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Symptoms, disabilities, and life satisfaction five years after whiplash injuries

  • Johan Styrke , Peter Sojka , Ulf Björnstig and Britt-Marie Stålnacke EMAIL logo
Published/Copyright: October 1, 2014
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Abstract

Background

Chronic whiplash-associated disorders (WADs) are often associated with social functioning problems and decreased ability to perform previous activities. This may lead to decreased life satisfaction, which is insufficiently studied in the context of whiplash injuries. Symptoms included in chronic WAD are similar to symptoms frequently reported by persons who have sustained mild traumatic brain injury (MTBI)/concussion. In cases of MTBI, the severity and number of symptoms have been suggested to have a diagnostic value. The corresponding importance of symptoms in chronic WAD has not been documented. Most studies of whiplash injuries have focused on neck pain because this is the dominant complaint, while other symptoms are less studied. The frequency of long-term symptoms after whiplash injuries seems to vary. It is difficult to compare the long-term outcome since the follow-up after whiplash injury in most studies has been rather short. Therefore, the primary aim of this investigation was to study neck pain and other symptoms, disability, and life satisfaction five years after whiplash injury in a defined population and geographical area.

Methods

The study was carried out at a public hospital in northern Sweden and was a cross-sectional survey of patients five years after the injury event in a cohort of whiplash-injured patients. Five years after the emergency department visit, 186 persons aged 18–64 answered questionnaires on symptoms (Rivermead Post-Concussion Symptoms Questionnaire, RPQ), disabilities (Rivermead Head Injury Follow Up Questionnaire, RHFUQ), and life satisfaction (LiSat-11). The answers were compared to those of a comparison cohort.

Results

The most common symptoms five years after whiplash injury were fatigue (41%), poor memory (39%), and headache (37%). Inability to sustain previous workload (44%) and fatigue at work (43%) were frequently reported disabilities. Only 39% were satisfied with their somatic health and 60% with their psychological health. Compared with healthy controls, the whiplash injured exhibited more symptoms and had lower life satisfaction. Women reported significantly higher pain intensity than men. Few significant differences between women and men regarding the other parameters were found.

Conclusions

This study shows that five years after a whiplash injury, patients reported symptoms that are typical of mild traumatic brain injury. Further, this study emphasizes the possibility of screening patients with chronic WAD for these symptoms as a complement to the assessment.

Implications

Untreated symptoms may negatively affect the outcome of pain rehabilitation. This implies that it might be clinically meaningful to quantify symptoms earlier in the rehabilitation process

1 Introduction

According to the Quebec Task Force on Whiplash Associated Dis-orders, whiplash trauma is defined as an acceleration-deceleration mechanism of energy transfer to the neck which can result in distortion of the neck (whiplash injury) [1]. A whiplash injury may lead to a variety of clinical manifestations known as whiplash-associated disorders (WADs). WAD is classified into 5 grades on the basis of symptom severity and clinical sign from WAD 0 (no symptoms) to WAD 4 (cervical fracture or dislocation) [1]. However, there has been a debate regarding the definition and classification system [2].

The incidence of whiplash injuries is 80-420/100,000/year [1,3]. Most injuries occur from motor vehicle crashes and result from frontal, rear-end, and side impacts; but other trauma mechanisms have been described [1,4,5]. Patients with WAD present a broad and varied symptomatology. The predominant symptoms reported within the first weeks after the injury are neck pain, neck stiffness and headache [6]. The natural course after whiplash injury is a restitution of symptoms within three months [7]. Although neck symptoms usually decrease, about 50% of injured persons report neck pain one year post trauma [8]. Several years after an incident, a significant number of persons also experience symptoms such as headache, anxiety, dizziness, fatigue, irritability, and cognitive disturbances [9, 10, 11, 12, 13, 14]. Some prognostic factors have been suggested such as pain intensity, headache, female sex, and catastrophizing [15]. No conclusive results on risk factors for WAD can be drawn as of today, because there is a wide variation in the outcome measurements used in different studies [7,8,16].

Why symptoms persist and how tissues are damaged after whiplash injury seems to be multifactorial [17]. Although several studies have failed to show pathology in the muscles and ligaments of the neck [14,15,18], cervical dysfunction because of injured facet joints, muscles, and nerves may partially explain the clinical picture of chronic WAD [19]. In a recent study WAD patients were found to have elevated levels of C-D-deprenyl, a potential marker for inflammation around the C2 spinous process, on positron emission tomography, thus suggesting long-term peripheral inflammation [20]. In a pilot study the presence of high blood flow in painful neck regions in people with WAD, was confirmed by colour Doppler (CD) ultrasound (US) [21]. Additionally, pain processing with central sensitization have been reported to play a crucial role in the alteration from acute to chronic WAD [22]. Recently, Malmström et al. have shown that neck pain affects the cervical proprioception which is of importance for postural control and orientation [23]. Other studies have pointed out the influence of similar factors in WAD as occur with chronic pain such as post-traumatic stress and depression [2].

Chronic WAD is often associated with social functioning problems and decreased ability to perform previous activities at work and leisure time, which may lead to decreased life satisfaction [14,24]. Quality of life is, however, insufficiently studied in the context of whiplash injuries [25]. Similar symptoms as included in chronic WAD are reported after mild traumatic brain injury (MTBI)/concussion [26]. In a sizable minority of persons symptoms persist longer than three months [27]. In cases of MTBI, the severity and number of symptoms has been suggested to have a diagnostic value [28]. For long-term symptoms, the diagnosis post-concussion syndrome is sometimes used [29]. The corresponding importance of symptoms in chronic WAD has not been documented; studies have mainly focused on neck pain because this is the dominant complaint following whiplash injury [12] while the persistence of other symptoms is less well investigated [30].

Although the ratio of whiplash injuries in car accidents is reported to be similar in women and men [31], some studies have documented differences between genders [12]. In an experimental study of the dynamic responses in rear impacts, an earlier and higher acceleration was found in women than in men [32]. Moreover, the disability risk for occupants of the driver’s seat and the rear seat is reported to be higher in women than in men [33], and women seem to run a higher risk of poor recovery [12]. Stemper et al. concluded that women are more likely to be injured under whiplash loading because their cervical facet joints sustain greater motion in comparison with men [34]. However, the outcome is difficult to compare because the follow-up time after whiplash injury differs between studies, and the length of time after injury in most studies has been rather short [35].

Therefore, the primary aim of this investigation was to study neck pain and other symptoms, disability, and life satisfaction five years after whiplash injury. Secondary aims were to compare disability and life satisfaction between the whiplash-injured persons and healthy references and to investigate sex differences.

2 Materials and methods

2.1 Participants and controls

Umeå University hospital’s ongoing injury and trauma register provided trauma history information of persons who, during 2001, sought acute medical care after whiplash trauma in the Umeå district of northern Sweden. The hospital had a well-defined catchment area of 137,000 inhabitants. To be included in the study, the injured person had to have arrived at the Emergency Department (ED) of the Umeå University hospital within three days of suffering whiplash trauma that caused any degree of neck pain or stiffness. Cases with the ICD-10 diagnosis S13.4 [29] and of WAD grades I–III were included in the present study, where as cases of acute fractures or dislocations of the cervical spine related to whiplash trauma (WAD-grade IV) were excluded. The patients were not in need of in-patient care.

Of the 325 persons injured in 2001; aged 18–64, a set of questionnaires was sent to 304 study eligible persons five years after the injury. In total, 186 persons (100 women and 86 men) answered the questionnaires and participated in the follow-up (Fig. 1). Demographic and injury characteristic information was collected from the injury register, medical records, and completed with answers from additional questions five years following the injury event (Table 1). Other injuries and diagnoses, in addition to the WAD categories, were found when the patients were investigated. Four patients also had knee contusions, three patients had superficial chest contusions, and three patients had arm contusions. The participants were compared with the non-participants (non-responders and those who declined to participate). The non-participants had higher proportion of males (p =0.050), but no significant differences were found regarding external cause of injury or any other information from obtained records or the injury and trauma register.The study population and the five persons with MTBI (n =191) have been used in another article [36].

Table 1

Demographic and injury characteristics

n %
Gender
Male 86 46
Female 100 54
Age (years) 32.9 ± 11.4
Education in years (n =178)
9 12 7
10-12 91 51
13-21 75 42
Work status at time of injury (n =182)
Working 126 69
Student 38 21
Unemployed-seeking work 3 2
Sick-leave 5 3
Working/sick leave part time 2 1
Other 8 4
Marital status (n = 178)
Married, cohabitating 123 69
Single, divorced or widowed 47 26
Living with parents 8 5
Cause of injury
Vehicle crash 149 80
Sporting mishap 22 12
Fall 6 3
Contact with object 5 3
Other 4 2
Position in vehicle (n =149)
Driver 116 78
Passenger front 21 14
Passenger back 7 5
Buss passenger 3 2
Passenger unknown 2 1
Seat belt (n = 149)
Yes 115 77
No 13 9
Not applicable 11 7
Unknown 10 7

Fig. 1 
              Flow chart.
Fig. 1

Flow chart.

The answers given on one of the instruments (the Rivermead Postconcussion Symptoms Questionnaire) were compared with a control group. The control group comprised 569 cases from 2007 of consecutive blood donors (ages 18 to 64) at the Blood Centre of UUH; the only area blood donor site (Nilsson Sojka & Sojka, unpublished, anonymously collected data). Only 461 of the RPQ controls stated their gender: 179 women and 282 men.

2.2 Instruments

Symptoms (pain intensity and whiplash-related symptoms) were assessed using the Visual Analogue Scale (VAS) [37] and the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) [38]. Disabilities were assessed using the Rivermead Head Injury Follow Up Questionnaire (RHFUQ) [39] and the LiSat-11 was used as life satisfaction assessment [40].

2.2.1 The Visual Analogue Scale

The Visual Analogue Scale (VAS) was used to rate the pain intensity for the previous seven days. The scale consists of a 100 mm straight line with defined end-points (“no pain” and “worst pain imaginable”). The study subjects were asked to indicate their experienced pain (results in mm). The VAS is considered to have a high degree of reliability and validity [37].

2.2.2 The Rivermead Post-Concussion Symptoms Questionnaire

The RPQ is a validated instrument used to assess the frequency and severity of 16 symptoms commonly encountered post-concussion. The instrument asks the participants to rate the extent to which the symptoms have been a problem over the previous 24h compared with the pre-morbid levels [38]. The RPQ uses arating scale with values 0–4, where 0 = not experienced at all, 1= no more of a problem, 2 = a mild problem, 3 = a moderate problem and 4 = a severe problem. A total symptom score can be calculated asa sum of all scores (possible score 0 – 64). Additionally, the RPQ was augmented by three questions regarding symptoms of neck pain, thoracic pain, and lumbar pain. The same 0–4 scale of symptom intensity was used for these additional questions. The answers were dichotomized into 0–1 = no symptom and 2–4 = symptoms experienced. The symptoms in the RPQ can be divided into three main categories (1) somatic (headache, dizziness, fatigue, blurred vision, etc.), (2) emotional (irritability, depression, frustration), (3) cognitive (poor memory, poor concentration, slower thinking).

2.2.3 Rivermead Head Injury Follow Up Questionnaire

The Rivermead Head Injury Follow Up Questionnaire (RHFUQ) is a short, reliable, and valid instrument that assesses the level of disability after mild to moderate TBI [39]. The ten items cover social and domestic activities, work and relations with friends and family. The participants are asked to rate changes in their abilities compared with prior to injury. The answers range from 0 = no change to 4 = a very marked change and were dichotomized into 0 = no disability, 1–4 = presence of disability.

2.2.4 LiSat-11

Life satisfaction at follow-up was assessed using the LiSat-11 questionnaire [40]. The questionnaire is composed of eleven items; one item addresses life as a whole and the ten remaining items address vocation, economy, leisure, contacts, sexual life, activities of daily living (ADL), family life, partner, somatic health, and psychological health. Levels of satisfaction are estimated on asix-grade scale (from 1 = very dissatisfied to 6 = very satisfied). The total score ranges from 6 to 66. The LiSat-11 scale was dichotomized into not satisfied (1–4) and satisfied (5–6).

2.3 Comparison with the control group and a reference group

There was no significant difference in gender-distribution between the RPQ control group and the study population. The RPQ control group had a significantly higher mean age (37.6±12.9 vs. 32.9 ± 11.4 years; difference 4.7, 95% CI 2.8–6.7, p< 0.001).

The LiSat-11 Swedish reference population: Life satisfaction on the LiSat-11 was also compared between the participants and a reference population. The LiSat-11 Swedish reference population consists of 2533 18–64 year-olds who filled out the questionnaire in 1996 [40]. No significant gender-difference between the study population and the LiSat-11 Swedish reference population was found. The mean age of the LiSat-11 references was unknown.

2.4 Ethics

The regional ethics committee, the Regional Ethical Board of Umeå University (Dnr: 06-010M) approved the study and informed consent was obtained from each participant.

2.5 Statistical analysis

All statistical analysis was performed with SPSS, version 20.0 for Windows. Data are reported as means with±Standard Deviations (SD) and medians, unless indicated otherwise. Comparison of means was made using the independent-samples t-test. Comparison of distribution across groups was made using the Mann–Whitney U-test, if the variables were not normally distributed. Normal distribution was assessed with histograms and Q–Q-plots. LiSat-11 was considered normally distributed where as RPQ, RHFUQ, and VAS were not. Contingency tables were analyzed with the Chi2-test.If numbers were less than five, Fisher’s exact test was used. Spearman’s correlation coefficients were calculated for the participants in the whiplash group to identify the relationships between the mean total scores of VAS, RPQ, RHFUQ, and LiSat-11. The level of statistical significance was set at p-value <0.05.

3 Results

3.1 Participants

The 186 cases consisted of 100 (54%) women and 86 (46%) men. The mean age of the participants was 32.9±11.4 years, median 31, at the time of injury. The majority of the participants had been injured in vehicle related incidents (80%), where as sporting mishaps (12%) were the second most common causes of injury (Table 1).

3.2 Pain intensity

Pain intensity on the VAS for all subjects was 30.2±29.1 mm, median 22.

3.3 Post-concussion symptoms (RPQ) with the addition of back pain, comparison of the whiplash-injured patients with the control group

The scores of the WAD subjects on all items of the RPQ with the addition of back pain are shown in Table 2. The most frequently reported symptoms (RPQ-score 2–4) were fatigue (41%), poor memory (39%), and headache (37%). Fifty-two per cent of the cases had an RPQ-score of 2–4 on at least three items. Presence of back pain (cervical, thoracic or lumbar) was encountered in 58% of the cases. The mean RPQ score of the whiplash-injured subjects (14.3±14.7, median 10) was compared with the mean RPQ score of the RPQ control group (3.9±4.6) (the mean difference between the groups was 10.4, 95% CI, 8.2–12.6, p <0.001). The subjects who suffered whiplash injury exhibited significantly higher mean scores of all symptoms (Table 3).

Table 2

Number of women/men exhibiting symptoms (on the Rivermead Post Concussion Symptoms Questionnaire) and back pain.

RPQ-score[a] 0 1 2 3 4 Sum 2–4
Headache 46/50 11/8 19/11 15/10 6/5 40/26
Dizziness 60/55 17/13 8/10 12/4 0/2 20/16
Nausea 68/72 15/7 5/1 7/3 2/1 14/5
Sleep disturbance 56/47 12/11 8/12 17/10 4/4 29/26
Fatigue 41/40 16/10 12/14 19/14 9/6 40/34
Irritability 44/42 20/18 20/12 11/8 2/4 33/24
Feeling depressed 58/51 18/16 9/13 6/4 6/0 21/17
Feeling frustrated 59/43 18/16 5/14 10/8 5/3 20/25
Poor memory 47/40 12/14 16/19 16/8 6/3 38/30
Poor concentration 49/41 16/17 13/18 15/6 4/2 32/26
Thinking slow 57/44 15/17 10/15 13/5 2/3 25/23
Noise sensitivity 53/55 7/8 14/15 14/4 9/2 37/21
Blurred vision 67/58 7/12 8/9 13/5 2/0 23/14
Sensitivity to light 57/47 10/15 10/14 15/7 5/1 30/22
Double vision 84/71 8/6 2/3 3/2 0/2 5/7
Restlessness 64/42 13/16 10/15 9/8 1/3 20/26
Back pain
Cervical 43/33 9/10 14/15 14/21 16/5 44/41
Thoracic 43/40 15/11 9/16 14/12 14/4 37/32
Lumbar 48/45 11/11 12/12 17/10 7/3 36/25

Table 3

Symptoms on the Rivermead Post Concussion Symptoms Questionnaire (mean score). Comparison between the WAD-cases (n = 181) and the control group (n = 569).

Mean difference WAD/control group
WAD Controls Dif. 95% CI p-Value
Headache 1.1 0.3 0.8 0.6–1.0 <0.001
Dizziness 0.7 0.2 0.5 0.3–0.6 <0.001
Nausea 0.4 0.04 0.4 0.2–0.5 <0.001
Noise sensitivity 0.9 0.2 0.8 0.6–1.0 <0.001
Sleep disturbance 1.0 0.4 0.6 0.4–0.8 <0.001
Fatigue 1.3 0.8 0.5 0.3–0.7 0.002
Irritability 1.0 0.2 0.8 0.6–1.0 <0.001
Feeling depressed 0.7 0.2 0.5 0.4–0.7 <0.001
Feeling frustrated 0.9 0.3 0.6 0.4–0.8 <0.001
Poor memory 1.1 0.3 0.8 0.6–1.0 <0.001
Poor concentration 1.0 0.3 0.7 0.5–0.9 <0.001
Thinking slow 0.9 0.2 0.7 0.5–0.8 <0.001
Blurred vision 0.6 0.1 0.5 0.3–0.7 <0.001
Sensitivity to light 0.9 0.2 0.7 0.5–0.9 <0.001
Double vision 0.3 0.03 0.2 0.1–0.3 <0.001
Restlessness 0.8 0.2 0.6 0.4–0.7 <0.001
  1. Significant p-values are highlighted in bold

3.4 Disabilities as revealed by the Rivermead Head Injury Follow Up Questionnaire

Difficulty sustaining previous workload (44%) and being tired at work (43%) were the most frequently reported complaints on the RHFUQ, followed by affected ability to enjoy previous leisure activities (34%). The mean score for all cases was 7.6±11.1, median 2.

3.5 Life satisfaction, comparison between the whiplash-injured subjects and the LiSat-11 Swedish reference population

The mean LiSat-11-score among the whiplash injured was 47.7±10.5, median 49. When comparing the study cases with the LiSat-11 Swedish reference population, there were significant differences with regard to six of the items on LiSat-11, see Table 4.

Table 4

LiSat-11 – Comparison between the WAD-cases (n=175) and the Swedish general population reference group (n=2533) (Fugl-Meyer et al. [40]) for the answers “very satisfied” or “satisfied” on all items.

WAD % References % p-Value
Life as a whole 56 70 <0.001
Closeness
Sexual life 49 (n= 169) 56 0.059
Partner relationship 79 (n= 144) 82 0.29
Family life 82 (n= 145) 81 0.75
Health
ADL 86 95 <0.001
Somatic health 39 77 <0.001
Mental health 60 81 <0.001
Spare time
Leisure 41 57 <0.001
Contacts 53 65 0.002
Provision
Vocation 47 54 0.067
Economy 32 39 0.052
  1. Significant p-values are highlighted in bold. ADL, activities of daily life

3.6 Comparison between women and men

3.6.1 VAS

Women reported statistically significant higher VAS-scores (36.4±31.7mm, median 26) than men (23.3±24.5 mm, median 16) (the mean difference between the groups was 13.1, 95% CI 3.4–22.8, p= 0.028).

3.6.2 RPQ with the addition of back pain

There was no significant difference on the mean RPQ total score between women (14.9±14.9, median 11) and men (13.7±14.5, median 9) (the mean difference between the groups was 1.2, 95% CI -3.1 to 5.5, p =0.62). Fifty-four per cent of the women and 50% of the men (p =0.63) had an RPQ-score of 2–4 on at least three of the items. Additionally, on the separate symptoms, only a few significant gender differences existed, see Table 5. Presence of back pain was shown in 57% of the women and 59% of the men (p =0.81). No significant gender difference in regard to the frequency of separate back pain locations (cervical, thoracic or lumbar) was found, see Table 5.

Table 5

Mean score on all items of the Rivermead Post Concussion Symptoms Questionnaire, back pain, Rivermead Head Injury Follow Up Questionnaire and LiSat-11. Comparison between women (n = 84) and men (n=97).

Mean score Mean difference
Women Men Dif. 95% CI p-Value
RPQ
Headache 1.2 1.0 0.3 –0.1 to 0.7 0.14
Dizziness 0.7 0.6 0.1 –0.2 to 0.4 0.58
Nausea 0.6 0.3 0.3 0.0 to 0.6 0.013
Noise sensitivity 1.2 0.7 0.5 0.1 to 0.9 0.036
Sleep disturbance 1.0 1.0 0.0 –0.4 to 0.4 0.97
Fatigue 1.4 1.2 0.1 –0.3 to 0.5 0.49
Irritability 1.0 1.0 0.1 –0.3 to 0.4 0.56
Feeling depressed 0.8 0.6 0.2 –0.2 to 0.5 0.69
Feeling frustrated 0.8 1.0 –0.1 –0.5 to 0.2 0.24
Poor memory 1.2 1.1 0.1 –0.2 to 0.5 0.60
Poor concentration 1.1 0.9 0.1 –0.2 to 0.5 0.74
Thinking slow 0.9 0.9 0.0 –0.4 to 0.3 0.61
Blurred vision 0.7 0.5 0.2 –0.1 to 0.5 0.63
Sensitivity to light 1.0 0.8 0.2 –0.2 to 0.5 0.73
Double vision 0.2 0.3 –0.1 –0.3 to 0.1 0.64
Restlessness 0.7 1.0 –0.3 –0.6 to 0.0 0.038
Back pain
Cervical 1.5 1.5 0.0 –0.4 to 0.5 0.98
Thoracic 1.4 1.1 0.2 –0.2 to 0.7 0.38
Lumbar 1.2 1.0 0.2 –0.1 to 0.6 0.29
RHFUQ
Conversation 1 person 0.4 0.4 0.0 –0.3 to 0.2 0.88
Conversation ≥2 persons 0.7 0.7 0.0 –0.4 to 0.4 0.94
Domestic work 0.8 0.7 0.1 –0.2 to 0.5 0.49
Social activities 0.7 0.7 0.0 –0.4 to 0.4 0.89
Leisure activities 1.0 0.9 0.1 –0.3 to 0.5 0.51
Workload 1.3 1.1 0.2 –0.3 to 0.6 0.41
Tired at work 1.2 1.0 0.2 –0.3 to 0.6 0.72
Relation with previous friends 0.6 0.5 0.2 –0.2 to 0.5 0.31
Relation with partner 0.6 0.5 0.1 –0.2 to 0.5 0.48
Family demands 0.8 0.6 0.2 –0.2 to 0.5 0.58
LiSat-11
Life as a whole 4.6 4.5 0.1 –0.2 to 0.4 0.59
Sexual life 4.2 4.0 0.2 –0.2 to 0.7 0.30
Partner relationship 5.4 5.0 0.4 0.1 to 0.8 0.012
Family life 5.4 5.0 0.4 0.1 to 0.7 0.006
ADL 5.5 5.5 0.1 –0.2 to 0.4 0.73
Somatic health 3.8 4.1 –0.4 –0.8 to 0.1 0.11
Mental health 4.7 4.7 0.0 –0.3 to 0.3 0.98
Leisure 4.2 4.0 0.2 –0.2 to 0.6 0.25
Contacts 4.6 4.3 0.3 0.0 to 0.6 0.042
Vocation 4.0 4.2 –0.3 –0.7 to 0.1 0.20
Economy 3.8 4.0 –0.2 –0.6 to 0.2 0.27
  1. Significant p-values are highlighted in bold

3.6.3 RHFUQ

Disability (RHFUQ-score 1–4) was found in 51% of the women and 54% of the men. There were no significant gender differences on the separate RHFUQ-items, see Table 5. The mean score for women was 8.0±11.6, median 2 and for men 7.0±10.5, median 2. The difference was not significant (the mean difference between the groups was 1.0, 95% CI -2.2 to 4.3, p=0.85).

3.6.4 Life satisfaction

No significant differences between women (48.5±10.2, median 50) and men (46.7±10.9, median 48) were found on the mean LiSat-11 score (the mean difference between the groups was 1.9, 95% CI -1.3 to 5.0, p=0.24). Men had significantly lower scores on three of the eleven items (Table 5).

3.7 Correlations

Asignificant correlation was found between pain intensity (total VAS score) and symptoms (total score of Rivermead Post Concussion Questionnaire, r = 0.67, p<0.001). The VAS score was also correlated to disability (total score of Rivermead Head Injury Follow Up Questionnaire, r = 0.71, p<0.001) and negatively correlated to life satisfaction (total LiSat-11 score, r= -0.39, p <0.001). In addition, Rivermead Post Concussion Questionnaire was significantly correlated to Rivermead Head Injury Follow Up Questionnaire (r= 0.74, p < 0.001) and LiSat-11 (r =-0.51, p <0.001). Finally, River-mead Head Injury Follow Up Questionnaire significantly correlated to LiSat-11 (r = -0.44, p < 0.001).

4 Discussion

The main findings of this study are that five years after sustaining whiplash injuries, patients reported the presence of post-concussion like symptoms such a scognitive deficits, pain, and low levels of life satisfaction significantly more often than healthy controls. The results also show that disability, especially regarding work and social activities, was common among the study population. Sex differences within the whiplash group were minor.

4.1 Symptoms and cognition

More than half of the participants with whiplash injury reported the presence of at least three post-concussion symptoms; this is clearly higher than a previous Swedish study of mild traumatic brain injury three months post injury by Lannsjö et al. (24%) [26] The mean scores of the cognitive symptoms ‘poor memory’ an ‘poor concentration’ were surprisingly high and in accordance with patients with mild traumatic brain injury injured during the same year and from the same geographical area [41].

Previous research has shown that mild traumatic brain injury is generally produced by an acceleration/deceleration of the head [42]. As similar movements of the neck are involved in whiplash trauma, these mechanisms could also be related to the development of memory and concentration dysfunction inour study. A few studies have demonstrated neuropsychological dysfunction based on test results in cases of persistent symptoms after whiplash injur [43]. However, the relevance of cognitive deficits in cases of chroni WAD has been discussed and studies have suggested that stress depressed mood, sleep disturbance, and fatigue may be related to impaired cognitive function[44, 45,46]. Pain can have an egative in fluence on cognition [47], therefore, it seems reasonable to assume that the high frequency of pain may also have contributed to the findings of cognitive symptoms in our study.

4.2 Pain distribution

Consistent with previous studies [6,12,13], neck/cervical pain was the most common symptom reported. The percentage (46–49%) were slightly lower than reported in a Swedish population 17 years after the whiplash injury (55%) [48]. Neck pain is the predominating persistent symptom and the most studied long-term outcome of WAD; pain-symptoms in other body regions have not been well studied. The frequencies of thoracic and lumbar back pain, in our study, were unexpectedly high and reported by nearl 40%. Possible causes for pain in the thoracic and lumbar spine may be relatedtothe trauma mechanisms and the body movement during the whiplash trauma. Patients with neck trauma could also have had the thoracic and lumbar spine affected. The majority of the patients in our study were injured by vehicle crashes, but we have no information on the crash courses. Rear-end collisions result in the majority of WAD [31]. However, during the last decade, the proportion of patients with long-lasting symptoms after rear-end impacts has been reduced because of effective preventive system in cars. In contrast, protective measures addressing the consequences from frontal and side impacts are less evaluated [49]. Another cause for the high frequency of back pain may be associated with altered central pain processing and central sensitization. Because these aspects have been reported in chronic WAD patient [22], this could possibly explain the spreading of pain from the neck to the lower regions of the back. In a previous study of whiplas injuries with several pain regions by Peolsson et al., an association between widespread pain, pain intensity, and symptoms, include in depression was reported [50]. Because pain intensity was correlated to the post-concussion symptoms the findings in the present study of the high frequencies of back pain together with neck pain may have contributed to the situation with the many symptoms in the whiplash participants.

4.3 Comparison with the control group

High frequencies of headache [51] and fatigue [52,53] have also been reported in the general population. We, therefore, decided to compare the post-concussion symptoms reported by the participants with the control group. Although the control group reported presence of some symptoms, the mean scores were significantly lower than in the participants. This supports the possibility of a rela-tionship between perceived symptoms and the previous whiplash injury in the WAD group.

4.4 Disability and sick leave

Although many studies of long-term problems after WAD have focused on neck pain, long-term effects on disabilities or activities have not been sufficiently investigated. In the present study the level of disability was surprisingly high. The most common disability items were workload, tired at work and leisure activities. This indicates that persons in the WAD-group may have difficulties maintaining both professional work and less demanding activities post injury. These findings are in line with previous studies of prolonged disability related to work after whiplash injury. In a follow-up study by Buitenhuis et al. of 879 subjects, 22% reported persistent work disability one year after the injury [54]. Work related consequences may last for a longer time.In a previous study including our study population the number of persons on long term sick leave (part-time or full-time) five years after whiplash injury had increased from seven to 23 in comparison with the sick leave at the time of injury. Twenty-one persons considered their sick leave to be related to the injury [36]. Pain intensity was correlated with the disability score indicating the importance of pain in WAD as documented by others [55].

4.5 Life satisfaction

Consequences of whiplash injury affect several aspects of life. In the present study, the fact that so many persons reported low satisfaction with life is remarkable as only 39% were satisfied with somatic health and 60% with psychological health. These ratings were significantly lower than those reported by the life satisfaction Swedish reference population [40] and are in accordance with other studies of chronic WAD-patients seeking hospital care [56].

4.6 Gender

It is often reported that women have worse outcomes after having experienced whiplash injury [57,58]. Our study could not support that conclusion. We found a significant difference for pain intensity in women which was higher than in men, yet neck pain is known to be more common in females than in males in the community [59]. In addition only very few significant differences regarding other studied symptoms and life satisfaction were found. However women rated higher satisfaction with family life than men.

4.7 Limitations

Some limitations of this study should be noted. Participants reported symptoms and disabilities that they attributed to a whiplash injury; however, these symptoms may have other causes than whiplash trauma (for example ageing factors) as the follow-up period was rather long (5 years). Therefore, we cannot rule out systematic distortions as other factors might have influenced the results. Although recent studies have suggested possible mechanisms for persisting symptoms [20], there is a lack of information regarding the pathological explanation. On the other hand, the finding of a higher proportion of persons with neck pain in the present study than previously documented in the general population [59] and higher mean scores of symptoms reported by the participants in comparison with the control group, along with the use of validated instruments, makes it seem reasonable that the study describes the experienced situation five years after whiplash injury.Some previous studies have drawn attention to the problems with selection bias and that long term consequences of whiplash injuries vary with the patient population [11]. In contrast to studies based on patients with prolonged symptoms or patients having made claims to insurance companies, the present study was based on all whiplash cases that during one year attended the emergency room at the only medical trauma facility with in alarge geographical area with a well-defined population.

Regarding the instruments, we used the RPQ and the RHFUQ to measure symptoms and disabilities. However, both these instruments are designed for mild traumatic brain injury and not for WAD. Although post-concussion symptoms are common in the general population and may have consequences on work and leisure there is no national reference group of RPQ or RHFUQ comparable with the LiSat-11 reference group.

5 Conclusions

This study shows that five years after sustaining a whiplash injury, patients reported symptoms and disabilities similar to those for mild traumatic brain injury; opening a possibility of also screening patients with chronic WAD for these symptoms and disabilities. Moreover, this implies that the measurements used in this study are not specific to mild traumatic brain injury and that whiplash patients present with a large variety of symptoms and disabilities other than neck pain. The high frequency of symptoms being reported indicates that it might be clinically meaningful to quantify those symptoms earlier in the rehabilitation process because areas suitable for treatment may be found. In a future perspective, continuous research within this area may provide a possibility to identify subgroups of the dominating symptoms in patients with WAD suchassomatic, emotional, or cognitive to tailor specific treatment and rehabilitation interventions. The high proportions of disability and low life satisfaction have to be taken into account when managing persons with chronic WAD.

Highlights

  • Symptoms proposed to reflect mild traumatic brain injury were commonly reported by the whiplash injured.

  • The whiplash injured exhibited more symptoms compared with healthy controls.

  • Disability, regarding work and social activities, was common among the whiplash injured.

  • In comparison with a national reference group lower levels of life satisfaction was found.


DOI of refers to article:http://dx.doi.org/10.1016/j.sjpain.2014.08.003



Department of Community Medicine and Rehabilitation, Rehabilitation Medicine, Umeå University, SE 90185 Umeå, Sweden Tel.: +46907850000

  1. Conflict of interest: The authors have no conflict of interest

Acknowledgements

We thank Per-Olov Bylund for his assistance in providing the data from the Umeå University Hospitals’ injury and trauma register. The Swedish Association of Survivors of Traffic Accidents and the Swedish Cancer and Traffic Injury Society Fund economically supported this study.

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Received: 2014-04-07
Revised: 2014-06-24
Accepted: 2014-06-25
Published Online: 2014-10-01
Published in Print: 2014-10-01

© 2014 Scandinavian Association for the Study of Pain

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