The association between exposure to a rear-end collision and future neck or shoulder pain: a cohort study

Neck pain is the most frequently reported feature in connection with whiplash injury, but it is also a common complaint in the general population. Therefore it is crucial to include an unexposed comparison group when evaluating the association between neck pain and a previous motor vehicle crash (MVC). To determine whether exposure to a rear-end collision, without or with whiplash injury, is associated with future neck or shoulder pain, a cohort study was conducted. The study population consisted of persons covered by traffic insurance at one of the largest insurance companies in Sweden. Claim reports were collected from the period November 1987 to April 1988. Drivers exposed to a rear-end collision were divided into two subgroups, without reported whiplash injury (n = 204) and with reported whiplash injury (n = 232). Two comparison groups, unexposed to MVCs, consisting of 1599 and 2089 persons, were selected with consideration taken to the age and gender distribution in the exposed subgroups. A questionnaire concerning neck or shoulder pain and other subjective health complaints was mailed to all the study subjects at follow-up in 1994, 7 years after the rear-end collision. The relative risk of neck or shoulder pain at follow-up was 1.3 (95% CI 0.8-2.0) in the exposed subjects without whiplash injury compared with the unexposed. The corresponding relative risk in subjects with whiplash injury was 2.7 (95% CI 2.1-3. 5). We conclude that there is no increased risk of future neck or shoulder pain in drivers who did not report whiplash injury in connection with a rear-end collision 7 years earlier. In drivers with reported whiplash injury, the risk of neck or shoulder pain 7 years after the collision was increased nearly three-fold compared with that in unexposed subjects.     

The association between exposure to a rear-end collision and future health complaints

Different symptoms, together with neck pain, have been attributed to persons with persistent complaints after a previous motor vehicle crash (MVC) and are sometimes referred to as the "late whiplash syndrome." A cohort study was conducted to determine whether exposure to a rear-end collision, with or without whiplash injury, is associated with future health complaints. The results regarding future neck or shoulder pain have previously been described, and the objective of the present report was to focus on outcomes other than neck pain. Included in the study were persons 18 to 65 years of age and covered by traffic insurance at one of the largest insurance companies in Sweden. Claim reports were collected from the period November 1987 to April 1988. Drivers exposed to a rear-end collision were divided into two subgroups: those with reported whiplash injury (n = 232) and those without reported whiplash injury (n = 204). For comparison, 3688 subjects who were unexposed to MVCs were selected, with consideration taken to the age and gender distribution in the exposed subgroups. The prevalence of different health complaints among the study subjects was estimated according to a mailed questionnaire at follow-up in 1994, 7 years after the rear-end collision. When exposed subjects with whiplash injury were compared to unexposed subjects, increased relative risks in the range of 1.6-3.7 were seen for headache, thoracic and low back pain, as well as for fatigue, sleep disturbances and ill health. No corresponding increased risks were found among the exposed subjects without reported whiplash injury. We conclude that rear-end collisions resulting in reported whiplash injuries seem to have a substantial impact on health complaints, even a long time after the collision. There is a need to identify factors that predict a non-favorable outcome in order to improve clinical management.     

Association between body mass index and recovery from whiplash injuries: a cohort study

It is hypothesized that excess weight is a risk factor for delayed recovery from neck pain, such as from whiplash injuries. However, the association between obesity and recovery from whiplash injury has not been studied. The authors examined the association between body mass index and time to recovery from whiplash injuries in a population-based cohort study of traffic injuries in Saskatchewan, Canada. The cohort included 4,395 individuals who made an insurance claim to Saskatchewan Government Insurance and were treated for whiplash injury between July 1, 1994, and December 31, 1995. Of those, 87.7% had recovered by November 1, 1997. No association was found between baseline body mass index and time to recovery. Compared with individuals with normal weight, those who were underweight (hazard rate ratio = 0.88, 95% confidence interval: 0.73, 1.06), overweight (hazard rate ratio = 1.01, 95% confidence interval: 0.94, 1.09), and obese (hazard rate ratio = 0.99, 95% confidence interval: 0.90, 1.08) had similar rates of recovery, even after adjustment for other factors. The results do not support the hypothesis that individuals who are overweight or obese have a worse prognosis for whiplash.     

The association between neck pain intensity, physical functioning, depressive symptomatology and time-to-claim-closure after whiplash

Time-to-claim-closure is a common outcome in cohort studies of whiplash injuries. However, its relationship to health recovery is unknown. We investigated the association between neck pain, physical functioning, depressive symptomatology and time-to-claim-closure in a Saskatchewan cohort of 5398 whiplash claimants in 1994-1995. Participants were surveyed five times over 1 year. In 1995, the insurance system changed from tort to no-fault, eliminating compensation for pain and suffering. Under tort, a 10-point increase in pain reduced the claim-closure rate by 13-24% while a 10-point increase in physical functioning increased it by 17%. Depressive symptomatology reduced the claim-closure rate by 37%. Under no-fault, a 10-point increase in pain reduced the claim-closure rate by 18% while a 10-point increase in physical functioning increased it by 10-35%. The presence of depressive symptomatology reduced the claim-closure rate by 36%. The results suggests lower pain, better function and the absence of depressive symptoms are strongly associated with faster time-to-claim-closure and recovery after whiplash, independent of the insurance system.     

Tragedy of conducting a clinical trial; generic alert system needed

Stopping a clinical trial without reaching the final objective is not the ideal outcome any researcher wants; sometimes ceasing is inevitable. Due to marginal inclusion of patients we were forced to cease our randomized clinical trial on the effectiveness of proprioceptive training on the development of chronic whiplash complaints a year after the start. Although incidence figures demonstrate that recruitment of the planned number of whiplash patients would be easily feasible, we were unable to enroll the amount of subjects. Several motives can be proposed that would have prevented this obliged halting from happening. Other studies also report impracticability of the planned number of whiplash injury patients.     

Occupant- and crash-related factors associated with the risk of whiplash injury

PURPOSE: Given that a motor vehicle crash (MVC) had occurred, to evaluate whether occupant- and crash-related factors, such as age, gender, seating position and type of MVC are associated with the risk of whiplash injury. METHODS: A study of occupants in cars covered by motor insurance at one of the largest insurance companies in Sweden, was undertaken during a one-year period. The study population comprised all occupants in cars exposed to an MVC in which at least one occupant was injured (n = 7120). Adjusted estimates of the relative risk of whiplash injury, associated with the different factors, were calculated by means of binomial regression analysis. RESULTS: Considering different MVCs, rear-end collisions were associated with the highest relative risk of whiplash injury when compared with side impacts (1.82; 95% CI 1.68-1.96), while drivers showed the strongest association with respect to seating position when compared with passengers in the rear seat (1.78; 95% CI 1.60-1.97). Females had a somewhat higher relative risk of whiplash injury than males (1.20; 95% CI 1.16-1.25). Regarding age, the relative risk was moderately increased across the different age groups when compared with the oldest age group. No interaction was observed on the additive scale. CONCLUSIONS: Given that an MVC had occurred, subjects exposed to a rear-end collision and drivers had a substantial increased risk of whiplash injury, while age and gender were of minor importance.     

Further Validation of a Measure of Injury-Related Injustice Perceptions to Identify Risk for Occupational Disability: A Prospective Study of Individuals with Whiplash Injury

Purpose Emerging evidence suggests that perceptions of injustice negatively impact return to work following whiplash injury. The Injustice Experiences Questionnaire (IEQ) is a recently developed measurement tool that may be used to assess injury-related perceptions of injustice following injury. To date, although research has supported the predictive validity of the IEQ, a clinical cut off for interpreting this measure has not been established. Increased support for the validity and clinical interpretation of the IEQ represents a first step towards identifying patients that might benefit from targeted intervention to mitigate the impact of perceived injustice. Methods The IEQ was completed by 103 whiplash-injured patients upon commencement and completion of a standardized multidisciplinary rehabilitation program. One year later, individuals reported on their employment activity, pain severity, and use of narcotics. A receiver operating characteristic (ROC) curve analysis was conducted to identify the post-treatment IEQ score that was optimally associated with unemployment status at the follow-up. Secondary ROC curve analyses examined IEQ scores best associated with high pain severity and narcotic use 1 year following treatment. Results Results indicated that IEQ scores significantly discriminated individuals who returned and did not return to work at the follow-up. An IEQ score of 19 optimally identified participants in terms of follow-up employment status. IEQ scores at the end of treatment also discriminated individuals with high and low pain severity ratings and narcotic use status at the follow-up. Post-treatment IEQ scores of 18 and 20 optimally identified participants who had high pain severity ratings and who were using narcotics at the follow-up, respectively. Conclusions These results further support the validity of the IEQ and provide a guideline for its clinical interpretation in patients with persistent pain and disability following musculoskeletal injury. IEQ scores above the identified cut off may represent a barrier to work return and may warrant targeted intervention.     

Practical guidelines for the prevention of chronic symptoms after a whiplash injury, based on published evidence

Recently, systematic reviews and evidence-based guidelines on whiplash have appeared, from which preventive recommendations can be derived. Fear of moving, catastrophic thoughts and avoidance of activity seem to play an important role in the transition from acute to chronic symptoms. Early reassurance and the advice to remain active can prevent the development of chronic symptoms following whiplash. In the acute and subacute phase, if there is still no recovery despite information designed to reduce anxiety, referral to a physiotherapist for active exercise therapy and management is indicated. In the chronic phase, depending on which factors play a role in the given patient, referral to active exercise therapy or a multi-disciplinary training programme may be considered.     

Long-term labour-market performance of whiplash claimants

A whiplash is a sudden acceleration–deceleration of the neck and head, typically associated with a rear-end car collision that may produce injuries in the soft tissue. Often there are no objective signs or symptoms of injury, and diagnosing lasting whiplash-associated disorders (WAD) is difficult, in particular for individuals with mild or moderate injuries. This leaves a scope for compensation-seeking behaviour. The medical literature disagrees on the importance of this explanation. In this paper we trace the long-term earnings of a group of Danish individuals with mild to moderate injuries claiming compensation for having permanently lost earnings capacity and investigate if they return to their full pre-whiplash earnings when the insurance claim has been assessed. We find that about half of the claimants, those not granted compensation, return to an earnings level comparable with their pre-whiplash earnings suggesting that these individuals do not have chronic WAD in the sense that their earnings capacity is reduced. The other half, those granted compensation, experience persistent reductions in earnings relative to the case where they had not been exposed to a whiplash, even when they have a strong financial incentive to not reduce earnings. This suggests that moderate injuries tend to be chronic, and that compensation-seeking behaviour is not the main explanation for this group. We find that claimants with chronic WADs used more health care in the year prior to the whiplash than claimants with non-chronic cases. This suggests that lower initial health capital increases the risk that a whiplash causes persistent WAD.     

The sensitization model: a method to explain chronic pain to a patient

Chronic pain is pain without a clear somatic substrate. As a result, patients with chronic pain often do not receive a clear diagnosis following a medical examination. In many patients, having pain without a proper explanation or diagnosis induces stress and the urge to search elsewhere for explanations and treatments. There is growing evidence that many chronic-pain syndromes, such as chronic low-back pain, whiplash and fibromyalgia, share the same pathogenesis: sensitisation of pain-modulating systems in the central nervous system at both spinal and supraspinal level. This central sensitisation is facilitated by numerous factors that contribute to the maintenance of pain in a way that differs from individual to individual. How sensitisation may develop and persist as a result of medical, psychological and social factors calls for research from the perspective of a bio-psycho-social model. If sensitisation is used to explain chronic pain to a patient and the patient understands the relation beween pain and the factors that play a role in the maintenance of the pain, this can lead to acceptation of a treatment learning to cope with these factors.     

Psychosocial Factors Related to Return to Work Following Rehabilitation of Whiplash Injuries

INTRODUCTION: The present study examined the effects of pain chronicity on the responsiveness of psychosocial variables to intervention for whiplash injuries. METHODS: Participants (N = 75) were work disabled patients with a diagnosis of Whiplash Grade II and were clients in a 10-week community-based, psychosocial intervention aimed at facilitating return to work. Individuals were classified as subacute (4-12 weeks; N = 25), early chronic (3-6 months; N = 25), and chronic (6-18 months; N = 25). Patients in the three groups were matched on sex (13 men, 12 women) and age (+/-2 years). Patients completed measures of pain severity, self-reported disability, pain catastrophizing and fear of movement at pre-treatment, mid-treatment and post-treatment. RESULTS: Return to work rates were 80, 72 and 32% for the subacute, early chronic and chronic groups, respectively. Individuals in the chronic group, compared to individuals in the subacute or early chronic groups, had significantly more elevated pre-treatment scores on measures of pain catastrophizing, F(2, 74) = 9.6, P < .001, and fear of movement, F(2, 74) = 3.4, P < .05. The magnitude of treatment-related reductions in catastrophizing, fear of movement and pain intensity was comparable across groups. However, individuals who were absent from work for more than 6 months showed the least amount of change in self-reported disability through the course of treatment. CONCLUSIONS: The findings suggest that self-reported disability is particularly resistant to change as the period of work disability extends over time. The findings emphasize the importance of early intervention and the need to develop strategies that specifically target disability beliefs in patients with whiplash injuries.     

Pain, medication, and injury in older farmers

BACKGROUND: Agricultural work continues to be a dangerous occupation. Older farmers experience high risks for work-related injury. The purpose of this research was to determine if there is a relationship between medication use and injury among older male farmers in Alberta. METHODS: Using probabilistic linkage between an Alberta Agriculture government registry of farm operators and the Alberta Health Plan registry file, older farmers (aged 66 and older) were identified. Farm related injuries were identified using an E-code search of both hospitalization and emergency department separations for a 3-year period. Cases were matched to controls on age, geographic health region, and index injury date at a ratio of 1:5. Co-morbidity and medication use for each of the cases and controls were derived from population based health system utilization files. Conditional logistic regression was used to determine which medications were related to injury. RESULTS: Overall, a total of 282 farm related injuries were suffered by the linked group. Controlling for co-morbidity, farmers who had stopped taking narcotic pain killers (OR = 9.37 [95% CI:4.95, 17.72]) and non-steroidal anti-inflammatories (OR = 2.40 [95% CI:1.43, 4.03]) 30 days prior to the date of injury were at risk of injury. Those farmers taking sedatives up until the date of injury were also at risk (OR = 3.01 [95 CI:1.39, 6.52]). In addition, those suffering from incontinence/urinary tract disorders (OR = 2.95 [95% CI:1.30, 6.71]), and prior injury (OR = 1.42 [95% CI:1.04, 1.95]) were also at greater risk of injury. CONCLUSIONS: The relationship of medication use and injury in this population is different from those observed in studies of falls in older persons. We hypothesize that distraction from either pain or co-morbidity may play an important role in the etiology of injuries suffered in this active older working population. Further investigations in this area are required to confirm these findings.     

Inviting pain? Pain,dualism and embodiment in narratives of self‐injury

The role of pain in the practice of self‐injury is not straightforward. Existing accounts suggest that self‐injury does not cause ‘physical’ pain, however self‐injury is also said to alleviate ‘emotional’ pain by inflicting ‘physical’ pain. This article explores these tensions using sociological theories regarding the socio‐cultural and subjective nature of pain. Analysis derives from in‐depth, life‐story interviews carried out in the UK with people who had self‐injured. Findings contribute to on‐going debates within social science regarding the nature of pain. Participants’ narratives about pain and self‐injury both drew on and challenged dualistic models of embodiment. I suggest that self‐injury offers a unique case on which to extend existing theoretical work, which has tended to focus on pain as an unwanted and uninvited entity. In contrast, accounts of self‐injury can feature pain as a central aspect of the practice, voluntarily invited into lived experience.     

Factors affecting work-related shoulder pain

Background Work-related shoulder pain is a common problem. Ergonomic factors in the workplace are thought to be important but a number of other factors have also been associated with shoulder pain. Aims To identify risk factors for work-related shoulder pain in Alberta, focusing particularly on ergonomic risk factors. Methods A case referent design was used to compare individuals who made a Workers' Compensation Board (WCB) claim for work-related shoulder pain with individuals who made a claim for other types of injury. Data were collected using a postal questionnaire and analysed by logistic regression. Results There were 1263 participants (562 cases, 701 referents). The participation rate was 25% among cases and 21% among referents (P < 0.01). Factors associated with an increased likelihood of claim for shoulder injury included lifting ≥10kg above shoulder height for ≥15min per day, shoulder pain in the month prior to injury, working in the 'Government, education, and health services' industry sector and being occasionally/never satisfied with support from colleagues. Conclusions These results support the importance of ergonomic factors in work-related shoulder pain claims, particularly the lifting of weights above shoulder level for even short periods. Relatively simple ergonomic measures, such as restricting above shoulder lifting, could be adopted with the aim of reducing the risk of shoulder injury at work.     

Conservatively managed tibial shaft fractures in Nottingham,UK: are pain,osteoarthritis, and disability long-term complications?

OBJECTIVES: To investigate longterm pain and disability subsequent to a tibial shaft fracture treated conservatively. DESIGN AND SETTING: Subjects who had sustained a tibial shaft fracture more than 27 years ago were compared with those who had not. SUBJECTS: 572 fracture patients (identified from the records of the plaster room) aged over 16 at the time of injury were contracted and were compared with 2285 randomly selected subjects matched for age, sex, and general practice. MAIN OUTCOME MEASURES: Self reported knee pain; self reported GP's diagnosis of osteoarthritis; ability to climb stairs, walk 100 yards, to bend, kneel, or stoop; and SF-36 physical functioning score. RESULTS: Subjects were reviewed between 27 and 41 years after tibial shaft fracture (mean 35 years). Fracture patients were more likely to suffer chronic knee pain (odds ratio 1.23; 95% confidence interval (CI) 1.00, 1.51) and report being given a diagnosis of osteoarthritis by their GP (odds ratio 1.46; 95% CI 1.08, 1.97). The ability to climb stairs, walk 100 yards, and bend, kneel, or stoop was less in the fracture group than the other subjects. The SF-36 physical function score was significantly lower in the fracture group. CONCLUSIONS: More than 27 years after a tibial shaft fracture, subjects have more knee pain than the rest of the population. They also have greater difficulty performing everyday physical activities. The excess morbidity may be due to injury factors or treatment factors, and further research is needed to investigate this important association further.     

Road traffic accidents before and after seatbelt legislation--study in a district general hospital.

Injuries among samples of car accident cases attending the Accident & Emergency (A & E) department of a District General Hospital (DGH) in the year before and after the introduction of seat belt legislation were classified applying the Abbreviated Injury Scale using information recorded in the patient case notes. Those who died or did not attend an A & E department were not included in the sampling frame. The number of those who escaped injury increased by 40% and those with mild and moderate injuries decreased by 35% after seatbelt legislation. There was a significant reduction in soft tissue injuries to the head. Only whiplash injuries to the neck showed a significant increase.     

臭氧联合治疗膝关节半月板损伤的临床研究

目的探讨臭氧冲洗联合手法整复治疗膝关节半月板损伤的临床效果。方法选择本院90例膝关节半月板损伤患者作为本次研究对象,病例收集时间为2017年5月-2018年5月。按照治疗分组,手法整复组采取手法整复治疗,臭氧治疗组采用臭氧冲洗治疗,手法整复联合臭氧组则采取手法整复治疗+臭氧冲洗治疗。比较三组疗效;膝关节疼痛缓解的时间、膝关节疼痛消失的时间;治疗前后患者膝关节疼痛VAS评分值以及生活质量QOL评分值;不良作用发生率。结果手法整复联合臭氧组疗效高于手法整复组与臭氧治疗组,P<0.05;手法整复联合臭氧组膝关节疼痛缓解的时间、膝关节疼痛消失的时间优于手法整复组与臭氧治疗组,P<0.05;治疗前三组膝关节疼痛VAS评分值以及生活质量QOL评分值接近,P>0.05;治疗后手法整复联合臭氧组膝关节疼痛VAS评分值以及生活质量QOL评分值优于手法整复组与臭氧治疗组,P<0.05。手法整复联合臭氧组不良作用发生率和手法整复组与臭氧治疗组接近,P>0.05。结论手法整复治疗+臭氧冲洗治疗膝关节半月板损伤的疗效好,可更好改善膝关节疼痛VAS评分值以及生活质量QOL评分值。     

Hospitalizations for injury: United States, 1996

OBJECTIVES: This report presents national estimates of the 1996 hospitalizations for injury in the United States. Numbers and rates of discharges are shown within sex, age, and racial groups by type of injury. Average lengths of stay and days of care data by injury type are also included. METHODS: Estimates are based on medical abstract data collected in the National Hospital Discharge Survey. Diagnoses are coded according to the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). Injuries are defined as ICD-9-CM codes 800-999. External causes of injury are defined as codes E800-E999 (E-codes). RESULTS: In 1996, there were 2.6 million hospitalizations for injury. Fractures resulted in over a million hospitalizations; medical injuries, including adverse effects and complications, were responsible for 666,000 hospitalizations. The medical records for 64 percent of the patients hospitalized for injuries had an external cause-of-injury code (E-code). Elderly people had the largest number and rate of injuries. CONCLUSIONS: Data on injuries requiring hospitalization and characteristics of patients differentially affected can be used to design and target more effective injury prevention programs. Preventing injuries would decrease the considerable pain, disability, and economic impact associated with these conditions.     

New directions in the understanding and management of pain

Control of pain and the suffering that it causes still eludes us. Despite impressive progress in the prevention and cure of disease and in care of the trauma victim, pain is still a frontier in medical research. It accompanies surgery, various diagnostic procedures and dental care as well as acute injury and disease. For a significant number of patients it persists after injury or illness into a chronic state. Chronic pain is recognized to be the most frequent cause of disability in the United States and many industrialized nations today, and is a major cost to society in both work hours lost and medical expenses. In addition to its social importance, pain is an intimate cause of personal concern for every human being throughout life. The progress, or lack of progress, achieved by medical research in pain control is of interest to us all. Pain disorders may be usefully classified in two categories: acute and chronic. The etiology, physiopathology, symptomatology, diagnosis and therapy of these two types of pain are quite different and require separate consideration. Acute pain is that which arises from an acute injury or disease process and persists only as long as the tissue pathology itself. If acute pain problems are not effectively treated, they may progress to chronic states. Chronic pain is that: (1) associated with chronic tissue pathology; or (2) which persists beyond the normal healing period for an acute injury or disease. There are unique challenges for health care providers associated with each of these two categories of problems, and failure to distinguish between these types of pain has led to a widespread, ongoing mismanagement of patients that can be prevented if strong efforts are made to better educate health care professionals about pain and its therapy. This paper presents an overview of current understanding about the nature of pain and its management. The physiology and psychology of pain are reviewed against a background of the concepts and information taught 25 years ago. Some common acute and chronic pain problems are reviewed and discussed. Finally, several new directions in pain control are described.