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THE FOLLOWING LECTURE HAS BEEN APPROVED FOR ALL STUDENTS BY BIRMINGHAM CITY UNIVERSITY health.bcu.ac.uk/craigjackson . This lecture may contain information, ideas, concepts and discursive anecdotes that may be thought provoking and challenging.

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THE FOLLOWING LECTUREHAS BEEN APPROVED FOR

ALL STUDENTS

BY BIRMINGHAM CITY UNIVERSITY

health.bcu.ac.uk/craigjackson

This lecture may contain information, ideas, concepts and discursive anecdotes that may be thought provoking and challenging

Any issues raised in the lecture may require the viewer to engage in further thought, insight, reflection or critical evaluation


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Psychosocial

Aspects

of

Whiplash

Injury

Craig Jackson

Prof. of Occupational Psychology

Division of Psychology

BCU


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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



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RTA Figures

Kills: 1,200,000 per year

Injured: 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?


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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



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Mechanics of Occupant RTAs

Hazards: Steering wheel / column

Instrument panel

Seatbelt

Windscreens


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RTA Brain injuries

Contre-Coup

Concussion

Intracranial Haematoma – Epidural, Intracerebral, Subdural

Diffuse axonal injury


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  • 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


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Mechanics of Whiplash

Hyperextension HyperFlexion

Majority of cases, no injury can be identified

Symptoms attributed to musculo-ligamental sprain


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Mechanics of Whiplash

Accelerating Duration Acceleration Head-Neck Movement

Phase

Phase 1 0-60 msec. 0 g 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 + de 400 msec. 0.8 g Little flexion, back to starting position


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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


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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


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Whiplash as a “Pseudo Psychiatric” Condition?

American Psychological Association recognises 3 types “dissimulating” disorders

1. Malingering

2. Somatoform disorders

3. Factitious disorders

Doctors, alternative practitioners, scientists,

lawyers, and patients have colluded in promoting

a disorderthat now afflicts millions and costs

billions

While patientswho sustain serious neck injuries

have a good prognosis minorcollisions producing

no demonstrable tissue damage now resultin

lifelong disability in around 10% of cases


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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 patientswho are either consciously or unconsciously seeking an escapefrom the pressures of modern life into the roles of sicknessand victim-hood?

Do these conditions risk degrading medicine and bankruptinghealth services? Worst of all, they condemn patients to disorders fromwhich there is little hope of recovery

Malleson 2002


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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


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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


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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


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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


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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


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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


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Chronic Whiplash

Complex interaction between many factors:

Biological

Psychosocial Legal

Economics Beliefs / Attitudes

Psychological factors are also hypothesized to influence the existence of whiplash-related cognitive impairments.


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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


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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


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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


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  • Myths about Whiplash

  • “Whiplash Personality”

  • Malingering (for monetary gain) is common

  • Illness & Disability are biological phenomena

  • Men are more vulnerable than women

  • Direct impact upon neck is necessary for WAD

  • X-ray shows nothing so no WAD

  • Complaints are psychosomatic

  • Rest, time, muscle relaxants and tranquillisers cure the distress

  • Seatbelts would prevent injury


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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.


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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.


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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.


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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. 


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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


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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


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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.


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Predictors of Disability in Patients

Reportedfrequencies of disability ranging from 0% to 50% in follow-up studies

After 1 year, (7.8%) persons with whiplash injuryhad not returned to usual level of activity or work

Initiation of lawsuit within first monthafter injury did not influence recovery

The cervical range-of-motion test has a high sensitivityin 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


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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.


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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

Musculature

Acute stress response

Head position @ impact

Vulnerability

Low mental ability

Past mental illness

Older age

Female

Narrow spinal canal

Biomechanical

Neural structures

Joints

Musculature

Manual work, expectation of disability and an ongoing compensation claim case seem to be important moderator variables affecting symptom formation


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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 para-clinical findings

Karlsborg et.al 1997


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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


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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


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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


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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 long-term 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


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Expectation of Problems in Patients

Compared self-reported outcomes of physicians and non-physicians

Physicians Non-Physicians

Recall being in RTA? 71% 60%

Recall acute symptoms? 31% 46%

Symptoms lasting > 1 year? 9% 32%

Physicians symptoms were shorter than non-physicians

Physicians appear, however, to be more resistant than non-physicians to the progression from acute pain to chronic pain and disability.

Virani et.al 2001



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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


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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


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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


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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


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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?


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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 following settlement of compensation issue ? ? ?

Miller 1961


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Abnormal Illness Behaviour after Compensable Injury

Accident neurosis Accident victim syndrome

Aftermath neurosis American disease

Attitudinal pathosis Barristogenic illness

Compensatory hysteria Compensationitis

Compensation neurosis Fright neurosis

Functional overlay Greek disease

Greenback neurosis Invalid syndrome

Justice neurosis Perceptual augmenter

Post accident anxiety syndrome Pensionitis

Postaccident fibromyalgia Post-traumatic syndrome

Profit neurosis Psychogenic invalidism

Railway spine Secondary gain neurosis

Traumatic hysteria Symptom magnification syndrome

Traumatic neurasthenia Traumatic neurosis

Triggered neurosis Unconscious malingering

Vertebral neurosis Wharfie’s back

Whiplash neurosis

Mendelson, 1984


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  • 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


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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


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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 ? ? ?


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