Psychological determinants of quality of life in patients with whiplash associated disorders–a prospective study

Purpose. To evaluate whether psychological factors and personality traits influence recovery in terms of quality of life in patients with subacute whiplash associated disorders (WAD).

Method. The data was obtained from a randomized controlled trial (RCT) on 47 patients. The patients completed measures of pain intensity, affective dimension of pain, pain location, psychological stress, heightened somatic awareness, depression, catastrophizing, self-efficacy, fear of movement (re)injury, and physical disability. After three months of physiotherapy interventions, the outcome of quality of life was measured with the Short Form Health survey (SF-12). All variables were entered in a multiple regression analysis, after controlling for age and sex.

Results. Forty patients (85%) completed the trial. The self-efficacy scale (SES) was the only variable in the model that significantly explained the fraction of the SF12-score. The correlation between the SES and SF-12 was B = 0.64 (p < 0.01), and the adjusted R² was 0.40 (p < 0.05), which means that 40% of the variation in the SF12 outcomes was explained by the SES.

Conclusion. In order to improve health-related quality of life in patients with WAD, the present study stresses the importance of targeting self-efficacy. A special effort should be made to enhance these beliefs in the rehabilitation process.     

The impact of subacute whiplash-associated disorders on functional self-efficacy: a cohort study

Self-efficacy is increasingly being recognized as an important factor to consider in medical research, especially in different pain conditions such as whiplash-associated disorders (WAD). When pain is not effectively treated or relieved, it may negatively affect patients' life situation and cause a decline in perceived self-efficacy. Knowledge of what level of self-efficacy can be considered an actual deficit in patients with WAD is, however, sparse. The purpose of this study is to analyze whether subacute WAD has an impact on self-efficacy beliefs. A cohort study was designed to identify the impact of WAD on self-efficacy beliefs. The exposed group consisted of 47 patients with subacute WAD following a whiplash trauma. The control group representing the general population consisted of 212 participants, and was randomly selected to match the distribution of age and sex in the exposed group. The Self-Efficacy Scale was used to assess the individuals' confidence in their ability to successfully carry out activities of daily living. In the exposed group, 47 responded (100%), and in the control group, 113 (53%) responded. The results show that the total scores on the Self-Efficacy Scale were significantly lower in the exposed group compared with the control group, concerning both the mean (P<0.001) and median (P<0.001) scores. In conclusion, patients with subacute WAD experience a decline in functional self-efficacy, which stresses the importance of incorporating these beliefs in clinical practice and research.     

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.     

Are altered smooth pursuit eye movements related to chronic pain and disability following whiplash injuries? A prospective trial with one-year follow-up

OBJECTIVE: To evaluate the ability of early smooth pursuit testing to predict chronic whiplash-associated disorders, and to study whether the presence of abnormal smooth pursuit eye movements at one-year follow-up is associated with symptoms at that time. DESIGN: Prospective cohort study with one-year follow-up. SETTING: The study was carried out at a university research centre and participants were recruited from emergency units and general practitioners. SUBJECTS: In all, 262 participants were recruited within 10 days from a whiplash injury. MAIN MEASURES: Smooth pursuit eye movements were tested with electrooculography (EOG) an average of 12 days after a whiplash trauma and again after one year. Analyses of EOG recordings were computerized. Associations between test results both from baseline and one-year tests and self-reported neck pain, headache, neck disability and working ability one year after the car collision were determined. RESULTS: Results of early eye movement tests were not associated with the prognosis. Reduced smooth pursuit performance when tested in static cervical rotation at the one-year follow-up was significantly associated with higher neck pain intensity at that time (regression coefficient 0.8, 95% confidence interval (CI) 0.04-1.5), but the association was too weak for the test to discriminate between recovered participants and those with lasting symptoms. CONCLUSIONS: Although reduced smooth pursuit performance at one-year follow-up was associated with persistent neck pain, smooth pursuit eye movement tests are not useful as predictive or diagnostic tests in whiplash-associated disorders.     

Acute stress response and recovery after whiplash injuries. A one‐year prospective study

Chronic whiplash‐associated disorder (WAD) represents a major medical and psycho‐social problem. The typical symptomatology presented in WAD is to some extent similar to symptoms of post traumatic stress disorder. In this study we examined if the acute stress reaction following a whiplash injury predicted long‐term sequelae. Participants with acute whiplash‐associated symptoms after a motor vehicle accident were recruited from emergency units and general practitioners. The predictor variable was the sum score of the impact of event scale (IES) completed within 10 days after the accident. The main outcome‐measures were neck pain and headache, neck disability, general health, and working ability one year after the accident. A total of 737 participants were included and completed the IES, and 668 (91%) participated in the 1‐year follow‐up. A baseline IES‐score denoting a moderate to severe stress response was obtained by 13% of the participants. This was associated with increased risk of considerable persistent pain (OR=3.3; 1.8–5.9), neck disability (OR=3.2; 1.7–6.0), reduced working ability (OR=2.8; 1.6–4.9), and lowered self‐reported general health one year after the accident. These associations were modified by baseline neck pain intensity. It was not possible to distinguish between participants who recovered and those who did not by means of the IES (AUC=0.6). In conclusion, the association between the acute stress reaction and persistent WAD suggests that post traumatic stress reaction may be important to consider in the early management of whiplash injury. However, the emotional response did not predict chronicity in individuals.     

NEWS SECTION

Different types of integrated management programmes have lately been introduced in the treatment of Whiplash Associated Disorders (WAD). In this study regular primary care physiotherapy and physiotherapy management with integrated components of cognitive-behavioural origin was compared in an experimental group study. The predictive value of self-efficacy was also addressed. Thirty-three patients with chronic WAD were included in the trial. Results revealed no significant differences between groups in self-ratings of disability or pain intensity. However, among the self-reported benefits of treatment, patients in the experimental group reported significantly less pain than did the comparison group. At three months follow-up the experimental group also reported better performance of daily activities. Between group differences in the coping repertoire were found at pre-, post-, and three-month follow-up. Generally, patients with high self-efficacy reported less use of "maladaptive" and passive coping style than patients with low self-efficacy, at all times. In conclusion cognitive behavioural components can be useful in physiotherapy treatment for patients with chronic WAD, but their contributions are not yet fully understood. Self-efficacy is related to patients' use of different coping styles. Positive long-term outcomes in WAD-patients could therefore be improved by enhancing patients' self-efficacy and by teaching them to use active, adaptive coping strategies.     

The perception of pain and pain-related cognitions in subacute whiplash-associated disorders: its influence on prolonged disability

Purpose. To clarify the relations between the sensory, affective and cognitive dimensions of pain and to analyse what influence these components have on persistent disability in patients with subacute whiplash-associated disorders (WAD).

Method. The data was obtained from an on-going randomised controlled trial (RCT) on 47 patients. The sensory dimension of pain was evaluated with a visual analogue scale (VAS) diary and a Painometer®. The affective dimension was assessed using the Painometer®. The Tampa Scale for Kinesiophobia (TSK) and the Self-Efficacy Scale (SES) were used as measures of pain-related cognitions. The Pain Disability Index (PDI) was used as the outcome measure.

Results. Forty patients (85%) completed the trial. The correlations between the sensory and affective dimensions of pain were non-significant, which indicates that they are two independent constructs that describe various dimensions of whiplash-related pain. High pain intensity and pain affect, more widespread pain, and high fear of movement/(re)injury corresponded to low self-efficacy. Multiple regression analyses showed that self-efficacy was the most important predictor of persistent disability contributing to 42% of the variation in the PDI score.

Conclusion. The treatment approach for patients with subacute WAD should incorporate the multidimensional nature of pain and to prevent disability special effort should be made to enhance the patient's self-efficacy beliefs.     

The perception of pain and pain-related cognitions in subacute whiplash-associated disorders: Its influence on prolonged disability

Purpose.?To clarify the relations between the sensory, affective and cognitive dimensions of pain and to analyse what influence these components have on persistent disability in patients with subacute whiplash-associated disorders (WAD).

Method.?The data was obtained from an on-going randomised controlled trial (RCT) on 47 patients. The sensory dimension of pain was evaluated with a visual analogue scale (VAS) diary and a Painometer®. The affective dimension was assessed using the Painometer®. The Tampa Scale for Kinesiophobia (TSK) and the Self-Efficacy Scale (SES) were used as measures of pain-related cognitions. The Pain Disability Index (PDI) was used as the outcome measure.

Results.?Forty patients (85%) completed the trial. The correlations between the sensory and affective dimensions of pain were non-significant, which indicates that they are two independent constructs that describe various dimensions of whiplash-related pain. High pain intensity and pain affect, more widespread pain, and high fear of movement/(re)injury corresponded to low self-efficacy. Multiple regression analyses showed that self-efficacy was the most important predictor of persistent disability contributing to 42% of the variation in the PDI score.

Conclusion.?The treatment approach for patients with subacute WAD should incorporate the multidimensional nature of pain and to prevent disability special effort should be made to enhance the patient's self-efficacy beliefs.     

Early interdisciplinary rehabilitation programme for whiplash associated disorders

Purpose : To assess the clinical outcomes of a multidisciplinary rehabilitation programme for early intervention of chronic whiplash associated disorders (WAD). The primary aim of the programme was to increase levels of activity and independence in patients suffering WAD. Methods : Ninety subjects with purported chronic symptoms associated with whiplash associated disorder (WAD) were referred to a multi-centre multi-modal 5- and 8-week rehabilitation programme in 1997-1998, during which prospective and retrospective functional and psychological evaluations were conducted, the follow-up was to 6 months. Results : Subjects indicated they were satisfied with the programme. Retrospective evaluation indicated increased ability to cope with and control pain and, to some extent, psychological aspects. The pain intensity in the neck and upper back were significantly decreased at 6 months follow-up. However, for most of the functional and psychological markers, no significant changes were found. Conclusions : A multi-modal rehabilitation programme for the chronic suffering attributed to WAD had positive effects according to several aspects of the retrospective evaluations, but according to most of the aspects evaluated prospectively the programme does not appear to have significant benefits.     

Early interdisciplinary rehabilitation programme for whiplash associated disorders

Purpose : To assess the clinical outcomes of a multidisciplinary rehabilitation programme for early intervention of chronic whiplash associated disorders (WAD). The primary aim of the programme was to increase levels of activity and independence in patients suffering WAD.

Methods : Ninety subjects with purported chronic symptoms associated with whiplash associated disorder (WAD) were referred to a multi-centre multi-modal 5- and 8-week rehabilitation programme in 1997-1998, during which prospective and retrospective functional and psychological evaluations were conducted, the follow-up was to 6 months.

Results : Subjects indicated they were satisfied with the programme. Retrospective evaluation indicated increased ability to cope with and control pain and, to some extent, psychological aspects. The pain intensity in the neck and upper back were significantly decreased at 6 months follow-up. However, for most of the functional and psychological markers, no significant changes were found.

Conclusions : A multi-modal rehabilitation programme for the chronic suffering attributed to WAD had positive effects according to several aspects of the retrospective evaluations, but according to most of the aspects evaluated prospectively the programme does not appear to have significant benefits.     

Responses to a clinical test of mechanical provocation of nerve tissue in whiplash associated disorder

Involvement of nerve tissue may contribute to the persistence of pain following a whiplash injury. This study aimed to investigate responses to the brachial plexus provocation test (BPPT) in 156 subjects with chronic whiplash associated disorder (WAD) with and without associated arm pain and 95 asymptomatic control subjects. The range of elbow extension (ROM) and visual analogue scale (VAS) pain scores were measured. Subjects with chronic WAD demonstrated significantly less ROM and higher VAS scores with the BPPT than the asymptomatic subjects (P<0.001). These effects occurred bilaterally. Within the whiplash population, subjects whose arm pain was reproduced by the BPPT demonstrated significantly less ROM on both the symptomatic and asymptomatic sides when compared to the whiplash subjects whose arm pain was not reproduced by the BPPT (P=0.003) and significantly less ROM and higher VAS scores than those whiplash subjects with no arm pain (P=0.003, 0.01). Only the whiplash subjects whose arm pain was reproduced by the BPPT demonstrated differences between the symptomatic and asymptomatic sides. These generalized hyperalgesic responses to the BPPT support the hypothesis of central nervous system hypersensitivity as contributing to persistent pain experienced by WAD patients.     

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.     

Ergebnisse der frühfunktionellen krankengymnastischen Übungsbehandlung nach HWS-Distorsion

BACKGROUND: Diagnostic evaluation and therapeutic management of acute neck pain after whiplash is a frequent but unsolved clinical problem. Long-lasting symptoms and disability are common. Former studies proposed beneficial effects of physiotherapy in the early management of whiplash injury. The purpose of this study was to assess the effects of early active mobilization versus standard treatment with a soft cervical collar. METHODS: Between August 1997 and February 2000 a prospective randomized clinical trial with a total of 168 patients was performed. Of these patients 81 (31 male, 50 female; average age 28,78 years) were randomly assigned to the standard therapy group, which received a soft cervical collar, and 87 (31 male, 56 female; average age 29,62 years) to the early mobilization group, treated by physiotherapy. Study participants documented pain and disability twice (baseline and six week follow-up) during a one week period by diary, using numeric rating scales ranging from 0 to 10. RESULTS: The initial mean pain intensity (4,75) reported by the standard therapy group was similar to disability (4,76). There were no significant differences to initial pain (4,50) and disability (4,39) reported by the early mobilization group. The mean pain intensity reported by the standard therapy group after 6 weeks was 2,66 and disability was 2,40. The mean pain intensity indicated by physiotherapy group was 1,44 and mean disability was 1,29. The differences between the groups were both significant. CONCLUSIONS: Early mobilization is superior to the standard therapy regarding pain intensity and disability. We conclude that mobilization should be recommended as the new adequate standard-therapy in the acute management of whiplash injury.     

Reduced cold pressor pain tolerance in non-recovered whiplash patients: a 1-year prospective study.

Whiplash injury and chronic whiplash syndrome represent major health problems in certain western communities, pain being the main symptom. Sensitization of the nociceptive system may play a role for non-recovery after whiplash injury. AIMS: This study examined if tolerance to endure pain stimuli may predict outcome in whiplash injury. In a prospective fashion, 141 acute whiplash patients exposed to rear-end car collision (WAD grade 1-3) and 40 ankle-injured controls were followed and exposed to a cold pressor test, respectively, 1 week, 1, 3, 6 and 12 months after the injury. VAS score of pain and discomfort was obtained before, during and after immersion of the dominant hand into cold water for 2 min. The McGill Pain Questionnaire showed that ankle-injured controls had higher initial pain scores than the corresponding whiplash group, while whiplash-injured subjects had higher scores at 6 months; pain scores being similar at other time points. No difference was found in cold pressor pain between recovered whiplash patients and ankle-injured subjects. Non-recovery was only encountered in whiplash injury. Eleven non-recovered whiplash patients (defined as: handicap after 1 year) showed reduced time to peak pain from 1 week to 3 months (P<0.001), 6 months (P<0.01), but not 12 months after the injury. A larger pain area was seen in non-recovered vs. recovered whiplash-injured subjects during the entire observation period (P<0.001). Non-recovery after whiplash was associated with initially reduced cold pressor pain endurance and increased peak pain, suggesting that dysfunction of central pain modulating control systems plays a role in chronic pain after acute whiplash injury.     

Deep muscle pain, tender points and recovery in acute whiplash patients: a 1-year follow-up study

Local sensitization to noxious stimuli has been previously described in acute whiplash injury and has been suggested to be a risk factor for chronic sequelae following acute whiplash injury. In this study, we prospectively examined the development of tender points and mechano-sensitivity in 157 acute whiplash injured patients, who fulfilled criteria for WAD grade 2 (n=153) or grade 3 (n=4) seen about 5 days after injury (4.8+/-2.3) and who subsequently had or had not recovered 1 year after a cervical sprain. Tender point scores and stimulus-response function for mechanical pressure were determined in injured and non-injured body regions at specific time-points after injury. Thirty-six of 157 WAD grade 2 patients (22.9%) had not recovered, defined as reduced work capacity after 1 year. Non-recovered patients had higher total tender point scores after 12 (p<0.05), 107 (p<0.05) and 384 days (p<0.05) relative to those who recovered. Tenderness was found in the neck region and in remote areas in non-recovered patients. The stimulus-response curves for recovered and non-recovered patients were similar after 12 days and 107 days after the injury, but non-recovered patients had steeper stimulus-response curves for the masseter (p<0.02) and trapezius muscles (p<0.04) after 384 days. This study shows early mechano-sensitization after an acute whiplash injury and the development of further sensitization in patients with long-term disability.     

Prospective PC-interactive pressure algesimetry of post-traumatic neck pain after whiplash injury

Cervical pain is a prominent symptom in both acute whiplash injury and late whiplash syndrome. However, no systematic analysis of post-traumatic pain development covering several weeks has yet been performed in whiplash patients. It was the aim of the present study to analyse the duration and course of post-traumatic muscle pain due to whiplash injury in a prospective follow-up examination with short investigation intervals. A recovery of initially increased muscle pain after whiplash injury within 1 month was hypothesized. Pressure pain of the splenius and trapezius muscles was recorded using PC-interactive pressure algesimetry. Whiplash patients were investigated during the acute injury stage and after 3, 4, and 6 weeks and compared with matched controls. We found significantly increased pressure pain of the splenius and trapezius muscles in the acute stage of whiplash injury. After 4 weeks patients' scores of pain parameters were comparable to those of healthy control subjects. Within the patient group the first changes of pressure pain were observed within 3 (splenius) and 4 weeks (trapezius). For most patients the recovery dynamics lasted 4-6 weeks. A minority of patients did not show any improvement after 6 weeks. The present study shows that the dynamics of pressure pain due to whiplash injury can be quantified by means of PC-interactive pressure algesimetry. Our results confirm the clinical experience that the acute post-traumatic cervical syndrome normally subsides within weeks.     

Is self-efficacy and catastrophizing in pain-related disability mediated by control over pain and ability to decrease pain in whiplash-associated disorders?

Pain perception is influenced by several cognitive and behavioral factors of which some identified as mediators are important in pain management. We studied the mediating role of control over pain and ability to decrease pain in relation to functional self-efficacy, catastrophizing, and pain-related disability in patients with Whiplash-Associated Disorders, (WAD). Further, if the possible mediating impact differs over time from acute to three and 12 months after an accident, cross-sectional and prospective design was used, and 123 patients with WAD were included. Regression analyses were conducted to examine the mediating effect. The results showed that control over pain and ability to decrease pain were not mediators between self-efficacy, catastrophizing, and disability. Self-efficacy had a larger direct effect on pain-related disability compared to catastrophizing. Thus, healthcare staff should give priority to increase patients’ self-efficacy, decrease catastrophic thinking, and have least focus on control over pain or ability to decrease pain.     

Pain neurophysiology education improves cognitions, pain thresholds, and movement performance in people with chronic whiplash: a pilot study

Chronic whiplash is a debilitating condition characterized by increased sensitivity to painful stimuli, maladaptive illness beliefs, inappropriate attitudes, and movement dysfunctions. Previous work in people with chronic low back pain and chronic fatigue syndrome indicates that pain neurophysiology education is able to improve illness beliefs and attitudes as well as movement performance. This single-case study (A-B-C design) with six patients with chronic whiplash associated disorders (WAD) was aimed at examining whether education about the neurophysiology of pain is accompanied by changes in symptoms, daily functioning, pain beliefs, and behavior. Periods A and C represented assessment periods, while period B consisted of the intervention (pain neurophysiology education). Results showed a significant decrease in kinesiophobia (Tampa Scale for Kinesiophobia), the passive coping strategy of resting (Pain Coping Inventory), self-rated disability (Neck Disability Index), and photophobia (WAD Symptom List). At the same time, significantly increased pain pressure thresholds and improved pain-free movement performance (visual analog scale on Neck Extension Test and Brachial Plexus Provocation Test) were established. Although the current results need to be verified in a randomized, controlled trial, they suggest that education about the physiology of pain is able to increase pain thresholds and improve pain behavior and pain-free movement performance in patients with chronic WAD.     

Central hypersensitivity in whiplash: implications for physiotherapy assessment and management

Abstract

It is emerging that whiplash-associated disorder (WAD) is a complex condition characterised by a variety of physical and psychological features. Generalised sensory hypersensitivity is one of these features and its presence reflects augmented central pain processing mechanisms. Whilst most studies have investigated these processes in chronic WAD, it is becoming clear that in some of the whiplash injured, sensory disturbances are present from soon after injury, and are associated with both poor recovery and recalcitrance to multimodal physiotherapy interventions. Evidence for sensory hypersensitivity in WAD and possible underlying mechanisms of these phenomena are reviewed. Physiotherapists play an important role in the evaluation and management of whiplash injury. It is important that sensory disturbances be identified early in the clinical assessment of the whiplash injured patient and that ensuing management strategies address these changes, if the aim of treatment is to prevent the transition to chronicity.     

Sensory hypersensitivity occurs soon after whiplash injury and is associated with poor recovery

Hypersensitivity to a variety of sensory stimuli is a feature of persistent whiplash associated disorders (WAD). However, little is known about sensory disturbances from the time of injury until transition to either recovery or symptom persistence. Quantitative sensory testing (pressure and thermal pain thresholds, the brachial plexus provocation test), the sympathetic vasoconstrictor reflex and psychological distress (GHQ-28) were prospectively measured in 76 whiplash subjects within 1 month of injury and then 2, 3 and 6 months post-injury. Subjects were classified at 6 months post-injury using scores on the Neck Disability Index: recovered (<8), mild pain and disability (10-28) or moderate/severe pain and disability (>30). Sensory and sympathetic nervous system tests were also measured in 20 control subjects. All whiplash groups demonstrated local mechanical hyperalgesia in the cervical spine at 1 month post-injury. This hyperalgesia persisted in those with moderate/severe symptoms at 6 months but resolved by 2 months in those who had recovered or reported persistent mild symptoms. Only those with persistent moderate/severe symptoms at 6 months demonstrated generalised hypersensitivity to all sensory tests. These changes occurred within 1 month of injury and remained unchanged throughout the study period. Whilst no significant group differences were evident for the sympathetic vasoconstrictor response, the moderate/severe group showed a tendency for diminished sympathetic reactivity. GHQ-28 scores of the moderate/severe group were higher than those of the other two groups. The differences in GHQ-28 did not impact on any of the sensory measures. These findings suggest that those with persistent moderate/severe symptoms at 6 months display, soon after injury, generalised hypersensitivity suggestive of changes in central pain processing mechanisms. This phenomenon did not occur in those who recover or those with persistent mild symptoms.