Late Whiplash Research Articles

The whiplash injury phenomenon: a review of the literature

A single traumatic injury to the head, neck and temporomandibular joint that occurs during a sudden motor vehicle collision, is known as whiplash. In spite of the fact that whiplash injury is undefined and does not reflect the biomechanical events of motor vehicle accidents, temporomandibular symptoms may be associated with or occur independently of whiplash-associated disorders. The purpose of this review is to clarify whether a true correlation between temporomandibular joint (TMJ) dysfunc-tion and whiplash injury exists. To this aim, a PubMed/Medline search was conducted using the terms “temporomandibular dysfunction”, “jaw pain”, “temporomandibular joint”, “whiplash”, “motor-vehicle accidents” and “motor-vehicle collisions”. Over 200 related articles were reviewed. The incidence of TMJ dysfunction resulting from whiplash varies from low to moderate and the mechanism of injury is poorly understood. Oral health care providers should be aware of the possible influence of litigation following motor vehicle accidents and its association with the so-called late whiplash syndrome. To date, there is no direct correlation between whiplash injury and TMJ dysfunction. The effect of whiplash on TMJ function is limited in terms of duration and often disappears without complications. A systematic and careful approach is needed when treating TMJ symptoms after whiplash and a differential diagnosis should be considered when temporomandibular joint disorder manifestations occur long after the whiplash incidence.

Women with late whiplash syndrome have greatly reduced load-bearing of the cervical spine. In-vivo biomechanical, cross-sectional, lateral radiographic study.

No study has been conducted to ascertain whether the load-bearing capacity of the cervical spine is reduced in vivo in late whiplash syndrome (LWS). To compare the segmental cervical angular values across C0-C6, between two conditions: without versus with external axial load upon the head in three groups of women. A single-blind, age-Body Mass Index (BMI) matched, radiographic, cross-sectional study. Radiographic Department at a University Hospital. One hundred eighty-two women, aged between 18-50 years were enrolled. Participants were divided into 3 groups: a group with LWS (N.=62) and two control groups: a chronic insidious neck pain (IONP) group (N.=60) and an asymptomatic group (N.=60). Prior to and on the same day as the radiographic examination took place, BMI in kg/m2 was recorded and all participants answered the Neck Disability Index (NDI). The two symptomatic groups answered also three other pain and disability questionnaires. Analysis of variance (mixed-model ANOVA) for repeated measures was used for comparison. Significant differences between groups, and the two conditions tested was revealed, but only within the asymptomatic and the IONP groups (P<0.0001), but not within the LWS group (P=0.9433). Unexpectedly the women with LWS adopted a rigid horizontal translation strategy when external load was applied upon their head. The inter-rater and intra-rater segmental measurements were highly reliable. Women with LWS scored significantly higher on all questionnaires. The results of this study strongly indicate that the load-bearing capacity of the cervical spine is reduced in vivo in women with LWS. The study shows, for the first time, that the cervical spine in women with LWS predominately functions such as a rigid cylinder when loaded. The study implies that the cervical column is extremely weak in the LWS and that the superficial neck muscles, which are designed to move the head-neck, must compensate and act as rigid stabilizers. This causes great joint reaction forces through the cervical spine and its injured inert structures maintaining the pain and disability, as the results of the questionnaires show.

The prevalence of temporomandibular disorders in patients with late whiplash syndrome who experience orofacial pain: A case-control series study

Background The authors conducted a study to compare the frequency of specific temporomandibular disorder (TMD) diagnoses in patients who had late whiplash syndrome (LWS) with that in a control group. Methods The authors recruited 65 patients who had orofacial pain and a previous diagnosis of LWS and 65 age- and sex-matched control patients who had chronic orofacial pain without a history of whiplash injury (WI) for a case-control series study. All patients completed a questionnaire pertaining to the Research Diagnostic Criteria for Temporomandibular Disorders and underwent a clinical examination. Results The authors compared the frequency of TMD diagnoses in case patients with that in control patients by using a χ2 test; they set the α level a priori at .05. The number of patients diagnosed with myofascial pain (MP) and disk displacement with reduction (DDWR) was significantly higher in the case group than in the control group (P = .002 and P = .001, respectively). Conclusions The results of this study show a higher frequency of MP and DDWR in patients with LWS than in patients with chronic orofacial pain and no history of WI. Practical Implications Clinicians should be knowledgeable about the correlation between WI and TMD so they can inform and treat patients accurately.

Osteopathic Treatment of Patients with Long-Term Sequelae of Whiplash Injury: Effect on Neck Pain Disability and Quality of Life

The clinical sequelae and manifestation resulting from whiplash injury are defined as late whiplash syndrome (LWS). The objective of this study was to investigate whether a series of osteopathic treatments of patients with LWS may improve their symptoms. The study was designed as a two-phase (pre-post) clinical intervention study. In phase one, the patients received no treatment for 6 weeks; in phase two, they received five test-dependent osteopathic treatments. Forty-two (42) patients (mean age 39 years) suffering from LWS due to car rear-end collisions were included. Five (5) individualized and custom-tailored osteopathic treatments at 1-week intervals were performed. Main outcome parameters were the neck-related pain and disability (determined by the Neck Pain and Disability Scale [NPAD]) and the quality of life (assessed on the SF-36). The presence of a post-traumatic stress disorder (PTSD) was diagnosed. A direct comparison between the untreated period and the treatment period revealed clinically relevant and statistically significant improvements in the osteopathic treatment period for the NPAD. In the intervention phase, the NPAD dropped from 41.5 to 26.0 points, which corresponds to an improvement of 37% (95% confidence interval=11.1-19.8; p<0.0005). For the SF-36, both the physical and the mental component summary showed a significant and substantial improvement during treatment phase (p=0.009 versus p=0.02). Prior to treatment, 17 patients (43.6%) were diagnosed with a positive PTSD; this number fell to only 6 (15.4%) during observation. Five (5) osteopathic treatments had a beneficial effect on the physical as well as the mental aspects of LWS and lives up to its claim of being a complementary modality in the treatment regimen of this condition. Based on these preliminary findings, rigorous randomized controlled studies are warranted.

Begutachtung von Beschleunigungsverletzungen der Halswirbelsäule

Formulating an expert opinion on whiplash injuries requires that consideration be given to biomechanical, orthopedic, neurological, psychiatric and medicolegal aspects. The greatest difficulties are encountered in cases of mild whiplash where patients complain of constant pain without any physical correlative. Diverse assessments and principles for approving a claim are reflected in the fact that the prevalence of chronic spine pain after whiplash injuries (late whiplash syndrome) varies between 16% and 71% in different countries, and the proportion of whiplash injuries involved in petitions for compensation differs greatly across Europe (UK 75%, Germany 47%, Finland 8.5% and France 3% of all personal injuries).Important biomechanical, orthopedic, neurological, psychiatric and medicolegal aspects of expert testimony on whiplash associated disorders (WAD) are delineated.

Are Symptoms of Late Whiplash Specific? A Comparison of SCL-90-R Symptom Profiles of Patients with Late Whiplash and Patients with Chronic Pain Due to Other Types of Trauma

Focusing on symptoms referred to as specific for late whiplash may contribute to misconceptions in assessment, treatment, and settlements. We compared Symptom Checklist 90-Revised (SCL-90-R) symptom profiles of patients with late whiplash and patients with chronic pain due to other types of trauma. We compared 156 late whiplash patients (WP group) with 54 chronic pain patients who had suffered different bodily trauma (non-WP group) with regard to the following aspects of the SCL-90-R: the Positive Symptom Total (PST); the nine SCL-90-R dimensions and additional global indices, i.e., Global Severity Index (GSI) and Positive Symptom Distress (PSD); and complaints referred to as specific for late whiplash syndrome. The mean adjusted T score for PST was in the normal range for the WP group (T = 56.1, 95% CI 54.1-58.1) and in the pathological range for the non-WP group (T = 61.1, 95% CI 57.3-64.9). Both the WP and non-WP groups showed mean T scores in the pathological range for the dimensions "Somatization," "Obsessive-Compulsive," and PSD. Only the non-WP group had an average score in the pathological range for the dimensions "Depression," "Anxiety," and "Phobic Anxiety" and for the global indices GSI and PST. Multivariable regression controlling for gender and education level was used to identify complaints "specific for late whiplash" that were significantly associated with being in the WP group rather than the non-WP group: greater headache (OR 1.54; 95% CI 1.16, 2.03; p = 0.003) and lower emotional lability (OR 0.96; 95% CI 0.93, 0.98; p = 0.003) were the only significant variables. Late whiplash is not a chronic pain condition characterized by specific symptoms, other than greater headache.

Comparison of randomized treatments for late whiplash

To compare 4 different treatment strategies in patients with late whiplash syndrome. Patients were randomly assigned to one of the following treatment groups: infiltration, physiotherapy, or medication. Group allocation was stratified according to gender, age, and education. Additionally, patients of each group were randomized 1:1 to cognitive-behavioral therapy (CBT) or no CBT. Patients were assessed at baseline, after an 8-week treatment period, and 3 and 6 months later. Main outcome measures were subjective outcome rating, pain intensity, and working ability. Of 91 enrolled patients, 73 completed the study; 62% were women. After treatment, 47 patients (64%) were subjectively improved (48%), or free of symptoms (16%), with a preponderance of women (73% vs 50%, p = 0.047). There was no difference regarding outcomes among the 3 treatment groups in men and women. The most robust difference was achieved with CBT, associated with a higher rate of recovery (23% vs 9%), and improvement (53% vs 42%) (p = 0.024), and with a gender difference (p = 0.01). All treatments significantly improved pain intensity and working ability. Intensive therapy in late whiplash syndrome can achieve improvement of different outcome measures including working ability in two-thirds of patients, more effective in women, persisting beyond 6 months in half. Additional cognitive-behavioral therapy was the most effective treatment modality. This interventional study provides Class III evidence that CBT used as an adjunct to infiltration, medication, or physiotherapy increases improvement rates in persons with late whiplash syndrome.

Dr. Harth replies

To the Editor: First, let us get a little detail in perspective, before dealing with more momentous matters. Russell and Ferrari point out that the article by Karnezis, et al 1, which I cited2, referred to Greek late whiplash sufferers who were all litigants — that is a highly selected group so “that generalizing their findings to the clinical population is impossible”. Quite right. The reason for citing it was that in … Address reprint requests to Dr. M. Harth, AIM Health Group, 140 Oxford Street East, Suite 300, London, Ontario N6A 5R9.

Alteraciones del control postural en fases iniciales del latigazo cervical

Background and objective Dizziness of variable intensity is a frequent complaint in patients who suffered whiplash and largely documented balance disturbances. The objective of the study was to identify balance disorders in early stage of whiplash after road traffic accidents. Patients and method Ninety nine women were included in the study. Fifty four women had suffered whiplash within two weeks and 45 were included in a healthy control group. Static posturography on a force platform was carried out in all study participants, by means of the Romberg test in four sequential phases, using the postural sway area (SA) as a dependent variable. Visual Analogic Scale (VAS) and Northwick Park Neck Pain Questionnaire (NPH) were used to evaluate pain and function. Results Postural sway area increased significantly in each of the consecutive phases in both groups. The differences of the means of the postural sway area were statistically significant in all Romberg phases ( p=.009 to P=.000). No correlation was found between SA and VAS or NPH scores. There was a positive correlation between the postural sway area standing on a thick foam cushion placed over the plate with closed eyes and the number of days of transitory incapacity ( r=0.414; P=.009). Conclusions Patients with recent whiplash show a postural control disturbance revealed trough a sequential static posturography analysis. This suggests that the balance disorder is not only a consequence of late whiplash syndrome evolution. Therefore, we should promote early instauration of a specific therapeutic approach if and when the patient refers dizziness and related symptoms.

Stopping Late Whiplash: Which Way to Utopia?

There is a story about a science professor giving a public lecture on the solar system. An elderly lady interrupts to claim that, contrary to his assertions about gravity, the world travels through the universe on the back of a giant turtle. “But what supports the turtle?” retorts the professor. “You can’t trick me, says the woman, “it’s turtles all the way down.” (The Economist, July 19-25, 2008, p. 79)

ESJ: expert comment on number and cost of claims linked to minor cervical trauma (manuscript number: ESJO-D-07-00195R1, B. Soltermann et al.)

ESJ: expert comment on number and cost of claims linked to minor cervical trauma (manuscript number: ESJO-D-07-00195R1, B. Soltermann et al.)

Late Whiplash Syndrome: A Clinical Science Approach to Evidence‐Based Diagnosis and Management

The purpose of this article is to narrow the gap that exists in the clinical application of scientific research and empiric evidence for the evaluation and management of late whiplash. Considering that 14% to 42% of patients are left with chronic symptoms following whiplash injury, it is unlikely that only minor self-limiting injuries result from the typical rear-end impact. As psychosocial issues play a role in the development of persistent whiplash symptoms, discerning the organic conditions from the biopsychosocial factors remains a challenge to clinicians. The term "whiplash" represents the multiple factors associated with the event, injury, and clinical syndrome that are the end-result of a sudden acceleration-deceleration trauma to the head and neck. However, contentions surround the nature of soft-tissue injuries that occur with most motor vehicle accidents and whether these injuries are significant enough to result in chronic pain and limitations. The stark contrast in litigation for whiplash that exists among industrialized nations and less developed countries suggests another factor that could influence one's interpretation of symptoms' chronicity associated with Late Whiplash Syndrome. There are no gold standard tests or imaging techniques that can objectify whiplash-associated disorders. A lack of supporting evidence and disparity in medico-legal issues have created distinct camps in the scientific interpretations and clinical management of late whiplash. It is likely that efforts in research and/or clinical practice will begin to explain the disparity between acute and chronic whiplash syndrome. Recent evidence suggests that Late Whiplash Syndrome should be considered from a different context. The purpose of this article is to expound on several of the significant findings in the literature and offer clinical applications for evaluation and management of Late Whiplash Syndrome.

A Systematic Literature Review of Physical Prognostic Factors for the Development of Late Whiplash Syndrome

Systematic Review. To summarize evidence concerning physical prognostic factors for development of Late Whiplash Syndrome (LWS). There have been 3 previous systematic reviews of prognosis of whiplash with conflicting findings. The Quebec Task Force concluded that high priority should be given to determining prognostic factors. Subsequently their review was updated by Cote et al (Spine 2001;26:E445-58) and most recently by Scholten-Peeters et al (Pain 2003;104:303-22). We searched electronic databases from their inception to August 2006 using a prespecified search strategy. We included prospective cohort and case control studies that studied physical prognostic factors at baseline. Two independent reviewers selected articles, extracted data, and assessed quality. Meta-analysis was not performed due to the heterogeneity between studies. Instead, levels of evidence were generated by grouping similar findings from cohorts. Thirty-eight articles from 26 cohorts were reviewed. The majority of articles (25 of 38) were rated as low quality. No studies were rated as high quality. Only a minority of studies used validated prognostic measures and/or outcome measures. High initial neck pain intensity, neck pain related disability, and cold hyperalgesia all had moderate evidence for an association with the development of LWS. No factor was rated as having strong evidence. Pain has a central role to play as a prognostic factor for the development of LWS. Other physical factors commonly used in the clinical setting showed inconclusive evidence for their influence on prognosis. There is a need for improved quality of studies with consistent use of validated measures of all categories of prognostic factors and outcome. This may then provide a clearer understanding of prognosis of Whiplash Associated Disorders and therefore facilitate effective management of this costly problem.

A systematic literature review of psychological factors and the development of late whiplash syndrome

This systematic literature review aims to assess the prognostic value of psychological factors in the development of late whiplash syndrome (LWS). We included prospective cohort studies that provided a baseline measure of at least one psychological variable and used outcome measures relating to LWS (i.e. pain or disability persisting 6 months post injury). A search of electronic databases (Pubmed, Medline, Cinahl, Embase and Psychinfo) up to August 2006 was done using a predetermined search strategy. Methodological quality was assessed independently by two assessors. Data extraction were carried out using a standardised data extraction form. Twenty-five articles representing data from 17 cohorts were included. Fourteen articles were rated as low quality with 11 rated as adequate quality. Meta-analysis was not undertaken due to the heterogeneity of prognostic factors, outcome measures and methods used. Results were tabulated and predefined criterion applied to rate the overall strength of evidence for associations between psychological factors and LWS. Data on 21 possible psychological risk factors were included. The majority of findings were inconclusive. Limited evidence was found to support an association between lower self-efficacy and greater post-traumatic stress with the development of LWS. No association was found between the development of LWS and personality traits, general psychological distress, wellbeing, social support, life control and psychosocial work factors. The lack of conclusive findings and poor methodological quality of the studies reviewed highlights the need for better quality research. Self-efficacy and post-traumatic distress may be associated with the development of LWS but this needs further investigation.

Physical therapy and active exercises – An adequate treatment for prevention of late whiplash syndrome?: Randomized controlled trial in 200 patients

The aim of this study was to compare the effect of a physical therapy regimen including active exercises with the current standard treatment on reduction of pain 6 weeks and 6 months after whiplash injury caused by motor vehicle collision. Two hundred patients were enrolled in a prospective randomized controlled trial. In the standard group, treatment consisted of immobilization with a soft collar over 7 days. In the physical therapy group, patients were scheduled for 10 physical therapy appointments including active exercises within 14 days after enrollment. Pain intensity was rated by all patients daily during the first week, the sixth week, and 6 months after recruitment, using a numeric rating scale (0–10). Data analyses were performed by comparing the mean (over 1 week) pain scores between the two different treatment groups. Ninety-seven patients were randomly assigned to the standard treatment group and 103 to the physical therapy group. During the first week, there was no significant difference in mean pain intensity between the standard treatment group (4.76 ± 2.15) and the physical therapy group (4.36 ± 2.14). However, after 6 weeks, mean pain intensity was significantly ( p = 0.002) lower in the physical therapy group (1.49 ± 2.26 versus 2.7 ± 2.78). Similarly, after 6 months, significantly ( p < 0.001) less pain was reported in the physical therapy group (1.17 ± 2.13) than the standard treatment group (2.33 ± 2.56). We conclude that a physical therapy regimen which includes active exercises is superior in reducing pain 6 weeks and 6 months after whiplash injury compared to the current standard treatment with a soft collar.

Altered cerebral blood flow in chronic neck pain patients but not in whiplash patients: a 99mTc-HMPAO rCBF study

A cross-sectional study to investigate regional cerebral blood flow (rCBF) in patients with chronic whiplash syndrome and chronic neck pain patients without previous history of trauma along with a healthy control group. Chronic neck pain is a common disorder and a history of cervical spine injury including whiplash trauma constitute a risk factor for persistent neck pain. The aetiology of the late whiplash syndrome is unknown with no specific diagnostic criteria based on imaging, physiological, or psychological examination. Earlier studies indicate a parieto-occipital hypoperfusion but it is unclear if the hypoperfusion represents a response to chronic pain. The rCBF was monitored in 45 patients with chronic neck pain: 27 cases with chronic whiplash syndrome and 18 age and gender matched cases with non-traumatic chronic neck pain. The rCBF was estimated with single-photon emission computed tomography (SPECT) using technetium-99m hexamethylpropylene amine oxime (HMPAO). The non-traumatic patients displayed rCBF changes in comparison with the whiplash group and the healthy control group. These changes included rCBF decreases in a right temporal region close to hippocampus, and increased rCBF in left insula. The whiplash group displayed no significant differences in rCBF in comparison with the healthy controls. The present study suggests different pain mechanisms in patients with chronic neck pain of non-traumatic origin compared to those with chronic neck pain due to a whiplash trauma.

Can Kinesiophobia Predict the Duration of Neck Symptoms in Acute Whiplash?

In low back pain, clinical studies suggest that kinesiophobia (fear of movement/(re)injury) is important in the etiology of chronic symptoms. In this prospective cohort study, the predictive role of kinesiophobia in the development of late whiplash syndrome was examined. Victims of car collisions with neck symptoms who initiated compensation claim procedures with a Dutch insurance company were sent a questionnaire containing symptom-related questions and the Tampa Scale of Kinesiophobia (TSK-DV). Follow-up questionnaires were administered 6 and 12 months after the collision. Survival analysis was used to study the relationship between the duration of neck symptoms and explanatory variables. Of the 889 questionnaires sent, 590 (66%) were returned and 367 used for analysis. The estimated percentage of subjects with neck symptoms persisting 1 year after the collision was 47% (SE 2.7%). In a regression model without symptom-related variables, kinesiophobia was found to be related to a longer duration of neck symptoms (P=0.001). However, when symptom-related information was entered into the model, the effect of kinesiophobia did not reach statistical significance (P=0.089). Although a higher score on the TSK-DV was found to be associated with a longer duration of neck symptoms, information on early kinesiophobia was not found to improve the ability to predict the duration of neck symptoms after motor vehicle collisions.

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.

Study to evaluate osteopathic treatment in late whiplash syndrome

Study to evaluate osteopathic treatment in late whiplash syndrome

The Case for and Against the MIST (Minor Impact Soft Tissue) Premise

AbstractMIST is an acronym for Minor Impact Soft Tissue. The term arises from the premise that a minimal damage motor vehicle collision cannot result in lasting or significant injury. The literature concerning late whiplash is reviewed, focusing on medical research that supports and refutes the MIST concept.Background. Minor Impact Soft Tissue (MIST) is a descriptive term coined by Allstate Insurance Corporation in 1996 as a means of identifying a segment of patients that are unlikely to sustain chronic symptoms following whiplash and in whom it is presumed that chronic complaints of pain are a psychosocial phenomenon. The MIST concept is based on the assertion that chronic pain following whiplash is not an organic phenomenon. No systematic review of the literature either supporting or refuting the MIST concept has ever been published.Objectives. To review the medical literature for evidence that chronic (late) whiplash is an organic disorder versus a largely psychosocial phenomenon.Methods. The medical l...