ArticlePDF Available

A new stratified risk assessment tool for whiplash injuries developed from a prospective observational study


Abstract and Figures

Objectives An initial stratification of acute whiplash patients into seven risk-strata in relation to 1-year work disability as primary outcome is presented. Design The design was an observational prospective study of risk factors embedded in a randomised controlled study. Setting Acute whiplash patients from units, general practitioners in four Danish counties were referred to two research centres. Participants During a 2-year inclusion period, acute consecutive whiplash-injured (age 18–70 years, rear-end or frontal-end car accident and WAD (whiplash-associated disorders) grades I–III, symptoms within 72 h, examination prior to 10 days postinjury, capable of written/spoken Danish, without other injuries/fractures, pre-existing significant somatic/psychiatric disorder, drug/alcohol abuse and previous significant pain/headache). 688 (438 women and 250 men) participants were interviewed and examined by a study nurse after 5 days; 605 were completed after 1 year. A risk score which included items of initial neck pain/headache intensity, a number of non-painful complaints and active neck mobility was applied. The primary outcome parameter was 1-year work disability. Results The risk score and number of sick-listing days were related (Kruskal-Wallis, p<0.0001). In stratum 1, less than 4%, but in stratum 7, 68% were work-disabled after 1 year. Early work assessment (p<0.0001), impact of the event questionnaire (p<0.0006), psychophysical pain measures being McGill pain questionnaire parameters (p<0.0001), pressure pain algometry (p<0.0001) and palpation (p<0.0001) showed a significant relationship with risk stratification. Analysis Findings confirm previous studies reporting intense neck pain/headache and distress as predictors for work disability after whiplash. Neck-mobility was a strong predictor in this study; however, it was a more inconsistent predictor in other studies. Conclusions Application of the risk assessment score and use of the risk strata system may be beneficial in future studies and may be considered as a valuable tool to assess return-to-work following injuries; however, further studies are needed.
Content may be subject to copyright.
Anewstratied risk assessment tool for
whiplash injuries developed from a
prospective observational study
Helge Kasch,
Alice Kongsted,
Erisela Qerama,
Flemming W Bach,
Tom Bendix,
Troels Staehelin Jensen
To cite: Kasch H,
Kongsted A, Qerama E, et al.
A new stratified risk
assessment tool for whiplash
injuries developed from a
prospective observational
study. BMJ Open 2013;3:
e002050. doi:10.1136/
Prepublication history and
additional material for this
paper are available online. To
view these files please visit
the journal online
Additional material is
published online only. To
view please visit the journal
online (
Received 17 September 2012
Revised 29 December 2012
Accepted 9 January 2013
This final article is available
for use under the terms of
the Creative Commons
Attribution Non-Commercial
2.0 Licence; see
For numbered affiliations see
end of article.
Correspondence to
Dr Helge Kasch;
An initial stratification of acute whiplash
patients into seven risk-strata in relation to 1-year work
disability as primary outcome is presented.
Design: The design was an observational prospective
study of risk factors embedded in a randomised
controlled study.
Setting: Acute whiplash patients from units, general
practitioners in four Danish counties were referred to
two research centres.
Participants: During a 2-year inclusion period, acute
consecutive whiplash-injured (age 1870 years, rear-
end or frontal-end car accident and WAD (whiplash-
associated disorders) grades IIII, symptoms within
72 h, examination prior to 10 days postinjury, capable
of written/spoken Danish, without other injuries/
fractures, pre-existing significant somatic/psychiatric
disorder, drug/alcohol abuse and previous significant
pain/headache). 688 (438 women and 250 men)
participants were interviewed and examined by a study
nurse after 5 days; 605 were completed after 1 year. A
risk score which included items of initial neck pain/
headache intensity, a number of non-painful
complaints and active neck mobility was applied. The
primary outcome parameter was 1-year work disability.
Results: The risk score and number of sick-listing
days were related (Kruskal-Wallis, p<0.0001). In
stratum 1, less than 4%, but in stratum 7, 68% were
work-disabled after 1 year. Early work assessment
(p<0.0001), impact of the event questionnaire
(p<0.0006), psychophysical pain measures being
McGill pain questionnaire parameters (p<0.0001),
pressure pain algometry ( p<0.0001) and palpation
(p<0.0001) showed a significant relationship with risk
Analysis: Findings confirm previous studies reporting
intense neck pain/headache and distress as predictors
for work disability after whiplash. Neck-mobility was a
strong predictor in this study; however, it was a more
inconsistent predictor in other studies.
Conclusions: Application of the risk assessment
score and use of the risk strata system may be
beneficial in future studies and may be considered as a
valuable tool to assess return-to-work following
injuries; however, further studies are needed.
Chronic pain represents a major problem in
the Western world with approximately 20%
of the adult population suffering from
chronic pain. Our ability to deal with these
chronic pain conditions is insufcient as it is
in various other areas, such as traumatic
injuries and pain following surgery or other
medical procedures. Identifying patients at
risk of developin g chronic pain is a pre-
requisite for establishment of prophylactic
When discussing pain following surgery, it
has been demonstrated that prior pain
Article focus
In an observational study of acute whiplash
patients performed earlier, we identified risk
factors which provided a risk assessment score.
The risk assessment score was applied in a new
1-year longitudinal multicentre cohort study of
acute whiplash patients with a main outcome
parameter of a 1-year work disability.
Key messages
Significant relation was found between the risk
assessment score and 1-year work disability.
Stratification early after whiplash injury into
seven risk strata was furthermore supported by
other findings concerning psychological, social,
work-related and psychophysical pain measures.
The Risk Assesment Score may be considered a
valuable tool for assessment of work disability in
future studies.
Strengths and limitations
Initially, risk factors were identified in an obser-
vational study and then applied and validated in
this multicentre study. To further validate find-
ings, other researchers should apply the risk
assessment score and the seven strata stratifica-
tion system on other populations for further
external validation.
Kasch H, Kongsted A, Qerama E, et al. BMJ Open 2013;3:e002050. doi:10.1136/bmjopen-2012-002050 1
Open Access Research
intensity, the duration of pain, the type of surgery, the
nerve damage during surgery as well as psychological
factors, information and the setting and the genetic
endowment are of signicant importance with respect to
the future development and persistence of chronic
Also, regarding musculoskeletal pain conditions,
such as headache,
cervical sprains
and low back pain,
there is an interest in exploring the potential risk factors
aligned with persistent pain. The specic type of distor-
tion of the cervical spine, stemming from a so-called
whiplash injury, in which the neck spine is exposed to a
forced extension-exion trauma, is often followed by a
late pain state known as whiplash-ass ociated disorders
These injuries may be associated with a reduction of
the pain threshold to mechanical pressure in the neck
11 12
a reduction of nociceptive exion
and an expansion of cutaneously referred
pain symptoms following the infusion of hypertonic
saline into the muscles both at the injury site and in
areas remote from the injury site.
These ndings
suggest generalised hyper-excitability following a whip-
lash injury, which resolves in patients recovering after
injury but persists in patients with ongoing symp-
Whiplash-associated disorders fall into the categories
OIV according to the Quebec WAD grading.
In a pre-
vious observational study, we found that a risk score
based on neck pain, headache, the number of non-
painful symptoms and reduced neck mobility was asso-
ciated with a marked risk of reduced recovery.
on these observations, the objective of this study was to
test a stratied risk assessment scoring system for predict-
ing long-term sequelae after a whiplash injury. A risk
index was developed in a previous cohort and the pre-
dictive capability of seven risk strata tested.
18 19
In the
present study, we test whether the seven risk strata are
useful for prediction of outcome in that second sample.
In addition, differences in psychological and social
factors across the strata are described.
Study overview
A risk stratication index based on the measures of
intensity of neck pain and headache, cervical range of
motion (CROM) and number of non-painful complaints
was developed in a previous sample of whiplash injured
seen in an emergency care unit.
Using a pragmatic
approach, seven risk strata were formed and this strati-
cation was strongly associated with outcome.
In the present study, these risk strata are tested in
another sample enrolled between May 2001 and June
2003. The study concludes a secondary analysis of two
parallel randomised controlled trials.
20 21
Patients were
enrolled within 10 days of a whiplash injury. Those with
a low-risk stratication index score were randomised to
either oral or written advice to act as usual,
patients with high-risk scores were randomised to immo-
bilisation (semi-rigid neck collar), active mobilisation
(McKenzie technique) or an oral recommendation to
act as usual
(gure 1). The oral and written advices
were delivered at the day of inclusion. The neck collar
and active mobilisation interventions involved contact
with a physical therapist for a maximum of 6 weeks.
Details about the interventions are reported else-
20 21
No signicant differences in treatment
effects were demonstrated and participants are therefore
considered in one cohort for the present study. The
study was approved by the local ethical committees (The
Scientic Committee for The Counties of Vejle and
Funen, Project number 20000268) and conducted in
accordance with the Helsinki II Declaration.
Study population
The cohort has been previously described.
11 2022
In short,
persons with complaints from the neck and/or shoulder
girdle (WAD grade IIII) seeking care at an emergency
unit or a general practitioner within 72 h after a motor
vehicle collision were potential participants. Other inclu-
sion criteria were the following: age 1870 years, exposure
to a rear-end or frontal-end car accident and that an exam-
ination could be performed within 10 days after the injury.
Exclusion criteria were inability to read and speak Danish,
injuries with fractures or dislocations (WAD grade IV),
Figure 1 Flowchart for the whiplash study.
2 Kasch H, Kongsted A, Qerama E, et al. BMJ Open 2013;3:e002050. doi:10.1136/bmjopen-2012-002050
Risk assesment score in whiplash injuries
additional trauma other than the whiplash injury, pre-
existing signicant somatic or psychiatric disease, known
active alcohol or drug abuse and signicant headache or
neck pain (self-reported average pain during the preced-
ing 6 months exceeding 2 on a 010 box scale, 0=no pain;
10=worst possible pain).
Risk Stratification Index measures
Pain: neck pain and headache since the collision were
scored on an 11-point Numeric Rating Scale (0=no pain;
10=worst imaginable pain).
23 24
Non-painful complaints: participants were asked whether
any of the 11 non-painful complaints (paresthesia, dizzi-
ness, vision disturbances, tinnitus, hyperacusis, dyspha-
gia, fatigue, irritation, concentration disturbances,
memory difculties and sleep disturbances) had started
or been markedly worse since the accident.
Active neck mobility: total CROM including exion, exten-
sion, right and left la teral-e xion and right and left rota tion
was assessed with a CROM device as formerly described.
22 25
Risk stratication was performed by combining scores
on pain intensity, CROM and a number of non-painful
Each factor was categorised and scored as
The highest score of neck pain and headache was
categorised into 02=0 points; 34=1 point; 58=4
points; 910=6 points.
Total active CROM was divided into: below 200°=10
points; 200220=8 points; 221240=6 points; 241260=4
points; 261280=2 points and above 280=0 points.
Number of non-painful complaints:02=0 points; 35=1
point and 611=3 points.
The following stratication was made: stratum 1=0
points; stratum 2=13 points; stratum 3=46 points;
stratum 4=79 points; stratum 5=1012 points; stratum
6=1315 points and stratum 7=1619 points (see table 1
for overview).
Outcome measures
Follow-up questionnaires were posted to participants
after 3, 6 and 12 months. Beside data on sick leave, only
12 months follow-up was used for the present study.
The primary outcome measure
The primary outcome variable selected a priori was
1-year work disability, which was dened as: (1) sick
leave> 3 months during the last 6 months; (2) work
inability during the entire last month or (3) not working
anymore because of the accident.
The number of days on sick leave was computed by
means of a completed diary (a patient log) and ques-
tionnaire data after 3, 6 and 12 months postinjury. Days
with sick leave counted as full days and days with
reduced working hours counted as half days of sick
leave. If the patient could manage a full-time job but
had changed functions after injury, it counted as full
working hours. Patients who did not work prior to the
injury (on leave, unemployed, disability pension,
retired) were not considered in the calculated risk of
1-year work disability but were included in computation
of the secondary outcome measures, which have been
described elsewhere.
20 21
Other outcome measures
Work-related factors: expected difculties with work were
measured by asking How big a problem do you expect
it to be to take care of your job/study 6 weeks from
now? (0=no problem at all; 10=a very big problem,
cannot work), and How likely do you consider it that
you will be working/studying 6 weeks from now?
(0=very likely; 10=very unlikely). Self-rated physical work
demands were registered asking: How physically
demanding do you consider your present/most recent
job (0=not physically demanding at all; 10=very physic-
ally demanding).
Post-traumatic stress response was measured by means
of the Impact of Event Scale (IES).
A total sum-score
was calculated from all 15 items of the scale. In addition,
an intrusion score (sum of 7 items) and an avoidance
score (sum of 8 items) were calculated.
Pressure algometry: the hand-held Algometer
(Somedic Algometer type 2) was applied with a slope of
30 kpa/s and a probe area of 1.0 cm
; pressure pain-
detection thresholds were measured in triplets, whereas
Table 1 The Danish whiplash study group risk assessment score
The Danish whiplash study group risk assessment score
Points 0 1 2 3 4 5 6 7 8 9 10
CROM >280 261280 241260 221240 200220 <200
Neck/head VAS 023458910
Number of non-pain symptoms 0235611
Stratum 1 0 points
Stratum 2 13 points
Stratum 3 46 points
Stratum 4 79 points
Stratum 5 1012 points
Stratum 6 1315 points
Stratum 7 1619 points
CROM, cervical range of motion; VAS, visual analogue scale.
Kasch H, Kongsted A, Qerama E, et al. BMJ Open 2013;3:e002050. doi:10.1136/bmjopen-2012-002050
Risk assesment score in whiplash injuries
pressure pain-tolerance thresholds were measured by
one application of pressure only.
Methodical muscle palpation was performed bilat-
erally at nine sites: (1) the anterior part of the temporal
muscle, (2) the posterior part of the temporal muscle,
(3) the masseter muscle, (4) the lateral pterygoid
muscle, (5) the sternocleid at the mastoid insertion
point, (6) the sternocleid at its middle belly, (7) the sub-
occipital muscle group, (8) the superior trapezius
muscle and (9) the rhomboid muscle along the medial
border of the scapula. At each palpation site, a pain
score (04) was obtained
11 27
0 Equalling neither pain nor reported tenderness;
1 Equalling complaints of mild pain but no facial
contortion (grimace), inch or withdrawal;
2 Equalling a moderate pain and degree of facial
contortion (grimace) or inch;
3 Equalling a severe pain and marked inch or
withdrawal and
4 Equalling unbearable pain and withdrawal without
Statistical analysis
Data analyses were made with Stata V.12.0 (StataCorp,
Texas, USA) and Microsoft Excel 2010 for Windows. The
non-parametric Kruskal-Wallis test was applied for ana-
lysis of the strata. Parametric data with normal distribu-
tion or log normal distribution were presented within
each risk stratum graph as mean±SEM values. Receiver
operating characteristic (ROC) curves are given for
applied individual factors in the risk assessment score
(see online supplementary gure S1), and sensitivity,
specicity and positive and negative Likelihood
ratios were computed for each stratum for 1-year work
disability (refer to online supplementary table S2).
Two-way analysis of variances (ANOVAs) were applied for
testing eventual variability difference between centres
for the clinical measures.
Variability: palpation, pressure algometry and cervical
range of motion measurement were standardised at
group meetings during the observation period to reduce
eventual intertester and intratester variability.
Details of the study population have been described pre-
viously; a ow chart is presented in gure 1.
Briey, a
total of 1495 (F/M: 898/597) acute whiplash patients
were contacted after being examined at the emergency
units or by their general practitioners. A total of 688 eli-
gible acute whiplash patients (F/M 443/252) gave
informed written and verbal consent to participate. Of
these, 30 were unemployed but considered capable of
working before injury, and 10 were either retired or on
disability pension and were not considered in primary
but only secondar y outcome measure (social factors are
tabulated in ref 22).
Two hundred (F/M: 102/98) patients refused to par-
ticipate. In total, 592 patients were not eligible, and 15
were excluded due to protocol violation (under-
reporting of previous neck pain, visual analogue scale
(VAS)>5 n=8; wrong initial group allocation in treatment
study, n=7).
Risk strata
Figure 2A shows a log-linear relationship between the
risk assessment score and the number of days being sick
for acute whiplash patients.
Figure 2B shows distribution in the risk strata after
1 year of patients (1) returning to work or (2) having
reduced functional capacity in full-time jobs or (3)
being work disa bled. Although 96% had returned to
work in stratum 1, only 32% of previous healthy
whiplash-exposed in stratum 7 were back at work after
1 year (Kruskal-Wallis, p<0.0001).
In gure 3AC, the ability to perform work within
6 weeks and the ability to return to work within 6 weeks
and the assessment of the physical demands of their
present/recent job were rated after 5 median days on an
NRS-11-point box scale. Job-related issues were
Figure 2 (A) Risk strata and the number of sick-listed days
during the first year after whiplash injury. (B) One year
recovery from whiplash injury in risk strata.
4 Kasch H, Kongsted A, Qerama E, et al. BMJ Open 2013;3:e002050. doi:10.1136/bmjopen-2012-002050
Risk assesment score in whiplash injuries
increasingly severe in the higher risk stratum of the
patient (Kruskal-Wallis, p<0.0001).
The components of the impact of event scale in gure 4
intrusion and avoidance and the total IES score were bar-
graphed for each stratum. There was an increase in
reported injury-related emotional distress in the risk strata
(Kruskall-W allis, p<0.0001).
Figure 5AD display the bar graphs of strata represent-
ing pressure algometry for both pain-detection thresh-
olds and pain-tolerance thresholds for the muscles in
the neck region: the masseter and the infraspinatus
muscles and at a remote control site at the left third
nger joint. All these psychophysical measures are differ-
ently distributed in the risk strata (K ruskall-Wallis ,
The total palpation score was similarly distributed and
signicantly different in risk strata (Kruskall-Wallis
p<0.0001) with a score of 6 in stratum 1 and 24 in
stratum 7 (refer to online supplementary gure S2).
The Copenhagen Neck Disability Index score after
1 year was signicantly related to risk strata
(Kruskall-Wallis , p<0.0001), and the 1-year 11-point box
scores of shoulderarm pain, and neck pain, headache
and global pain were signicantly related to risk strata
(p<0.0001) as well as all McGill Pain Questionnaire
derived pain-rating indices (PRI-T; PRI-S, PRI-A, PRI-E,
PRI-M) and number of word count (Kruskall-Wallis,
p<0.0001) .
Multicentre implications
There were no signicant differences regarding the dis-
tribution of age, gender and strata, as well as the risk
measures of CROM (ANOVA, p>0.19), VAS neck/
Figure 4 The impact of event scale with subscales of
intrusion and avoidance shown in risk strata.
Figure 5 (A) Pressure algometry in the neck and head and
remote from injury in risk strata. (B) Pressure algometry in the
neck and head and remote from injury in risk strata. (C)
Pressure algometry in the neck and head and remote from
injury in risk strata. PPT pressure pain tolerance threshold
and PPDT pressure pain detection threshold (Kilo Pascal,
Mean±SEM), (D) Pressure algometry in the neck and head
and remote from injury in risk strata.
Figure 3 Initial numeric rating of work related issues in risk strata. (A) Expecting problems managing ones job/education in
6 weeks. (B) likelihood of being back to work/education in 6 weeks and, (C) evaluation of the physical job requirement of the
current or most recent job/education.
Kasch H, Kongsted A, Qerama E, et al. BMJ Open 2013;3:e002050. doi:10.1136/bmjopen-2012-002050 5
Risk assesment score in whiplash injuries
headache (ANOVA, p>0.20) and non-painful symptoms
(ANOVA, p>0.58). However, there were differences in
intertester variability for total palpation (ANOVA,
p<0.001) and pressure algometry (p<0.01).
Embedded in treatment study
The present study was embedded in a treatment study in
which patients were divided into low-risk and high-risk
treatment groups (gure 1). A stratied analysis of the
seven strata, split into low-risk and high-risk groups,
yielded no difference on 1-year work disability based on
their given treatment (K-W p>0.15 for patients in the
high-risk group; p>0.91 for low-risk patient s).
This study shows that an early classication of patients
into risk strata based on biological and certain psycho-
social functions predicts non-recovery. In order to group
patients into seven different strata, we used a scaling
system resulting from observational ndings from a
former study. This system included four predened cat-
egories: neck pain intensity, headache intensity, the
number of non-painful symptoms and reduced neck
mobility. The strata set in the present study were applied
in clinical procedures undertaken at a time point where
chronic symptoms could not have developed, that is,
<median 5 days after injury. The scoring on neck mobil-
ity and non-painful symptoms was based on previous
observations where a control group was included.
summation score was arbitrarily determined, and it may
be argued that if another scoring had been used, other
ndings might have been ascertained. Nevertheless, the
scoring was derived from the ndings from a prospective
observational study of acute whiplash patients (WAD
IIII) with an ankle-injured control group in which
active neck mobility was the most signicant predictor
for 1-year work disability.
Neck pain/headache inten-
sity, as well as a high number of non-painful complaints,
was also predictive, though to a lesser extent,
similar to
the present ndings (see ROC curves in online supple-
mentary gure S1 AD). In the present work and in our
previous studies,
we used return-to-work and number
of days parameters with sick leave of 1 year as indicators
of 1-year work disability. The use of sick leave as a par-
ameter of non-recover y has been discussed previously.
It may be argued that sick leave is not a direct measure
of non-recovery. But as for subjective symptoms such as
pain, it is crucial to select robust and directly quanti-
able factors in order to reduce the risk of investigator
bias. Moreover, the fact that all measures concluding the
risk assessment score were completed shortly after injury
means that patients were in all probability prevented
from changing their habitual, preinjury health belief,
which could have been affected by various sources, like
the mass media, healthcare persons, family or
24 28
Furthermore, patients were not informed or made
aware of whether they belonged to a high-risk or a
low-risk group, and factors for the risk assessment score
were obtained before randomisation. Biological
responses like neck strength, duration of neck move-
and psychophysical-like muscle tenderness by
palpation and pressure algometry and the coldpressor
pain response,
as well as stressful parameters like fear
avoidance and intrusion parameters and work-related
issues, are logically distributed in the risk strata. We did,
however, nd intertester variability for algometry and
palpation, which may need more attention than we
offered in this setting (see Methods section), and which
has been reported in other studies.
29 30
neck pain/headache and the number of non-painful
symptoms did, however, not show unacceptable variabil-
ity in the current study.
The present risk stratication scheme rests on a
selected and limited number of symptoms and signs
based on prior observed ndings. Legislative and
detailed psychosocial factors were not included in the
stratication. Such factors might also have an impact,
although the chances are that legislative issues hardly
affect recovery as early as 5 days after injury. There may
be other possible factors that can affect recovery.
the present paper, we suggest a way of stratifying whip-
lash patients in the acute state in order to improve the
predictive power of prognosis. Although the risk strata
presented here need to be tested as prognostic factors in
other cohorts in order to validate our ndings, the
present study is one of the largest materials in the litera-
ture. Moreover, the system has not yet been tested in
relation to its possible usefulness in guiding clinical deci-
sions about the choice of treatment. It is a possible
downside to risk assessment that healthcare professionals
could make premature or hasty decisions when faced
with a certain patient who scores high on a prognostic
scale like ours. With such scorings, healthcare profes-
sionals might unconsciously associate the patients injury
with a prognosis of the chronicity type and act accord-
ingly to some extent. The Quebec Task ForcesWAD
grading represented a rst attempt to better characterise
and identify patients at risk for long-term consequences
after a whiplash injury. However, subsequent studies
demonstrated that the Quebec WAD grading was of little
value in predicting long-term sequelae.
More recent
prospective papers have stressed the importance of em o-
tional distress, and social factors as risk factors for
reduced recovery,
post-traumatic stress disorder
15 33
28 31 35
are factors associated with the risk of
persistent complaints. A trajectory system has been pro-
posed by Sterling et al
including four groups from no
pain/disability to severe pain/disability, in accordance
with post-traumatic stress, which ne eds further valid-
ation. It is generally agreed upon that there is a need
for studies conrming and validating prognostic models
and a need for improved models after acute WAD.
6 Kasch H, Kongsted A, Qerama E, et al. BMJ Open 2013;3:e002050. doi:10.1136/bmjopen-2012-002050
Risk assesment score in whiplash injuries
Other studies have found post-traumatic stress,
as well
as the presence of sensitisation
and neck pain and
headache intensities to be predictive of chronic neck dis-
ability 1 year after injury.
10 39
These ndings are consist-
ent with the present results. Expectations for recovery
perceived injustice after the accident.
Reduced active
neck mobility has assumed importance in some, but not
a majority of, prospective studies.
It is of interest when
the CROM test, on its own, reaches an area under the
ROC curve of 0.79 (CI 95 075 to 0.85) (see online sup-
plementary gure S1 B) in this multicentre study in a
prediction of 1-year work disability. A critical view on
design, taking other risk factors into account, is however
also needed for future prediction studies that are highly
needed in the whiplash area.
The risk assessment score is applicable and inexpensive.
The early identication of whiplash-exposed persons at
risk for chronic pain and work disability is important for
planning future treatment in scientic studies.
More research is needed at present, but risk stratica-
tion might have a place in the clinic for individual guid-
ance and management of the acute and the subacute
whiplash patient. Application of the risk assessment
score may be a valuable alternative to the present WAD
grading system in predicting work disabi lity and pain
and certain psychosocial parameters after neck injury.
Furthermore, a simila r biopsychosocial risk assessment
could be considered in other acute conditions bearing a
risk of long-term development of other chronic dysfunc-
tional pain conditions.
Author affiliations
Department of Neurology, The Danish Pain Research Center, Aarhus
University Hospital, Aarhus, Denmark
Department of Research, Spine Center of Southern Denmark, Hospital
Lillebaelt, Institute of Regional Health Research, University of Southern
Denmark, Odense M, Denmark
Department of Neurophysiology, Aarhus University Hospital, Aarhus,
Department of Neurology, Aarhus University Hospital, Aalborg Hospital,
Aalborg, Denmark
Department of Rheumatology, Copenhagen Spine Center, Glostrup Hospital,
Glostrup, Denmark
Acknowledgements Participants were recruited with the help of the staff at
the emergency units at hospitals in the four former counties of Viborg,
Aarhus, Vejle and Funen during the enrolment period. Statistical consultation
was provided from the Department of Statistics, University of Southern
Denmark on designing the study.
Contributors HK, TJ, TB and FB initially conceived the idea of the study;
further elaboration of the protocol was made by AK and EQ, and all authors
were responsible for the design of the study. Analysis of data was performed
by HK, TJ and AK. HK, TJ, FB, TB, EQ and AK contributed to the
interpretation of results. HK, TJ, TB, FB and AK were involved in the
development of graphs and tables for the manuscript. The main draft of the
manuscript was performed by HK and TJ. Critical revisions were made by AK,
TB and FB. All writers took part in the successive drafts of the manuscript.
Funding Financial support was provided by an unrestricted grant from
The Danish Insurance Association.
Competing interests None.
Ethics approval The Scientific Committee for The Counties of Vejle and
Funen, Project number 20000268, Denmark.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement There are no additional data available.
1. Brandsborg B, Dueholm M, Nikolajsen L, et al. A prospective study
of risk factors for pain persisting 4 months after hysterectomy. Clin J
Pain 2009;25:2638.
2. Nikolajsen L, Brandsborg B, Lucht U, et al. Chronic pain following
total hip arthroplasty: a nationwide questionnaire study. Acta
Anaesthesiol Scand 2006;50:495500.
3. Aasvang EK, Gmaehle E, Hansen JB, et al. Predictive risk factors
for persistent postherniotomy pain. Anesthesiology
4. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk
factors and prevention. Lancet 2006;367:161825.
5. Nikolajsen L, Ilkjaer S, Christensen JH, et al. Pain after amputation.
Br J Anaesth 1998;81:486.
6. Rasmussen BK. Migraine and tension-type headache in a general
population: precipitating factors, female hormones, sleep pattern and
relation to lifestyle. Pain 1993;53:6572.
7. Galasko CSB, Murray PM, Pitcher M, et al. Neck sprains after road
traffic accidents: a modern epidemic. Injury 1993;24:1557.
8. Kongsted A, Leboeuf-Y de C. The Nordic back pain subpopulation
program: course patterns established through weekly follow-ups in
patients treated for low back pain. Chiropr Osteopat 2010;18:2.
9. Spitzer WO, Skovron ML, Salmi LR, et al. Scientific monograph of
the Quebec Task Force on Whiplash-Associated Disorders:
redefining Whiplash and its management. Spine 1995;20:1S73S.
10. Williams M, Williamson E, Gates S, et al. A systematic literature
review of physical prognostic factors for the development of Late
Whiplash Syndrome. Spine 2007;32:E76480.
11. Kasch H, Qerama E, Kongsted A, et al. Deep muscle pain, tender
points and recovery in acute whiplash patients: a 1-year follow-up
study. Pain 2008;140:6573.
12. Kasch H, Stengaard-Pedersen K, Arendt-Nielsen L, et al. Pain
thresholds and tenderness in neck and head following acute
whiplash injury: a prospective study. Cephalalgia 2001;21:18997.
13. Sterling M. Differential development of sensory hypersensitivity and
a measure of spinal cord hyperexcitability following whiplash injury.
Pain 2010;150:5016.
14. Koelbaek Johansen M, Graven-Nielsen T, Schou-Olesen A,
et al.
Generalised muscular hyperalgesia in chronic whiplash syndrome.
Pain 1999;83:22934.
15. Sterling M, Hendrikz J, Kenardy J. Similar fact ors predict disability and
posttr au mati c stres s disorder trajectories after whiplash injury. Pain 2011.
16. Gottrup H, Andersen J, Arendt-Nielsen L, et al. Psychophysical
examination in patients with post-mastectomy pain. Pain
17. Aasvang E, Kehlet H. Chronic postoperative pain: the case of
inguinal herniorrhaphy. Br J Anaesth 2005;95:6976.
18. Kasch H, Bach FW, Jensen TS. Handicap after acute whiplash injury: a
1-year prospective study of risk factors. Neurology 2001;56:163743.
19. Kasch H, Qerama E, Kongsted A, et al. The risk assessment score
in acute whiplash injury predicts outcome and reflects
biopsychosocial factors. Spine (PA 1976) 2011;36:S2637.
20. Kongsted A, Qerama E, Kasch H, et al. Education of patients after
whiplash injury: is oral advice any better than a pamphlet? Spine
(PA 1976) 2008;33:E8438.
21. Kongsted A, Qerama E, Kasch H, et al. Neck collar, act-as-usual
or active mobilization for whiplash injury? A randomized
parallel-group trial. Spine (PA 1976) 2007;32:61826.
22. Kasch H, Qerama E, Kongsted A, et al. Clinical assessment of
prognostic factors for long-term pain and handicap after whiplash
injury: a 1-year prospective study. Eur J Neurol 2008;15:12 2230.
23. Collins SL, Moore RA, McQuay HJ. The visual analogue scale: what
is moderate pain in millimetres? Pain 1997;72:957.
24. Dworkin RH, Turk DC, Wyrwich KW, et al. Interpreting the clinical
importance of treatment outcomes in chronic pain clinical trials:
IMMPACT recommendations. J Pain 2008;9:10521.
25. Horowitz M, Wilner N, Alvarez W. Impact of Event Scale: a measure
of subjective stress. Psychosom med 1979;41:20918.
26. Kasch H, Stengaard-Pedersen K, Arendt-Nielsen L, et al. Headache,
neck pain, and neck mobility after acute whiplash injury: a
prospective study. Spine (PA 1976) 2001;26:124651.
Kasch H, Kongsted A, Qerama E, et al. BMJ Open 2013;3:e002050. doi:10.1136/bmjopen-2012-002050 7
Risk assesment score in whiplash injuries
27. Wolfe F, Smythe HA, Yunus MB, et al. The American College of
Rheumatology 1990 Criteria for the Classification of Fibromyalgia.
Report of the Multicenter Criteria Committee. Arthritis Rheum
28. Bunketorp L, Lindh M, Carlsson J, et al. The perception of pain and
pain-related cognitions in subacute whiplash-associated disorders:
its influence on prolonged disability. Disabil Rehabil 2006;28:2719.
29. Jensen K. Quantification of tenderness by palpation and use of
pressure algometers. Advances in Pain Research and Therapy
New York: Raven Press, 1990:16581.
30. Bendtsen L, Jensen R, Jensen NK, et al. Pressure-controlled
palpation: a new technic which increases the reliability of manual
palpation. Cephalalgia 1995;15:20510.
31. Pedler A, Sterling M. Assessing fear-avoidance beliefs in patients
with whiplash-associated disorders: a comparison of 2 measures.
Clin J Pain 2011;27:5027.
32. Kivioja J, Jensen I, Lindgren U. Neither the WAD-classification nor
the Quebec Task Force follow-up regimen seems to be important for
the outcome after a whiplash injury. A prospective study on 186
consecutive patients. Eur Spine J 2008;17:9305.
33. Carstensen TB, Frostholm L, Oernboel E, et al. Post-trauma ratings
of pre-collision pain and psychological distress predict poor outcome
following acute whiplash trauma: a 12-month follow-up study. Pain
34. Rivest K, Cote JN, Dumas JP, et al. Relationships between pain
thresholds, catastrophizing and gender in acute whiplash injury. Man
Ther 2010;15:1549.
35. Buitenhuis J, Jaspers JP, Fidler V. Can kinesiophobia predict the
duration of neck symptoms in acute whiplash? Clin J Pain
36. Kongsted A, Bendix T, Qerama E, et al. Acute stress response and
recovery after whiplash injuries. A one-year prospective studyEur J
Pain 2008;12:45563.
37. Sterling M, Carroll LJ, Kasch H, et al . Prognosis following whiplash
injury: where to from here? Spine 2011;36:S33034.
38. Sterling M, Jull G, Kenardy J. Physical and psychological factors
maintain long-term predictive capacity post-whiplash injury. Pain
39. Scholten-Peeters GGM, Verhagen AP, Bekkering GE, et al.
Prognostic factors of whiplash-associated disorders: a systematic
review of prospective cohort studies. Pain 2003;104:30322.
40. Holm LW, Carroll LJ, Cassidy JD, et al. Expectations for recovery
important in the prognosis of whiplash injuries. PLoS Med 2008;5:e105.
41. Sullivan MJ, Scott W, Trost Z. Perceived injustice: a risk factor for
problematic pain outcomes. Clin J Pain 2012;28:4848.
42. Hendriks EJM, Scholten-Peeters GGM, van der Windt D, et al.
Prognostic factors for poor recovery in acute whiplash patients. Pain
8 Kasch H, Kongsted A, Qerama E, et al. BMJ Open 2013;3:e002050. doi:10.1136/bmjopen-2012-002050
Risk assesment score in whiplash injuries
... We have previously developed and validated 8,9 a risk assessment score: The Danish Whiplash Group Risk Assessment Score (DWGRAS) and the 7 derived Risk Strata have shown a capability of predicting a 1-year pain disability and work disability. DWGRAS was reported to reflect biological factors, including a 1-year development in neck strength and endurance 10 using a control group sustaining an acute ankle injury, and to reflect changes in pain response. ...
... DWGRAS has been used to reflect differences in social performance including factors related to work, for example, predicting a 1-year work disability 8 and also the changes in daily life functioning. 12 From a psychological point of view, factors like impact of event, intrusion and avoidance related to cognitive psychological impact of the exposure to whiplash injury, are significantly different after 1 year in risk strata derived from the DWGRAS score. ...
... 12 From a psychological point of view, factors like impact of event, intrusion and avoidance related to cognitive psychological impact of the exposure to whiplash injury, are significantly different after 1 year in risk strata derived from the DWGRAS score. 8 The Quebec Task Force Grading system is considered the gold standard for describing whiplash patients and was introduced by the Quebec Task Force in 1995, 5 but has not been helpful in predicting long-term pain and disability after whiplash injuries. 3 One reason could be an underlying biologically oriented explanation of the traumatic event. ...
Full-text available
Objective: To evaluate the long-term predictive value of The Danish Whiplash Group Risk Assessment Score (DWGRAS) with 7 risk-strata. Design: E-questionnaire based follow-up study (n=927) combining two cohorts of whiplash injured subjects, one observational (n=187) one interventional RCT (n=740). Methods: 927 previously healthy persons exposed to acute whiplash injury during motor vehicle collision were sent letter by postal service asking the addressee if they would respond to an e-questionnaire. Outcome measures were: whiplash-related disability, pain, use of medication/non-medical treatment, work-capacity. Results: The response rate was 37%. Fifty-five percent reported whiplash-related disability. Fourteen percent reported daily complaints. A strong relationship was found between risk-strata and Impact of Event and between risk strata and disabling symptoms. Conclusion: Internal and long-term validation of DWGRAS has now been performed, but a low response rate of 37% indicates that results should be interpreted with caution. Furthermore, external validation needs to be done in long-term studies. A ROC curve of 0.73 (CI95 0.67; 0.79) predicting daily or weekly whiplash related disability after 12-14 years was found using the DWGRAS Risk Score.
... 1,2 WAD can be classified by the severity of signs and symptoms from grades 0 (no complaints or physical signs) to 4 (fracture or dislocation). 2,3 Factors related to poor recovery following whiplash injury are high initial neck pain intensity, socio-demographic status, compensation (litigation), psychosocial factors, and physical factors including reduced neck mobility, impaired sympathetic vasoconstriction, and reduced cold pain tolerance. [4][5][6] Individuals sustaining apparently mild head injuries often complain of several physical, cognitive, and emotional/behavioural symptoms referred to as post-concussion symptoms 7-9 and 10 main symptoms are included in the post-concussion syndrome (PCS as defined by the Mayo Clinic; ...
... Of the remaining 198 subjects, 55 did not show up at the first examination. One hundred and forty-three whiplash-exposed subjects (WAD grades I-III) were examined and completed semi-structured interviews on pain and PCS symptoms and the RHFUQ 1 3 week post-injury. At 6-month follow-up, 122 patients underwent semi-structured interview and 112 completed RHFUQ. ...
... Better tests are however available. 3,13 Even so, the findings of this study suggest the appropriateness of performing causal considerations regarding the origin of symptoms ascertained in or reported by victims/injured subjects, eg, carefully considering stress-related mechanisms, neuroinflammation, genetic susceptibility, and social constructions, but also reconsidering head-neck kinematics. 10,[21][22][23] ...
Full-text available
Aim To examine concussion-related disability in neck injuries, the Rivermead Head Injury Follow-Up Questionnaire (RHFUQ) was applied. Furthermore, we wanted to investigate symptoms found in post-concussion syndrome (PCS) and global pain, neck pain intensities obtained from acute whiplash patients within 1 week and at 6 months after injury in a prospective study on 1-year work disability. Methods A total of 143 consecutive acute whiplash-injured patients were admitted to the study from the Emergency Unit (Aarhus University Hospital). Patients with direct head trauma or reported retro- or anterograde amnesia were excluded from the study. Average neck pain and global pain intensity were measured on a Visual Analogue Scale (VAS 0-10). The RHFUQ (10 items, score from 0 to 4, total score from 0 to 40) was fulfilled after 1 week and 6 months. Patients underwent neurological examination within 1 week after injury. Recovery (return to work) was assessed 1 year post-injury. Results In total, 97% completed the study, and 9% (12/138) did not recover. Non-recovered patients reported more neck pain and global pain after 1 week ( P < .003) and 6 months ( P < .008) and higher PCS symptom score after 1 week ( P < .001) and 6 months ( P < .002). Using the RHFUQ total score as a predictive test, a receiver-operating characteristic curve (ROC) area of 0.77 (0.61-0.92) and a cut-off at 10 points revealed a sensitivity of 75% and a specificity of 67.2%. At 1 week, 8 of 10 items reached higher scores among non-recovered and 10 of 10 items after 6 months post-injury. Conclusions RHFUQ is useful in acute whiplash patients for predicting 1-year work disability. PCS-related symptoms along with neck pain and global pain are more burdensome in the non-recovered group. This emphasizes that post-concussion symptoms are not a sign of brain injury alone, but are found in other types of mishaps like whiplash injuries.
... Each stage has important methodological considerations, for example, during derivation, data should be acquired from prospective longitudinal cohorts [12] of adequate size to accommodate 10-15 study participants per predictor variable [13,14]. Whilst multiple risk assessment tools exist for estimating the likelihood of recovery following WAD [15][16][17][18][19][20][21][22][23][24][25], their statistical approaches vary considerably, as do their outcomes of interest. For example, Bohman et al. (2012) [17] developed a model for the prediction of recovery from WAD using seven variables; age, number of days to report the motor vehicle collision, headache before injury, pain other than neck and back, neck pain intensity, low back pain intensity and expectations of recovery. ...
... The primary outcome was global self-perceived recovery and concordance statistics revealed a c-index (or area under receiver operator curve; AU ROC, of 0.68, 95% CI: 0.65-0.71). Shortly following the publication of this study, the 'Danish Whiplash Group Risk Assessment Score' (DWGRAS) [16] was published, with an AU ROC of 0.79 for 'total risk score' in predicting 1-year work disability. The DWGRAS calculated a total risk score from three variables; neck pain and headache intensity scores (0-10, where 0 = no pain, 10 = worst imaginable pain, with the highest score of either neck pain or headache intensity considered), the total number of non-painful complaints (e.g. ...
Full-text available
Background WhipPredict, which includes prognostic factors of pain-related disability, age and hyperarousal symptoms, was developed and validated for prediction of outcome in people with whiplash associated disorders (WAD). Patient expectations of recovery was not an included factor, though is known to mediate outcomes. The aim of this study was to determine whether the addition of expectations of recovery could improve the accuracy of WhipPredict. Methods Two hundred twenty-eight participants with acute WAD completed questionnaires (WhipPredict and expectations of recovery) at baseline. Health outcomes (neck disability index (NDI) and Global Perceived Recovery (GPR)) were assessed at 6- and 12-months post injury. Cut-off points for expectations of recovery predictive of both full recovery (NDI ≤10 % , GPR ≥ 4) and poor outcome (NDI ≥30 % , GPR ≤ − 3) were determined, and multivariate logistic regression analyses were used to compare models with and without this variable. Results Expectations of recovery improved or maintained the accuracy of predictions of poor outcome (6-months: sensitivity 78 to 83%, specificity maintained at 79.5%; 12-months: sensitivity maintained at 80%, specificity 69 to 73%). The sensitivity of predictions of full recovery improved (6-months: 68 to 76%; 12-months: 57 to 81%), though specificity did not change appreciably at 6 months (80 to 81%) and declined at 12 (83 to 76%). ROC curves indicated a larger and more consistent improvement in model performance when expectations of recovery were added to the pathway predictive of full recovery. Conclusions The addition of expectations of recovery may improve the accuracy of WhipPredict, though further validation is required.
... paresthesia, dizziness, fatigue, memory deficit and other cognitive symptoms. The risk of chronic symptoms can be predicted based on early stratification in clinical settings and the prognosis for full recovery is poor if symptoms persist beyond one year [3,4]. In most cases of acute whiplash injury the causal inferences are readily made in the clinical setting, i.e. acute symptoms (temporality) following a rear-impact collision (relevant trauma) and consistency of clinical findings (complaints, signs and symptoms). ...
... The clinical assessment tools utilized in this study were relevant in defining a study population of chronic whiplash patients. In fact, most of the tests are part of the DWGRASS stratification system, which enables baseline evaluation and prognostication at an early stage after whiplash injury [3,4]. This evidence based risk assessment system of acute whiplash patients is based on ACROM, neck/head VAS and number of non-painful symptoms, and can after stratification, to a certain extent, predict outcome 12-14 years ahead [3]. ...
Full-text available
Background Whiplash injury is common following road traffic crashes affecting millions worldwide, with up to 50% of the injured developing chronic symptoms and 15% having a reduced working capability due to ongoing disability. Many of these patients receive treatment in primary care settings based upon clinical and diagnostic imaging findings. Despite the identification of different types of injuries in the whiplash patients, clinically significant relationships between injuries and chronic symptoms remains to be fully established. This study investigated the feasibility of magnetic resonance imaging (MRI) techniques including quantitative diffusion weighted imaging and measurements of cerebrospinal fluid (CSF) flow as novel non-invasive biomarkers in a population of healthy volunteers and chronic whiplash patients recruited from a chiropractic clinic for the purpose of improving our understanding of whiplash injury. Methods Twenty chronic whiplash patients and 18 healthy age- and gender matched control subjects were included [mean age ± SD (sex ratio; females/males), case group: 37.8 years ± 9.1 (1.22), control group: 35.1 years ± 9.2 (1.25)]. Data was collected from May 2019 to July 2020. Data from questionnaires pertaining to the car crash, acute and current symptoms were retrieved and findings from clinical examination and MRI including morphologic, diffusion weighted and phase-contrast images were recorded. The apparent diffusion coefficient and fractional anisotropy were calculated, and measurement and analysis of CSF flow was conducted. Statistical analyses included Fisher’s exact test, Mann Whitney U test and analysis of variance between groups. Results The studied population was described in detail using readily available clinical tools. No statistically significant differences were found between the groups on MRI. Conclusions This study did not show that MRI‐based measures of morphology, spinal cord and nerve root diffusion or cerebrospinal fluid flow are sensitive biomarkers to distinguish between chronic whiplash patients and healthy controls. The detailed description of the chronic whiplash patients using readily available clinical tools may be of great relevance to the clinician. In the context of feasibility, clinical practice-based advanced imaging studies with a technical setup similar to the presented can be expected to have a high likelihood of successful completion.
... While the ACR-AC clinical condition of Suspected Spine Trauma provides some guidance as to who should get imaging to detect acute injury, it does not suggest how front-line providers should or could correlate non-emergency imaging findings with the subsequent clinical course. It is known that pre-injury neck pain, older age, high baseline pain intensity, higher self-reports of neck related disability, pre-collision medical diagnoses [13], and signs of peritraumatic distress are associated with poor recovery [7,14], and delayed return to work [15]. It is, however, not clear if indeterminate imaging findings, beyond fracture and ligamentous instability, may be associated with the subsequent clinical course of whiplash. ...
... The diagnostic and prognostic value of traditional imaging in whiplash injury remains unclear at least in part due to the variability in the approaches used in assessment, analysis of imaging findings [17][18][19][20][21]31,34,[36][37][38][39][40][41]53,54], and a lack of recognition for current knowledge regarding the known risk factors for poor recovery following whiplash [7,14,15,33,55,56]. Furthermore, unlike other common clinical diagnostic tests with wellestablished values of normative ranges (e.g. standard blood tests), there is a lack of easily accessible normative radiologic reference values to understand the presence and significance of soft-tissue pathologic findings for a relatively asymptomatic, but ageing, spine. ...
Background and purpose: There remains limited evidence for the clinical importance of most imaging findings in whiplash. However, it is possible the type and number of findings on Computed Tomography (CT) may contribute to prognostic recovery models. The purpose is to interpret cervical spine pathologies in the context of known factors influencing recovery. Materials and methods: This is a secondary analysis from a database of 97 acutely injured participants enrolled in a prospective inception cohort study. Thirty-eight participants underwent standard of care cervical spine CT in the emergency medicine department. All 38 participants were assessed at <1-week, 2-weeks, and 3-months post-injury and classified using percentage scores on the Neck Disability Index (recovered/mild (NDI of 0-28%) or moderate/severe (NDI ≥ 30%)). Between-group comparison of categorical variables (gender (male/female), presence of at least one CT finding (yes/no), and presence of ≥3 pathologies on CT (yes/no)) was conducted using 2-tailed Fisher's exact test. Results: Participants from both groups demonstrated at least one observable pathology. The group with persistent moderate/severe symptoms presented with significantly more pathology at baseline than those who later reported recovery or milder symptoms at 3-months post injury (p = 0.02). Conclusions: This preliminary study, which needs replication in a larger cohort, provides foundation that the number of degenerative pathologies seen on initial post MVC CT may be associated with the subsequent clinical course of whiplash.
... 1,2 Of those diagnosed with WAD, up to 55% may still experience symptoms such as neck pain and stiffness, dizziness, and/or sleep problems several years after the incident. [3][4][5][6] However, despite significant advances in the understanding and management of WAD, there seems to be no reduction in the proportion of people developing persistent symptoms. 7 WAD is a complex and multifactorial condition with a great need for understanding potential underlying mechanisms. ...
Objectives: To investigate the pain-sensory profile of patients with whiplash-associated disorders (WAD) prior and post 2-weeks of standardized rehabilitation and after at 6-months follow-up. Methods: Twenty-two WAD-participants (Grade-II; 14 women) and 22 sex-and age-matched healthy controls were enrolled. Pressure pain thresholds (PPTs) were assessed at local and distal muscles. Conditioned pain modulation (CPM) of PPTs was assessed using cuff-pressure around the upper-arm. Referred area of pain following supra-threshold pressure stimulation of the infraspinatus muscle was recorded on a body chart. Psychometric variables (Pain intensity, area of perceived pain, pain catastrophizing, kinesiophobia, sleep problems, depression level) were assessed. WAD-group additionally completed the Neck Disability Index (NDI). Results: The WAD-group demonstrated lower local PPTs compared to controls at all timepoints (P<0.05) and lower distal PPTs at baseline and at 2 weeks when compared to 6-months (within-group) (P<0.05). The WAD-group had a reduced CPM response and larger induced referred pain areas compared to controls (P<0.05), while no within-group changes were observed at any time point. The WAD-group reported higher pain intensity and perceived area of pain compared to controls at all timepoints (P<0.05) and a mean NDI-score of 41% at baseline, 16% at 2-weeks, and 4% at 6-months. Furthermore, the WAD-group reported improvements in all other psychometric variables (P<0.05), although only pain catastrophizing levels were comparable to controls at 2-weeks. Discussion: PPTs but not CPM improved in the WAD-group and were comparable to controls following 2-weeks following standardized rehabilitation, indicating that normalization of CPM may not be required to recover from WAD.
... 83 In a similar manner, it should be possible to convert generic (ie, VAS-P, PCI and FABQ) and nongeneric (ie, previous history of neck injury, type and number of whiplash-related symptoms, and NDI scores) prognostic factors into a sum score as a tool to steer treatment plans for WAD, and a comparable tool (risk assessment score) has already been developed by the Danish Whiplash Study Group. 84 Optimizing physiotherapy treatment based on a sum score of generic and nongeneric prognostic factors is a challenge, but will likely improve the process of clinical reasoning, decision making, and outcomes in patients with WAD. ...
Full-text available
Background: Whiplash-associated disorders (WADs) constitute a state of health characterized by a wide diversity of symptoms as a result of impairments of functions, activity limitations, and participation restrictions. Patient-reported outcome measurements (PROMs) and patient-reported outcomes (PROs) seem appropriate when describing and evaluating the health status of patients with WAD. Aim: To measure the use of PROMs and PROs as quality indicators in clinical reasoning, and to analyze and evaluate pre- and post-treatment 'pain intensity' and 'functioning', and for 'perceived improvement' in patients with WAD in primary care physiotherapy practice by year of referral, with the phase after accident and prognostic health profile embedded in the clinical reasoning process. Materials and methods: Data were collected over a period of 10 years. Pain intensity, functioning, and perceived improvement were measured using the Visual Analogue Scale for Pain (VAS-P), the Neck Disability Index (NDI) and the Global Perceived Effect scale (GPE). Pre- and post-treatment mean differences were tested for statistical significance and compared to minimal clinically important differences (MCID). Effect sizes were expressed as Cohen's d. Multivariable regression analysis was performed to explore independent associations of year of referral, phase after the accident, and the patient's prognostic health profile with post-treatment pain intensity and functioning. Results: A consecutive sample of 523 patients was included. Pre- and post-treatment mean differences on VAS-P and NDI were statistically significant (P<0.000) and clinically relevant, with 'large' effect sizes for pain intensity and functioning. MCIDs were achieved by 80% for VAS-P and for 60% for NDI. Year of referral and phase after the accident were independently associated with worse post-treatment functioning. About half of the patients (n=241 [46.1%]) perceived themselves as improved. Conclusion: The PROMs and PROs pain intensity, functioning and perceived improvement were integrated as quality indicators in the physiotherapy clinical reasoning process for patients with WAD. Significant differences in pain intensity and functioning were found but were unrelated to year of referral, phase after whiplash-related injury or prognostic health profile. The MCID VAS-P scores did not differ depending on experienced pain.
... The group of acute-traumatic cervical-spine injury was those cervical spine lesions, stemming from a so-called whiplash injury, in which the neck spine was exposed to a forced extension-flexion trauma [16], with symptoms of late neck pain within a 72 hours period since motor vehicle collision. These patients did not have any other sign or symptom of myelopathy and with MRI findings showing only rectification of the cervical canal. ...
Background The two of the most common indications for magnetic resonance (MR) imaging of the cervical spine include acute spine trauma and degenerative disease. Objective We aimed to correlate the measurements of the free area of the spinal canal (FASC), a new approach to the cervical spinal canal compromise, with the Torg´s ratio quantification of the cervical spine. Methods Cross-sectional study including 50 cervical-spine MR evaluations of patients with acute cervical trauma or degenerative disease. We used multivariate analysis of covariance (MANCOVA) to identify the type of lesion, intervertebral level and gender differences between FASC and Torg´s ratio quantification of the cervical spine; age was the controlled covariate. Correlates between FASC and Torg´s ratio were obtained at each intervertebral level. Results There was a non-significant interaction between the type of lesion, gender and intervertebral levels between FASC and Torg´s ratio measurements, F (8, 456) 0.260, p = .978; Wilks' Lambda 0.991; with a small effect size (partial η2 = .005). Among the main effects, only the gender was statistically significant: F (2, 228) = 3.682, p = .027. The age (controlled covariate) was non-significantly related to FASC and Torg´s ratio quantification: F (2, 228) = .098, p = .907. The Pearson´s correlation coefficient depicted a poor, non-significant agreement between FASC and Torg´s ratio. Conclusions FASC provide an integrative evaluation of the cervical spinal canal compromise in acute, cervical spine trauma and degenerative disease. Further observations and correlation with specific neurological symptoms, surgical findings and outcome are necessary to assess the usefulness of FASC in clinical settings.
... In two Phase I studies from the same cohort (and no external validation), a risk score was developed to predict WAD recovery; the risk score consisted of cervical range of motion, neck/head pain intensity, sex, number of non-pain symptoms and pain on palpation predicted WAD recovery outcomes [98,119]. ...
Purpose: To update the findings of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force) on prognostic factors for whiplash-associated disorder (WAD) outcomes. Materials and methods: We conducted a systematic review and best-evidence synthesis. We systematically searched MEDLINE, EMBASE, CINAHL and PsycINFO from 2000–2017. Random pairs of reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Results: We retrieved 10,081 articles. Of those, 100 met inclusion criteria. After critical appraisal, 74 were judged to have low risk of bias. This adds to the 47 admissible studies found by the Neck Pain Task Force. Twenty-two related to course of recovery; 59 to prognostic factors in recovery; and 16 reported other WADs outcomes. Some studies related to more than one category. Findings suggest that half of those with WADs will experience substantial improvement within three months and cessation of symptoms within six months. Among factors associated with recovery are post-crash psychological factors, including expectations for recovery and coping. Conclusions: Our review adds to the Neck Pain Task Force by clarifying the role of prognostic factors. Evidence supports the important role of post-crash psychological factors in WADs recovery. Systematic Review Registration Number: CRD42013004610
... Delayed recovery is not satisfactorily explained by detectable patho-anatomical changes [6][7][8][9]. Instead, a plethora of complex and intertwined characteristics such as initial pain levels, reduced cervical range of motion, PTSD symptoms, age, gender, education, depression, and pre-injury sick leave have been associated with negative outcomes [10][11][12][13][14][15]. ...
Full-text available
Objective To describe the development of a preventive educational video for patients exposed to whiplash trauma following motor vehicle accidents. Methods The development followed a systematic approach and was theory-driven supplemented with available empirical knowledge. The specific content was developed by a multidisciplinary group involving health professionals and visual production specialists. Results A 14-min educational video was created. The video content focuses on stimulating adaptive recovery expectations and preventing maladaptive illness beliefs. The video presents a multifactorial model for pain incorporating physiological and cognitive-behavioural aspects, advice on pain relief, and exercises. Subjects interviewed for a qualitative evaluation found the video reassuring and that it aligned well with verbal information received in the hospital. Conclusions The development of the visual educational intervention benefitted from a systematic development approach entailing both theoretical and research-based knowledge. The sparse evidence on educational information for acute whiplash trauma posed a challenge for creating content. Further knowledge is required regarding what assists recovery in the early stages of whiplash injuries in order to improve the development of educational interventions.
To develop criteria for the classification of fibromyalgia, we studied 558 consecutive patients: 293 patients with fibromyalgia and 265 control patients. Interviews and examinations were performed by trained, blinded assessors. Control patients for the group with primary fibromyalgia were matched for age and sex, and limited to patients with disorders that could be confused with primary fibromyalgia. Control patients for the group with secondary-concomitant fibromyalgia were matched for age, sex, and concomitant rheumatic disorders. Widespread pain (axial plus upper and lower segment plus left- and right-sided pain) was found in 97.6% of all patients with fibromyalgia and in 69.1% of all control patients. The combination of widespread pain and mild or greater tenderness in ⩾ 11 of 18 tender point sites yielded a sensitivity of 88.4% and a specificity of 81.1%. Primary fibromyalgia patients and secondary-concomitant fibromyalgia patients did not differ statistically in any major study variable, and the criteria performed equally well in patients with and those without concomitant rheumatic conditions. The newly proposed criteria for the classification of fibromyalgia are 1) widespread pain in combination with 2) tenderness at 11 or more of the 18 specific tender point sites. No exclusions are made for the presence of concomitant radiographic or laboratory abnormalities. At the diagnostic or classification level, the distinction between primary fibromyalgia and secondary-concomitant fibromyalgia (as defined in the text) is abandoned.
Emerging research suggests that perceptions of injustice after musculoskeletal injury can have a significant impact on a number of pain-related outcomes. The purpose of this paper is to review evidence linking perceptions of injustice to adverse pain outcomes. For the purposes of this paper, perceived injustice is defined as an appraisal cognition comprising elements of the severity of loss consequent to injury ("Most people don't understand how severe my condition is"), blame ("I am suffering because of someone else's negligence"), a sense of unfairness ("It all seems so unfair"), and irreparability of loss ("My life will never be the same"). Cross-sectional studies show that high scores on perceptions of injustice are correlated with pain catastrophizing, fear of movement, and depression. Prospective studies show that high scores on perceived injustice are a prognostic indicator of poor rehabilitation outcomes and prolonged work disability. Research shows that perceptions of injustice interfere not only with physical recovery after injury, but perceptions of injustice also impact negatively on recovery of the mental health problems that might arise subsequent to traumatic injury. Although research has yet to address the process by which perceptions of injustice impact on pain-related outcomes systematically; possible mechanisms include attentional disengagement difficulties, emotional distress, maladaptive coping, heightened displays of pain behavior, anger, and revenge motives. Perceived injustice appears to be associated with problematic health and mental health recovery trajectories after the onset of a pain condition. Future directions for research and treatment are addressed.
Chronic pain, lymphoedema, post-irradiation neuropathy and other symptoms are reported in as many as 75% of women following breast cancer treatment. This study examined pain and sensory abnormalities in women following breast cancer surgery. Sensory tests were carried out on operated and contralateral sides in 15 women with spontaneous pain and sensory abnormalities and 11 pain-free women. Testing included the VAS score of spontaneous pain, detection and pain threshold to thermal and mechanical stimuli, temporal summation to repetitive heat and pinprick stimuli, and assessment of skin blood flow during repetitive brush and pinprick stimulation. Sensory threshold to pinprick and thermal stimuli was significantly higher on the operated side in both groups while pressure pain threshold was significantly lower in pain patients on the operated side compared to the contralateral side. No side to side difference was seen in pressure pain threshold in the pain-free group. Evoked pain intensity to repetitive stimuli at 0.2 and 2.0 Hz was significantly higher on the operated side in pain patients compared to the control area while no such difference was seen in pain-free patients. Cutaneous blood flow measured by laser Doppler (flux) was significantly higher when the skin was tapped at 2.0 Hz on the operated side compared to contralaterally in pain patients, while no side to side difference was seen in pain-free patients. Pinprick-evoked pain was correlated to spontaneous pain but not to flux. Spontaneous pain was not correlated to flux. Sensitization seems to be a feature in breast cancer-operated women with pain, but not in pain-free women.
One-year prospective study of 141 acute whiplash patients (WLP) and 40 acute ankle-injured controls. This study investigates a priori determined potential risk factors to develop a risk assessment tool, for which the expediency was examined. The whiplash-associated disorders (WAD) grading system that emerged from The Quebec Task-Force-on-Whiplash has been of limited value for predicting work-related recovery and for explaining biopsychosocial disability after whiplash and new predictive factors, for example, risk criteria that comprehensively differentiate acute WLP in a biopsychosocial manner are needed. Consecutively, 141 acute WLP and 40 ankle-injured recruited from emergency units were examined after 1 week, 1, 3, 6, and 12 months obtaining neck/head visual analog scale score, number of nonpainful complaints, epidemiological, social, psychological data and neurological examination, active neck mobility, and furthermore muscle tenderness and pain response, and strength and duration of neck muscles. Risk factors derived (reduced cervical range of motion, intense neck pain/headache, multiple nonpain complaints) were applied in a risk assessment score and divided into seven risk strata. A receiver operating characteristics curve for the Risk Assessment Score and 1-year work disability showed an area of 0.90. Risk strata and number of sick days showed a log-linear relationship. In stratum 1 full recovery was encountered, but for high-risk patients in stratum 6 only 50% and 7 only 20% had returned to work after 1 year (P < 5.4 × 10). Strength measures, psychophysical pain measurements, and psychological and social data (reported elsewhere) showed significant relation to risk strata. The Risk Assessment score is suggested as a valuable tool for grading WLP early after injury. It has reasonable screening power for encountering work disability and reflects the biopsychosocial nature of whiplash injuries.
Nonsystematic review and discussion of prognosis after whiplash injury. To summarize the research and identify a research agenda for improving prognostic models after whiplash injury. With up to 50% of individuals failing to fully recover after whiplash injury, the capacity to determine a precise estimate of prognosis will be important. Systematic reviews note inconsistencies and shortcomings of research in this area. A nonsystematic review and discussion. Most prognostic whiplash studies are phase 1 (exploratory) studies with few confirmatory or validation studies yet available. It is recognized that whiplash is a heterogeneous condition and clinicians require prognostic indicators for clinical use. Although the evidence is not sufficiently strong to make firm recommendations, there are some prognostic factors that have shown consistency across studies and could be considered as preliminary flags or guides to gauge patients potentially at risk of poor recovery. These include pain and/or disability levels, neck range of movement, cold and mechanical hyperalgesia and psychological factors of recovery beliefs/expectations, post-traumatic stress symptoms, depression, and pain catastrophizing. It is not known whether these factors can be modified or whether modification will improve outcomes, thus they should not be considered directives for management. Research priorities identified to develop improved predictive models include confirmation and validation of factors identified in phase 1 studies; investigation of the interaction between variables; investigation of the predictive value of changes in variables over time; the inclusion of validated outcomes including measures of pain and disability as well as perceived recovery and psychological outcomes. The current evidence is not sufficiently robust to be able to confidently predict outcome after whiplash injury. A preliminary set of consistent factors has been proposed to assist clinicians in identifying individuals at risk of poor recovery. Directions for the development of improved prognostic models are discussed.
Distinct developmental trajectories for neck disability and posttraumatic stress disorder (PTSD) symptoms after whiplash injury have recently been identified. This study aimed to identify baseline predictors of membership to these trajectories and to explore their dual development. In a prospective study, 155 individuals with whiplash were assessed at <1 month, 3, 6, and 12 months postinjury. Outcomes at each time point were assessed according to the Neck Disability Index and the Posttraumatic Stress Diagnostic Scale. Baseline predictor variables were age, gender, initial pain (based on a visual analogue scale [VAS]), pressure pain thresholds (PPT), cold pain thresholds (CPT), and sympathetic vasoconstrictor responses. Group-based trajectory analytical techniques were used to parameterise the optimal trajectories and to identify baseline predictors. A dual trajectory analysis was used to explore probabilities of conditional and joint trajectory group membership. CPT > or = 13° C (OR = 26.320, 95% CI = 4.981-139.09), initial pain level (VAS) (OR = 4.3, 95% CI = 4.98-139.1), and age (OR = 1.109, 95% CI = 1.043-1.180) predicted a chronic/severe disability trajectory. The same baseline factors also predicted chronic moderate/severe PTSD (CPT > or = 13° C, OR = 9.7, 95% CI = 2.22-42.44; initial pain level [VAS]: OR = 2.13, 95% CI = 1.43-3.17; age: OR = 1.07, 95% CI = 1.01-1.14). There was good correspondence of trajectory group for both disability and PTSD. These findings support the proposal of links between the development of chronic neck related disability and PTSD after whiplash injury. Developmental trajectories of disability and posttraumatic stress disorder (PTSD) after whiplash injury are mostly in synchrony, and similar factors predict their membership. This suggests links between the development of chronic neck pain-related disability and PTSD.
To examine the development of fear avoidance behaviours following whiplash injury using two different measures of fear avoidance, the Pictorial Fear of Activities Scale-Cervical (PFActS-C), and the Tampa Scale of Kinesiophobia (TSK-17). Secondarily we assessed the capacity of these measures to predict recovery status at long term follow up and initial cervical range of movement (ROM). Ninety-eight patients with acute WAD were recruited and completed measures of pain and disability (NDI), fear avoidance beliefs and cervical ROM at baseline (<4 weeks), 3 and 6 months post injury. Participants were grouped based on NDI scores at 6 months follow up as either recovered (NDI <10), mild (NDI 10-28) or moderate/severe (NDI ≤ 30). Repeated measures, linear mixed model analysis showed a significant main effect for time and group for both TSK-17 and PFActS-C scores (P ≤ 0.001). On both measures the moderate/severe group scored significantly higher than the mild and recovered groups. TSK-17 scores, age and initial pain intensity at baseline significantly predicted NDI scores at 6 months (P = 0.002). PFActS-C scores, age and initial pain intensity at baseline significantly predicted initial cervical extension and rotation ROM (P = 0.001). Fear avoidance beliefs and behaviours develop quickly following whiplash injury and influence both the initial physical presentation and long term outcome of patients with WAD. The PFActS-C may provide a measure of fear of movement which is more specific to the cervical spine in patients with WAD in comparison to the TSK-17.
Widespread sensory hypersensitivity is present in acute whiplash and is associated with poor recovery. Decreased nociceptive flexion reflex (NFR) thresholds (spinal cord hyperexcitability) are a feature of chronic whiplash but have not been investigated in the acute to chronic injury stage. This study compared the temporal development of sensory hypersensitivity and NFR responses from soon after injury to either recovery or to transition to chronicity. It also aimed to identify predictors of persistent spinal cord hyperexcitability. Pressure and cold pain thresholds, NFR responses (threshold and pain VAS) were prospectively measured in 62 participants at <3 weeks, 3 and 6 months post whiplash injury and in 22 healthy controls on two occasions a month apart. Pain levels and psychological distress (GHQ-28; IES) were measured at baseline. Whiplash participants were classified at 6 months post-injury using the Neck Disability Index: recovered (8%), mild pain and disability (10-28%) or moderate/severe pain and disability (30%). All whiplash groups demonstrated spinal cord hyperexcitability (lowered NFR thresholds) at 3 weeks post-injury. This hyperexcitability persisted in those with moderate/severe symptoms at 6 months but resolved in those who recovered or reported lesser symptoms at 6 months. In contrast generalized sensory hypersensitivity (pressure and cold) was only ever present in those with persistent moderate/severe symptoms and remained unchanged throughout the study period. This suggests different mechanisms underlie sensory hypersensitivity and NFR responses. In multivariate analyses only initial NDI scores (p=0.003) were a unique predictor of persistent spinal cord hyperexcitability indicating possible ongoing peripheral nociception following whiplash injury.