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health.bcu.ac.uk/craigjackson
Psychosocial
Aspects
of
Whiplash
Injury
Craig Jackson
Prof. of Occupational Psychology
Head of Division of Psychology
BCU
Whiplash
Harold Crowe in 1928, first used term to describe movement of
neck in accident
Acceleration then Deceleration
Now describes “injuries” induced by this motion
Arthur E Davis in Erie, Penn. first used term in 1945
“Most patients recovered well”
Used in 1953 in relation to auto-accidents (Gay & Abbott)
Used the term “psychoneurotic reaction” to explain delayed
recovery
RTA Figures
RTA Figures
Kills:
Injured:
1,200,000 per year
10,000,000 per year
RTA most common cause of Head Injury
Most Head Injuries are mild
Many left with long-lasting problems
Young males at biggest risk – alcohol often implied
Data suggests female drinking habits catching up with males
Implications for Female RTAs?
RTA Figures
80% of serious RTA injury is to head
1 concussion every 15 seconds in USA
Head Injury major cause of death and injury in RTAs
15,000,000 Brain Injuries per year in USA
RTAs
Playgrounds
Sports
1990 - 5,563,000 intra-cranial injuries worldwide from RTA
Murray et.al 1996
Psychological de-briefing after RTAs may help
Hobbs et.al 1996
RTA Figures
Mechanics of Occupant RTAs
Hazards:
Steering wheel / column
Instrument panel
Seatbelt
Windscreens
RTA Brain injuries
Contre-Coup
Concussion
Intracranial Haematoma – Epidural, Intracerebral, Subdural
Diffuse axonal injury
How are Brain Injuries Assessed?
PAA
Post Accident Amnesia – memory problems when regaining
consciousness
• Minor Brain Injury
Unconscious for < 15 mins
• Moderate Brain Injury
Unconscious > 15 mins but < 6 hrs + PTA < 24 hrs
• Severe Brain Injury
Unconscious > 6 hrs OR PTA > 24 hrs
• Very Severe Brain Injury
Unconscious > 48 hrs OR PTA > 7 days
Mechanics of Whiplash
Hyperextension
HyperFlexion
Majority of cases, no injury can be identified
Symptoms attributed to musculo-ligamental sprain
Mechanics of Whiplash
Accelerating
Phase
Duration
Acceleration
Head-Neck Movement
Phase 1
0-60 msec.
0g
Rest State
Phase 2
60-120 msec.
0.3 g
Head rise, neck flexion and
backbone extension
Phase 3
120-200 msec.
4.3 g
Neck extension
Phase 4
200-300 msec.
2.8 g
Head and neck
hyperextension
Phase 5
300-400 msec.
1.0 g
Head forwards with neck
flexion (whiplash)
Phase 6
starting
+ de 400 msec. 0.8 g
Little flexion, back to
position
Whiplash Associated Disorder
Transfer of energy into the neck
May result from rear-end or side
impact collision
Can occur with other accidents
Impact of injury can occur on soft tissue and bone in the neck
Can lead to a variety of clinical
presentations known as WAD
Whiplash injury feasible at 5 MPH
85% of UK RTA injury insurance claims
Whiplash Statistics
USA 1995:
5.5 million people involved in traffic accidents
53% of them suffered whiplash injury
Germany 1992:
395,462 traffic accidents
197,731 (49%) suffered whiplash injury
Whiplash as a “Pseudo Psychiatric” Condition?
American Psychological
“dissimulating” disorders
Association
recognises
1. Malingering
2. Somatoform disorders
3. Factitious disorders
Doctors, alternative practitioners, scientists,
lawyers, and patients have colluded in promoting
a disorder that now afflicts millions and costs
billions
While patients who sustain serious neck injuries
have a good prognosis minor collisions producing
no demonstrable tissue damage now result in
lifelong disability in around 10% of cases
3
types
Whiplash as a “Pseudo Psychiatric” Condition?
One of a family of fashionable conditions, including:
Fibromyalgia
Repetitive strain injury
Chronic fatigue syndrome
Occupational back pain
Chronic pain syndrome
Are these diagnoses are offered to patients who are either
consciously or unconsciously seeking an escape from the
pressures of modern life into the roles of sickness and victimhood?
Do these conditions risk degrading medicine and bankrupting
health services? Worst of all, they condemn patients to
disorders from which there is little hope of recovery
Malleson 2002
Prevention is OK Lots of research in area of whiplash injury prevention
Cars better at preventing injury than ever before
Not much known about prevention of chronic pain after incident
Some treatment may foster chronic pain
Quebec Task Force on Whiplash
Extensive literature review of work from 1980 – 1993
10,382 papers examined
Only 62 (0.6%) were relevant and scientifically good
Papers before 1980 generally of little clinical / scientific value
Pathophysiology – a Sprain
Majority of whiplash injuries arise in soft tissue injury to neck
involving ligaments, joints, joint capsules, muscles and
tendons
Type 1:
Injury at microscopic level without altering
structure
Type 2:
Partial tear at macroscopic level no separation
Type 3:
Severe stretching and tearing with separation of
tissues
Whiplash Associated Disorders (WAD)
Classed by severity of signs and symptoms
WAD 0
No complaints or physical signs
WAD 1
Neck complaints but no physical signs
WAD 2
Neck complaints and musculoskeletal signs
WAD 3
Neck complaints and neurological signs
WAD 4
Neck complaints and fracture / dislocation
Most whiplash injury results from low impact collisions
Prolonged and Escalated Symptoms
Excess stress
Psychosocial difficulties
Anxiety (approx 40%)
Depression (approx 40%)
PTSD
Poor sleep
Ear pain
Poor posture
Dizziness
Memory problems
Concentration problems
Headaches
Movement difficulty
10% have WAD symptoms for > 2
years after accident:
Caused by. . .
Poor sleep
Depression, Anxiety, Stress
Psychosocial difficulties
Pre-existing conditions
Inappropriate therapeutics
Prolongation of litigation
Post Traumatic Fibromyalgia?
Saskins & Moldofsky 1986
11 cases of PTFS
Generalised pain on 11 of 18 designated
tender points
A happy marriage of Whiplash and Fibromyalgia?
Post Traumatic Fibromyalgia abandoned in 1994
Wolfe 1996
Chronic Whiplash
Complex interaction between many factors:
Biological
Psychosocial
Economics
Legal
Beliefs / Attitudes
Psychological factors are also hypothesized to influence
the existence of whiplash-related cognitive impairments.
Other Countries 1
Mills & Horne 1986 – New Zealand
Very low incidence
Significantly lower than Australia
Difference in process of dealing with:
insurance companies
lawyers
therapists
Awerbuch 1992 - Australia
WAD claims dropped from 6000 to 2000 / year in 1987
Legislative changes limited compensation and claim sizes
Claimants had to: bear initial cost of claim
report to police
have minimum 30% disability
Other Countries 2
Cassidy et.al 1995 – Canada
27% reduction in claims under a “no fault system” in courts
Statute of limitations to 200 days after accident
“No Crash No Cash”
Obelieniene 1999 – Lithuania
No notion of chronic pain resulting from rear end collision
No fear of long term disability
No involvement of lawyers
Partheni et.al 1997 – Greece
91% of WAD victims recover in 4 weeks
Treatments – Quebec Task Force (1995)
Most studies show little or no efficacy of treatments
Collar and NSAIDs on short term basis
Avoid long term physiotherapy
Mobilization by trained person & active exercise for grade 2 & 3
Drugs for insomnia or anxiety
Early return to activities and promote mobility
Myths about Whiplash
1. “Whiplash Personality”
2. Malingering (for monetary gain) is common
3. Illness & Disability are biological phenomena
4. Men are more vulnerable than women
5. Direct impact upon neck is necessary for WAD
6. X-ray shows nothing so no WAD
7. Complaints are psychosomatic
8. Rest, time, muscle relaxants and tranquillisers cure the
distress
9. Seatbelts would prevent injury
Case Summary of a Whiplash Patient
Male, Age 34.
Head Injury, Whiplash, Headaches, Sleep Disorder, Fatigue.
Suffered a head injury during an auto accident in which he was
rear-ended at 50mph. He described severe pain in his neck and
back and headaches that originated at the base of his skull and
spread to his left eye. His pain was so severe that it prevented
him from sleeping, so he suffered from severe fatigue. To
maintain some level of function during the day, he relied on
multiple caffeinated beverages such as jolt or bull colas and/or
coffee. At the time of his initial upper cervical chiropractic
evaluation (14 months after the accident), he had been suffering
with all of the above symptoms for over a year. He had sought
help from numerous practitioners including physicians,
neurologists, and therapists, to no avail. He reported receiving
some temporary relief from Pilates.
Case Summary of a Whiplash Patient
Female, Age 56.
Neck Pain, Headaches, Chronic Fatigue.
Suffered from chronic neck pain, headaches, and fatigue for
years. She thought the problems may have started sometime
after an auto accident she experienced 14 years before. During
the accident, she was hit head-on and totalled her car. The pain
bothered her on and off for years-- sometimes on a daily basis
and other times a month would go by without pain. She tried
many practitioners such as massage therapists and
chiropractors and received some relief but still the problem
continued year after year. Finally, after struggling over a
decade, she sought help from upper cervical chiropractic care.
Case Summary of a Whiplash Patient
Female. Age 52.
Migraine Headaches, Neck Pain, Whiplash, Head Injury.
Involved in two auto accidents three years apart. The first
accident (she was rear-ended) caused migraines, neck pain,
and head injury symptoms, including insomnia, depression,
memory loss, and inability to multi-task. These symptoms were
worsened after her second auto accident in which she was also
rear-ended. She tried multiple therapies including physical
therapy, chiropractic care, cranial sacral therapy, as well as
medications from her neurologist but she could hardly function
due to severity of her cognitive symptoms and pain.
Case Summary of a Whiplash Patient
Female, Age 49.
Headaches, Neck Pain, Loss of Sense of Taste
Involved in 6 different auto accidents during a 5-year period.
After each accident, she suffered increased pain in her neck
and head. Her third accident was most severe in that she
suffered a head injury. After that accident, in addition to
experiencing an increase in pain, she lost her sense of taste.
Her neurologist told her the damage to the nerves controlling
taste was most likely permanent and due to the head injury. She
tried many forms of treatment over the years including pain
pills, chiropractic care, and physical therapy. Sometimes she
received benefit, sometimes not, but the results were never
consistent or long lasting. After struggling for 8 years with
headaches and neck pain and 6 years with loss of her sense of
taste, she sought help from upper cervical chiropractic care.
Chronic Patient’s Attributions of Ill-Health
Work
Environment
Chemicals
Stress
Toxins
Virus
Allergies
Anatomy / Ergonomic
Traumatic injury
Non-Traumatic injury
Living in a litigious society
“Victim” culture
Living in a “risk-controlled” world
Someone must therefore always be to blame
Urgency of Treatment?
Poor knowledge of management of acute whiplash symptoms
Best early treatment involves:
1) Frequently repeated active sub-maximal movements
2) Mechanical diagnosis
3) Therapy
More effective in reducing pain than standard program of:
a) Initial rest
b) Use of a soft collar
c) Gradual self-mobilization
This therapy could be performed as home exercises initiated
and supported by a physiotherapist
Rosenfeld et.al 2000
Treatment For Patients – Cochrane Review 2004
15 studies met the inclusion criteria – only 3 were good quality
Overall a poor methodological quality
Passive & Active interventions more effective than no treatment
Found conflicting evidence about the effectiveness of active
interventions compared to passive ones
Data of the high quality studies were conflicting
‘Rest makes rusty', can no longer be justified
There is a suggestion that active interventions are more
effective than passive ones, but no clear conclusion about
chronic WAD can be drawn.
Predictors of Disability in Patients
Reported frequencies of disability ranging from 0% to 50% in
follow-up studies
After 1 year, (7.8%) persons with whiplash injury had not
returned to usual level of activity or work
Initiation of lawsuit within first month after injury did not
influence recovery
The cervical range-of-motion test has a high sensitivity in
prediction of handicap after acute whiplash injury
Kasch et.al 2001
WAD patients' self-efficacy at an early stage after injury
significantly predicts the development of pain intensity and
disability. Patients' confidence in performing daily activities
should be reinforced in order to optimize treatment after injury
Kyhlback et.al 2002
Cognitive Dysfunction in Patients
Bosma & Kessells 2002
WAD Patients often experience cognitive impairments
Neuro(psycho)logical test results do not always support this
WAD Patients performed similarly to neurology patients on the
cognitive tasks and performed worse on memory and attention
tasks compared with the control group
WAD Patients had high scores on subscales measuring
somatization and displayed a palliative coping style
Somatization, in combination with inadequate coping, might
play a role in the development, persistence, or aggravation of
whiplash-related symptoms, such as pain or cognitive
dysfunction.
Prognostic Factors in Patients
Malt & Sundet 2002
15% of WAD patients suffer long lasting health problems
5% do not return to work
Psychosocial impairment following injury is influenced by:
Symptom Formation
Vulnerability
Biomechanical
Low mental ability
Past mental illness
Older age
Female
Narrow spinal canal
Neural structures
Joints
Musculature
Musculature
Acute stress response
Head position @ impact
Manual work, expectation of disability and an ongoing
compensation claim case seem to be important moderator
variables affecting symptom formation
Prognostic Factors in Patients
Psychological factors more important than crash parameters
(e.g. velocity) in predicting course of WAD at 6 months
Greater initial pain or symptoms persisting for 28 days were
associated with reduced QoL and PTSD symptoms
Richter et.al 2004
Stress at time of accident predicted > symptoms at follow-up
Long-lasting distress and poor outcome were more related to
the occurrence of stressful life events than to clinical and paraclinical findings
Karlsborg et.al 1997
Prognostic Factors in Patients
WAD patients 2 times sensitive to cold in neck
Overall elevated level of distress > in the WAD gp than controls
Neither vibration or heat caused different responses
Pain in response to non-noxious stimulation over presumably
healthy tissues suggests that central mechanisms are
responsible for ongoing pain in at least some whiplash patients
Moog et.al 2002
WAD patients have lower pain thresholds for electrical stimulus
Hypersensitivity to peripheral stimulation in WAD patients
Curatolo et.al 2001
Hassles and Daily Problems in Patients
“Everyday Problem Checklist” (EPCL) scores were higher in
WAD patients than healthy controls
Chronic WAD patients report a high stress load
WAD patients (especially those with a low educational level)
appear to be more vulnerable and react with more distress than
healthy people to all kinds of stressors
Stress responses probably play an important role in the
maintenance or deterioration of whiplash-associated complaints
Blokhorst et.al 2002
Anxiety and Depression in Patients
Depression & Anxiety 2 years before accident, significantly
overlaps with WAD patients
Wenzel et.al 2002
Depression & Anxiety greater in WAD patients than controls
Those with longest history of pain gave highest ratings of pain
Those with longest history of pain were most depressed
Most of these patients were involved in litigation.
Whiplash injury sufferers are anxious and depressed
Their psychological distress could be aggravated by litigation
Lee et.al 1993
Pre-injury Psychiatry in Patients
Outcome measured for 33 WAD patients and correlated with a
range of pre-accident variables
No association between pre-accident psychiatric factors and
overall outcome
Older age and pre-accident history of MSD complaints
correlated with physical and psychiatric outcomes
Pre-accident psychiatric factors may have little bearing on longterm prognosis
Outcome of late whiplash syndrome is probably worse in older
individuals and in patients with a pre-accident history of MSD
complaints
Turner et.al 2003
Expectation of Problems in Patients
Compared self-reported outcomes of physicians and nonphysicians
Physicians
Non-Physicians
Recall being in RTA?
71%
60%
Recall acute symptoms?
31%
46%
9%
32%
Symptoms lasting > 1 year?
Physicians symptoms were shorter than non-physicians
Physicians appear, however, to be more resistant than nonphysicians to the progression from acute pain to chronic pain
and disability.
Virani et.al 2001
Cognitive Model of Physical Symptoms in WAD
Preventing Chronicity of Pain
Teach professionals
Educate patients
Avoid anxiety provoking terms e.g. “PTFS” or “disc bulge”
Avoid excessive investigation & test – Iatrogenesis
Be rational
Avoid prolonged litigation involvement
Make patient aware of lengthy outcomes of litigation
Patient Education
Explain benign nature of WAD
Avoid confusing and conflicting info
Watch for factors leading to pain chronicity
Home / work programmes as effective as physiotherapy
Teach relaxation and stress management
Educate posture and neck care
Ergonomics at home and work
Home program of heat and cold & exercises
Self Monitor stress, sleep and mood
Headaches
Avoid excessive investigation
Acute Rational Care
Take good history
Physical examination
X-ray of cervical spine
Analgesics and muscle relaxants
Use of local cold and heat
Cervical collar for a few days
NSAIDS for few weeks
Gradual mobilization
Correction of disturbed sleep
Compensation Neurosis
Pending litigation
Treatment results often poor
Some overt malingering
Exaggerated illness due to:
suggestion
+
somatization
rationalization
+
distorted sense of justice
victim status
+
entitlement beliefs
Adverse legal / admin. systems
Harden patient’s convictions
With time, care-eliciting behaviour may remain permanent
Bellamy, 1997
Compensation Neurosis
Improvement in health.....
...may result in loss of status
Patient compelled to guard against getting better
Financial reward for illness is a powerful nocebo
Exacerbates illness
In a litigious society, will compensation neurosis become more
widespread?
Accident Neurosis
Failure to improve with treatment until compensation issue
settled
Accident must occur in circumstances with potential for
compensation payment
Inverse relationship to severity of injury - Accident neurosis rare
in cases of severe injury
Low socio-economic status favors accident neurosis
Complete
recovery common
compensation issue ? ? ?
following
settlement
of
Miller 1961
Abnormal Illness Behaviour after Compensable Injury
Accident neurosis
Aftermath neurosis
Attitudinal pathosis
Compensatory hysteria
Compensation neurosis
Functional overlay
Greenback neurosis
Justice neurosis
Post accident anxiety syndrome
Postaccident fibromyalgia
Profit neurosis
Railway spine
Traumatic hysteria
Traumatic neurasthenia
Triggered neurosis
Vertebral neurosis
Whiplash neurosis
Accident victim syndrome
American disease
Barristogenic illness
Compensationitis
Fright neurosis
Greek disease
Invalid syndrome
Perceptual augmenter
Pensionitis
Post-traumatic syndrome
Psychogenic invalidism
Secondary gain neurosis
Symptom magnification syndrome
Traumatic neurosis
Unconscious malingering
Wharfie’s back
Mendelson, 1984
Secondary Gain Pre-disposition
Potential Claimants
• Military patients nearing severance
• Workers under retirement age
• Workers soon to be made redundant
•Low job satisfaction
• Members of support groups
Non-economic motivation
Loneliness
Depression
Anxiety
Difficulty expressing emotional pain
Previous history of attention seeking when ill
Summary of Whiplash
Most common injury following RTA (Spitzer et al. 1995)
Sufferers no more likely to be worriers or have psychiatric
problems than non-suffers who had RTAs
Sufferers more likely to find an accident frightening and be the
innocent party than non-suffers who had RTAs
33% of sufferers have psychiatric complications at 1 year after
accident
No “psychology of whiplash” – many physical and
psychological interactions combine together to produce a
complicated clinical problem
Finally. . .
It’s a sexual thing – theory that anal retentive people (especially
females) find being shunted / rear-ended to be distressing
Is psychoanalytic theory any more unlikely than that of other
whiplash theories ? ? ?