the head, neck, and upper extremities are common. The mechanism and pathophysiology of this injury, and the occurrence of associated injuries are discussed. Patient evaluation, treatment, and prognosis are reviewed. A thorough understanding of this common injury should facilitate treatment and provide the patient and physician with realistic expectations for recovery.

Whiplash in Australia: illness or injury?

OBJECTIVE

To provide a perspective on "whiplash" injury in Australia by examining conflicting evidence, which suggests on the one hand that the disorder is a culturally conditioned and legally sanctioned illness and on the other, that it is an occult injury which can cause chronic pain.

DATA SOURCES

The published English language literature derived from MEDLINE covering epidemiological, pathogenetic and psychological aspects of "whiplash" injury, post-traumatic stress disorder, abnormal illness behaviour and iatrogenicity; the Australian legal literature; the printed news media; the Transport Accident Commission of Victoria and the State Government Insurance Commission of South Australia.

DATA SYNTHESIS AND CONCLUSIONS

Comparative studies suggest that "whiplash" is an illness reinforced by legal and social sanction. Evidence from Victoria indicates that the reported incidence of "whiplash" can be reduced by minor legislative change. Occult injury to cervical intervertebral discs, vertebral end plates and cervical zygapophysial joints may be responsible for "whiplash" symptoms in some who are involved in motor vehicle accidents. This is likely to be confined to a small number of those involved in unexpected rear-end collisions.