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The association between a lifetime history of a neck injury in a motor vehicle collision and future neck pain: A population-based cohort study

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The objective of this population-based cohort study was to investigate the association between a lifetime history of neck injury from a motor vehicle collision and the development of troublesome neck pain. The current evidence suggests that individuals with a history of neck injury in a traffic collision are more likely to experience future neck pain. However, these results may suffer from residual confounding. Therefore, there is a need to test this association in a large population-based cohort with adequate control of known confounders. We formed a cohort of 919 randomly sampled Saskatchewan adults with no or mild neck pain in September 1995. At baseline, participants were asked if they ever injured their neck in a motor vehicle collision. Six and twelve months later, we asked about the presence of troublesome neck pain (grade II-IV) on the chronic pain grade questionnaire. Multivariable Cox regression was used to estimate the association between a lifetime history of neck injury in a motor vehicle collision and the onset of troublesome neck pain while controlling for known confounders. The follow-up rate was 73.5% (676/919) at 6 months and 63.1% (580/919) at 1 year. We found a positive association between a history of neck injury in a motor vehicle collision and the onset of troublesome neck pain after controlling for bodily pain and body mass index (adjusted HRR = 2.14; 95% CI 1.12-4.10). Our analysis suggests that a history of neck injury in a motor vehicle collision is a risk factor for developing future troublesome neck pain. The consequences of a neck injury in a motor vehicle collision can have long lasting effects and predispose individuals to experience recurrent episodes of neck pain.
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ORIGINAL ARTICLE
The association between a lifetime history of a neck injury
in a motor vehicle collision and future neck pain:
a population-based cohort study
Paul S. Nolet Pierre Co
ˆte
´J. David Cassidy
Linda J. Carroll
Received: 26 September 2009 / Accepted: 11 February 2010 / Published online: 7 March 2010
ÓSpringer-Verlag 2010
Abstract The objective of this population-based cohort
study was to investigate the association between a lifetime
history of neck injury from a motor vehicle collision and
the development of troublesome neck pain. The current
evidence suggests that individuals with a history of neck
injury in a traffic collision are more likely to experience
future neck pain. However, these results may suffer from
residual confounding. Therefore, there is a need to test this
association in a large population-based cohort with ade-
quate control of known confounders. We formed a cohort
of 919 randomly sampled Saskatchewan adults with no or
mild neck pain in September 1995. At baseline, partici-
pants were asked if they ever injured their neck in a motor
vehicle collision. Six and twelve months later, we asked
about the presence of troublesome neck pain (grade II–IV)
on the chronic pain grade questionnaire. Multivariable Cox
regression was used to estimate the association between a
lifetime history of neck injury in a motor vehicle collision
and the onset of troublesome neck pain while controlling
for known confounders. The follow-up rate was 73.5%
(676/919) at 6 months and 63.1% (580/919) at 1 year. We
found a positive association between a history of neck
injury in a motor vehicle collision and the onset of trou-
blesome neck pain after controlling for bodily pain and
body mass index (adjusted HRR =2.14; 95% CI 1.12–
4.10). Our analysis suggests that a history of neck injury in
a motor vehicle collision is a risk factor for developing
future troublesome neck pain. The consequences of a neck
injury in a motor vehicle collision can have long lasting
effects and predispose individuals to experience recurrent
episodes of neck pain.
Keywords Neck pain Whiplash Epidemiology
Risk Cohort
Introduction
Whiplash is an acceleration–deceleration mechanism of
energy transfer to the neck that occurs in motor vehicle
collisions [10,24]. The trauma can lead to whiplash-
associated disorders (WAD), which includes neck pain and
other symptoms such as headache, dizziness, and upper
extremity numbness [24]. As many as 83% of individuals
involved in traffic collisions suffer from whiplash injuries
[10,24,26]. Consequently, WAD is a common source of
pain, disability, and health care utilization in the Western
world.
P. S. Nolet J. D. Cassidy
Centre of Research Expertise in Improved Disability Outcomes
(CREIDO), University Health Network Rehabilitation Solutions,
Toronto Western Hospital, Toronto, Canada
P. S. Nolet
Public Health Program, Lakehead University,
Thunder Bay, Canada
P. Co
ˆte
´J. D. Cassidy
Division of Epidemiology, Dalla Lana School of Public Health,
University of Toronto, Toronto, Canada
P. Co
ˆte
´J. D. Cassidy
Division of Health Care and Outcomes Research,
Toronto Western Research Institute, Toronto, Canada
L. J. Carroll
Department of Public Health Sciences, The Alberta Centre
for Injury Control and Research, School of Public Health,
University of Alberta, Alberta, Canada
P. S. Nolet (&)
86 Dawson Road, Unit 3, Guelph, ON N1H 1A8, Canada
e-mail: pnolet@rogers.com; pnolet@uhnresearch.ca
123
Eur Spine J (2010) 19:972–981
DOI 10.1007/s00586-010-1344-7
The recently published report of the Bone and Joint
Decade 2000–2010 Task Force on Neck Pain and its
Associated Disorders found that a significant proportion of
patients with WAD develop persistent or recurrent neck
pain. Specifically, more than 50% of patients report neck
pain 1 year after their injury [9]. Recovery from WAD is
negatively associated with initial symptom severity, post-
injury psychological distress, passive coping, and the
intense initial health care utilization [9].
It has been proposed that individuals with a history of
whiplash injuries are more likely to suffer from future
episodes of musculoskeletal pain, including neck pain, than
those without a history of whiplash injuries. This associa-
tion is supported by five studies conducted in various
source populations [4,7,11,15,16]. However, two
Lithuanian studies of individuals sampled from police
records did not support this association [18,23]. The
varying evidence reported in the literature is likely attri-
butable to the differences in study samples, exposure and
outcome definition and measurement, and to inadequate
control of confounding. Therefore, there is a need for a
rigorous, population-based cohort study where the associ-
ation between a lifetime history of neck injury in a motor
vehicle collision and future neck pain can be tested with
good control of confounding factors. The objective of this
study was to determine whether a lifetime history of neck
injury in a motor vehicle collision is associated with an
incident episode of troublesome neck pain.
Methods
Study design and source population
We used data from the Saskatchewan Health and Back Pain
Survey, a population-based mailed survey of the distribu-
tion, determinants, and risks of spinal disorders in the
province of Saskatchewan [11]. Saskatchewan is a Cana-
dian province of approximately one million inhabitants that
provides universal health care coverage. Eligible for the
study were Saskatchewan residents between the ages of 20
and 69 who held a valid Health Services card on August 31,
1995. Excluded were inmates of correctional facilities,
residents under the Office of the Public Trustee, foreign
students and workers holding employment or immigration
visas, and residents of special care homes [8].
An age-stratified random sample of residents was
selected from the Saskatchewan Health Insurance Regis-
tration File. The Health Insurance Registration File is a
representative and complete list of Saskatchewan residents
that includes more than 99% of the population. Saskatch-
ewan Health randomly selected the participants and mailed
all surveys to protect the confidentiality of the participants.
Participation was voluntary. The University of Saskatche-
wan Advisory Committee on Ethics in Human Experi-
mentation approved the Saskatchewan Health and Back
Pain Survey, and the analysis presented in this paper was
approved by the University Health Network Research
Ethics Board, Toronto, Canada.
Study sample and population at risk
Of the eligible 593,464 individuals, 2,184 were randomly
selected. One-hundred nineteen baseline questionnaires
were returned due to mailing errors, five because of ‘health
reasons’, four individuals had emigrated and one had died.
Of the 2,055 remaining participants, 1,133 (55.1%) returned
baseline questionnaires. Two questionnaires were com-
pleted by participants outside of the pre-determined age
range, and 30 participants did not complete the neck pain
questionnaire. Therefore, the eligible sample for this ana-
lysis includes 1,101 participants. A comparison of the eli-
gible population and the randomly selected sample revealed
no important differences in age, gender, and geographic
location of residence. However, a comparison of partici-
pants and non-participants suggested that older individuals,
women, those married, and those with intense non-disabling
neck pain were slightly more likely to participate [8].
The population at risk for this analysis includes indi-
viduals who reported grade 0 or I neck pain on the chronic
pain grade questionnaire (Table 1). This information was
collected in the baseline questionnaire. Given that most
individuals suffer from mild (trivial) neck pain annually,
we were interested in determining whether neck injury in a
motor vehicle collision was a risk factor for significant
neck problems.
Data collection
The baseline data were collected in September 1995, and
the follow-up data collected 6 and 12 months later. The
6-month follow-up questionnaire was sent to respondents
of the baseline questionnaire, and the 12-month follow-up
to respondents of the 6-month follow-up.
Table 1 Classification of neck pain grade (as reproduced from Co
ˆte
´
et al. [11])
Grade Scoring Interpretation
0 No pain, no disability No chronic pain
IPI\50; DP \3 Low pain intensity/low disability
II PI C50; DP \3 High pain intensity/low disability
III DP =3–4 High disability/moderately limiting
IV DP =5–6 High disability/severely limiting
PI pain intensity; DP disability points
Eur Spine J (2010) 19:972–981 973
123
Exposure
The exposure was measured by asking participants: ‘‘Have
you ever injured your neck in a motor vehicle accident?’’
Outcome
Neck pain was measured with the chronic pain question-
naire at baseline, and 6 and 12 months later. The ques-
tionnaire measures the 6-month period prevalence of neck
pain, and grades neck pain and its related disability into
five ordered categories, based on seven questions and has
been described elsewhere [11,28]. The instrument has
good psychometric properties [14]. Participants reporting
grade II, III or IV neck pain in the previous 6 months were
classified as having troublesome neck pain.
Potential confounders
The following potential confounders were identified a pri-
ori: demographic characteristics (age, gender, marital sta-
tus, and location of residence), socioeconomic variable
(education, income, and employment status), general health
(SF36), comorbidities, depression, cigarette smoking, BMI,
and exercise. We did not test the confounding effect of
baseline neck pain grade (grade 0 or I) because it lies on
the casual pathway between our exposure of a neck injury
in a motor vehicle collision and outcome of troublesome
neck pain. As such, it is an intermediate variable and does
not meet the definition of a confounder.
Socio-demographics
Gender, age, marital status, education level, income,
employment status, and location of residence (city, town,
village, rural municipality, and Indian Reserve) were
included in the analysis.
Health-related quality of life (SF36)
The Medical Outcomes Study SF-36 standard English-
Canadian version 1.0 was used to measure self-perceived
general health status [30]. The questionnaire assesses health-
related quality of life in eight domains: physical functioning,
bodily pain, role limitations due to physical health problems,
role limitations due to emotional health, mental health,
social functioning, vitality, and general health. The SF-36
has been shown to have high internal consistency [6] and
test–retest reliability [1]. The SF-36 has been shown to have
good validity in studies involving physical and mental health
criteria when compared to the longer questionnaire used in
the Medical Outcomes Study [29].
Comorbidities
The presence of comorbidities and their self-perceived
impact on health were measured with the comorbidity
questionnaire. The questionnaire includes questions about
allergies, arthritis, high blood pressure, heart/circulation,
digestive disorders, headache, and mental/emotional dis-
orders. The self-perceived impact of each comorbidity on
one’s health is rated on a 4-point ordinal scale as: (1) not at
all, (2) mild, (3) moderate, and (4) severe. The question-
naire has been shown to have good test–retest reliability
(ICC =0.93) and adequate face, concurrent, and conver-
gent validity [20,27].
Depressive symptomatology
The Center for Epidemiological Studies Depression scale
(CES-D) was used to measure depressive symptomatology
[19]. This questionnaire has a possible score of 60 with
16 as the cutoff score for depression in the general popu-
lation. The 16-point cutoff for depressive symptomatology
had a sensitivity of 100% for major depression and 88%
for the specificity [2]. The questionnaire has been shown
to be reliable and valid in various populations with good
internal consistency (alpha coefficients [0.85) [5,13,19,
20].
Exercise
Exercise frequency was measured with a question asking
the average number of days per week participating in a
minimum of 30 min of exercise. The question asked about
the frequency of exercise during the previous 6 months.
Cigarette smoking
Self-report of smoking status was obtained and categorized
as non-smoker, ex-smoker or current smoker.
Body mass index
Self-reported height and weight were used to calculate the
body mass index (BMI, kg/m
2
).
Analysis
We described the baseline characteristics of the sample
stratified by exposure status. We aimed to determine
whether loss to follow-up led to attrition bias by comparing
responders and non-responders to the 6 and 12-month
follow-ups by comparing the baseline characteristics of
exposed and non-exposed participants.
974 Eur Spine J (2010) 19:972–981
123
Our objective was to determine whether a history of
neck injury in a motor vehicle collision is independently
associated with the development of troublesome neck pain.
However, identifying confounders of the association
between a lifetime history of neck injury in a traffic col-
lision and troublesome neck pain is challenging. The dif-
ficulty lies in insuring that the variables considered as
potential confounders are indeed confounders and not
mediators of the association of interest. A mediator is an
intermediate effect of the exposure, and lies on the causal
pathway between the exposure and the outcome.
We built Cox proportional hazard models to measure the
association between a history of neck injury in a motor
vehicle collision and troublesome neck pain. Our modeling
included three steps. First, we built a univariate model to
estimate the crude association between our exposure and
outcome. Second, we built as series of bivariate models to
determine which variables were confounders of the asso-
ciation of interest. Variables that led to a 10% change in the
exposure regression coefficient were deemed to be con-
founders and included in the final model. Finally, our final
model included the exposure and all confounders identified
in the second step [22]. SPSS version 15 was used for the
analysis [25].
Results
Sample characteristics
Our population at risk included 919 participants. The fol-
low-up rate was 73.5% (676/919) at 6 months and 63.1%
(580/919) at 12 months.
Of the 919 eligible adults with grade 0 or I neck pain
at baseline, 122 (13.3%) reported a history of neck
injury in a motor vehicle collision. Fewer participants
with a history of neck injury in a motor vehicle collision
were married and a higher percentage lived in urban
Saskatchewan. A higher proportion of exposed than
unexposed individuals reported a household income of
less than $20,000 and fewer reported incomes over
$60,000. Further, more participant with a history of neck
injury worked part time or were unemployed, but fewer
were retired. With the exception of hypertension and low
back pain, all comorbidities were more common among
participants with a history of neck injury in a motor
vehicle collision. Further, the self-perceived impact of
comorbidities was more pronounced in individuals who
had a neck injury in a motor vehicle collision. Exposed
subjects (70.5%) were more likely to suffer from grade I
neck pain than unexposed (41.4%). The proportion of
current smokers was higher in the exposed group
(Table 2).
Attrition
In the group not exposed to a neck injury in a motor vehicle
collision, response to the follow-up survey was positively
associated with female gender. In the exposed group, non-
response to the follow-up survey was positively associated
with increased depression and headaches that moderately
to severely impact their health (Tables 3,4).
Association between history of neck injury in a motor
vehicle collision and troublesome neck pain
We found a positive crude association between a history of
neck injury in a motor vehicle collision and the develop-
ment of troublesome neck pain at 6 and/or 12 months
(HRR =2.43; 95% CI 1.28–4.60). Age and gender did not
alter this association. However, scores on the bodily pain
scale of the SF-36 and BMI mildly reduced the strength of
the crude association (HRR =2.14; 95% CI 1.12–4.10).
Discussion
Our survey was the first North American cohort study to
investigate the association between a lifetime history of
neck injury resulting from a motor vehicle collision and the
development of troublesome neck pain. Our results suggest
that the incidence of troublesome neck pain is higher in
individuals who have a history of neck injury in a motor
vehicle collision.
Our study has limitations. Neck pain follows a recurrent
course and that risk factors for future episodes, such as
motor vehicle collisions, may have a mediating effect on
the incidence of pain and disability in those with a prior
history of neck pain. Future studies need to test this
hypothesis.
Our exposure, neck injury in a motor vehicle collision,
could suffer from differential misclassification. It is pos-
sible that participants with recurrent neck pain were more
likely to remember an injury in a traffic collision than those
who remained free of neck pain. However, we believe that
this bias had minimal impact on our results because it is
likely that all participants would remember an event such
as being injured in a motor vehicle collision. Data from two
studies support the view that individuals can recall injuries
sustained in a recent motor vehicle collision. Self-reported
motor vehicle collision injuries 12 months earlier in the
Canadian National Population Health Survey were not
significantly different from the police reported data from
Transport Canada [21]. Moreover, in a small sample of
young adults, self-reported injury over the previous 3 years
was comparable to hospital discharge file data and police
motor vehicle collision reports [3].
Eur Spine J (2010) 19:972–981 975
123
Table 2 Frequency distribution of the demographic socioeconomic
characteristics, comorbidities, and health-related characteristics by
exposure category at baseline
Characteristic History of neck injury
in motor vehicle collision
Yes (%) No (%)
Age (years) [mean (SD)] 42.0 (12.3) 44.9 (14.4)
Gender (no., %)
Male 45 (36.8) 406 (50.9)
Female 77 (63.2) 391 (49.1)
Marital status (no., %)
Married 86 (71.7) 605 (76.6)
Divorced 14 (11.6) 49 (6.2)
Widowed 3 (2.5) 20 (2.5)
Single 18 (14.9) 116 (14.7)
Location of residence (no., %)
Urban 65 (53.3) 278 (35.0)
Rural 57 (46.7) 517 (65.0)
Annual household income (no., %)
$0–20,000 27 (23.7) 140 (19.1)
$20,001–40,000 38 (33.3) 263 (35.8)
$40,001–60,000 28 (24.6) 171 (23.3)
Over $60,000 21 (18.4) 160 (21.8)
Education (no., %)
Less than grade 8 7 (5.8) 44 (5.6)
High school 29 (24.0) 171 (21.6)
High-school grade 36 (29.8) 207 (26.2)
Post-secondary 36 (29.8) 248 (31.4)
University grade 13 (10.7) 120 (15.2)
Full time worker (no., %)
Yes 60 (50.0) 408 (51.8)
No 60 (50.0) 380 (48.2)
Part time worker (no., %)
Yes 22 (18.3) 118 (15.0)
No 98 (81.7) 669 (85.0)
Unemployed (no., %)
Yes 11 (9.2) 38 (4.8)
No 109 (90.8) 750 (95.2)
Retired (no., %)
Yes 3 (2.5) 106 (13.5)
No 117 (97.5) 682 (86.5)
Homemaker (no., %)
Yes 23 (19.2) 134 (17.0)
No 97 (80.8) 654 (83.0)
Student (no., %)
Yes 7 (5.8) 30 (3.8)
No 113 (94.2) 758 (96.2)
Comorbidities
Allergy
Absent 57 (47.1) 472 (60.8)
No/Min impact on health 45 (37.2) 227 (29.3)
Table 2 continued
Characteristic History of neck injury
in motor vehicle collision
Yes (%) No (%)
Mod./Sev. impact on health 19 (15.7) 77 (9.9)
Arthritis
Absent 85 (71.4) 579 (75.1)
No/Min impact on health 17 (14.3) 129 (16.7)
Mod./Sev. impact on health 17 (14.3) 63 (8.2)
Breathing disorders
Absent 80 (66.7) 565 (72.4)
No/Min impact on health 29 (24.2) 169 (21.7)
Mod./Sev. impact on health 11 (9.2) 46 (5.9)
Cardiovascular disorders
Absent 98 (80.3) 687 (87.9)
No/Min impact on health 19 (15.6) 74 (9.5)
Mod./Sev. impact on health 5 (4.1) 21 (2.7)
Hypertension
Absent 103 (85.1) 666 (85.4)
No/Min impact on health 13 (10.7) 84 (10.8)
Mod./Sev. impact on health 5 (4.1) 30 (3.8)
Digestive disorders
Absent 88 (73.9) 596 (76.0)
No/Min impact on health 18 (15.1) 141 (18.0)
Mod./Sev. impact on health 13 (10.9) 47 (6.0)
Low back pain
Absent 31 (25.8) 254 (32.3)
Low intensity/low disability 68 (56.7) 394 (50.1)
High intensity/low disability 8 (6.7) 81 (10.3)
High disability 13 (10.8) 57 (7.3)
Depressive symptomatology
Absent 90 (75.6) 628 (83.0)
Present 29 (24.4) 129 (17.0)
Cigarette smoking
Never smoked 53 (44.9) 417 (54.0)
Past smoker 31 (26.3) 191 (24.7)
Current smoker 34 (28.8) 164 (21.2)
Body mass index (kg/m
2
)—quartiles
[28.71 31 (26.1) 196 (25.2)
25.77–28.71 28 (23.5) 203 (26.1)
23.42–25.76 32 (26.9) 186 (23.9)
B23.41 28 (23.5) 193 (24.8)
General health [Mean (SD)] 63.7 (14.5) 65.3 (12.6)
No. of days of exercise/week
[Mean (SD)]
2.93 (2.07) 2.83 (2.16)
Graded neck pain
Grade 0 36 (29.5) 467 (58.6)
Grade 1 86 (70.5) 330 (41.4)
Min minimal; Mod moderate; Sev severe
976 Eur Spine J (2010) 19:972–981
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Table 3 Comparison of responders and non-responders at 6 months for frequency distribution of the demographic socioeconomic characteristics
and comorbidities by exposure category at baseline
Characteristic Exposed to neck injury in a MVC Not exposed to neck injury in MVC
Responder Non-responder Responder Non-responder
Age (years) [Mean (SD)] 43.5 (12.38) 39.3 (11.67) 46.1 (13.30) 40.8 (14.04)
Gender (no., %)
Male 28 (36.4) 17 (37.8) 304 (49.0) 102 (58.0)
Female 49 (63.6) 28 (62.2) 317 (51.0) 74 (42.0)
Marital status (no., %)
Married 54 (70.1) 32 (72.7) 480 (77.8) 125 (72.3)
Divorced 8 (10.4) 6 (13.6) 39 (6.3) 10 (5.8)
Widowed 2 (2.6) 1 (2.3) 20 (3.2) 0 (0.0)
Single 13 (16.9) 5 (11.4) 78 (12.6) 38 (22.0)
Location of residence (no., %)
Urban 41 (53.2) 24 (53.3) 224 (36.1) 54 (30.9)
Rural 36 (46.8) 21 (46.7) 396 (63.9) 121 (69.1)
Annual household income (no., %)
$0–20,000 13 (17.3) 14 (35.9) 102 (17.6) 38 (24.4)
$20,001–40,000 29 (38.7) 9 (23.1) 208 (36.0) 55 (35.3)
$40,001–60,000 19 (25.3) 9 (23.1) 134 (23.2) 37 (23.7)
Over $60,000 14 (18.7) 7 (17.9) 134 (23.2) 26 (16.7)
Education (no., %)
Less than grade 8 4 (5.2) 3 (6.8) 32 (5.2) 12 (6.9)
High school 16 (20.8) 13 (29.5) 128 (20.7) 43 (24.9)
High school grade 26 (33.8) 10 (22.7) 154 (25.0) 53 (30.6)
Post-secondary 21 (27.3) 15 (35.1) 199 (32.3) 49 (28.3)
University grade 10 (13.0) 3 (6.8) 104 (16.9) 16 (9.2)
Full time worker (no., %)
Yes 39 (51.3) 21 (47.7) 306 (49.8) 102 (58.6)
No 37 (48.7) 23 (52.3) 308 (50.2) 72 (41.4)
Part time worker (no., %)
Yes 16 (21.1) 6 (13.6) 94 (15.3) 24 (13.8)
No 60 (78.9) 38 (86.4) 519 (84.7) 150 (86.2)
Unemployed (no., %)
Yes 4 (5.3) 7 (15.9) 25 (4.1) 13 (7.5)
No 72 (94.7) 37 (84.1) 589 (95.9) 161 (92.5)
Retired (no., %)
Yes 2 (4.0) 1 (2.3) 98 (16.0) 8 (4.6)
No 74 (97.4) 43 (97.7) 516 (84.0) 166 (95.4)
Homemaker (no., %)
Yes 14 (18.4) 9 (20.5) 111 (18.1) 23 (13.2)
No 62 (81.6) 35 (79.5) 503 (81.9) 151 (86.8)
Student (no., %)
Yes 4 (5.3) 3 (6.8) 21 (3.4) 9 (5.2)
No 72 (94.7) 41 (93.2) 593 (96.6) 165 (94.8)
Comorbidities (no., %)
Allergy
Absent 36 (46.8) 21 (47.7) 361 (59.3) 111 (66.5)
No/Min impact on health 29 (37.7) 16 (36.4) 185 (30.4) 42 (25.1)
Mod./Sev. impact on health 12 (15.6) 7 (15.9) 63 (10.3) 14 (8.4)
Eur Spine J (2010) 19:972–981 977
123
Our analysis of attrition suggests that the hazard rate
ratio of this study could have been underestimated. A
higher percentage of females responded to the follow-up
surveys in the non-exposed group, and females are more
likely to report neck pain than males [17].
There were a lower percentage of responders in the
exposed group with depression at 6 months, and depression
is a risk factor for the development of neck pain [17].
Finally, in the exposed group, participants with headaches
that had a moderate to severe impact on health were less
likely to respond to the survey at both 6 and 12 months.
Attrition varied across employment status, education, and
income, but there was no clear trend in attrition to suggest
that the results were biased.
Our analysis may have underestimated the true effect of
neck injury in a motor vehicle collision on the development
of a future episode of troublesome neck pain. It is likely
that in excluding subjects with prevalent troublesome neck
pain from our cohort, we excluded some subjects that had
developed a new episode of troublesome neck pain (inci-
dent cases) after exposure to a motor vehicle collision but
prior to the baseline survey. Excluding these cases would
likely cause an underestimation of the true incidence of
troublesome neck pain after a motor vehicle collision.
Our study augments the evidence of a positive associa-
tion between neck injury in a motor vehicle collision and
future neck pain. The strength of our study is in our ability
to test for the confounding effect of more variables than
Table 3 continued
Characteristic Exposed to neck injury in a MVC Not exposed to neck injury in MVC
Responder Non-responder Responder Non-responder
Arthritis
Absent 53 (69.7) 32 (74.4) 445 (73.7) 134 (80.2)
No/Min impact on health 10 (13.2) 7 (16.3) 106 (17.5) 23 (13.8)
Mod./Sev. impact on health 13 (17.1) 4 (9.3) 53 (8.8) 10 (6.0)
Breathing disorders
Absent 56 (73.7) 24 (54.5) 444 (72.8) 121 (71.2)
No/Min impact on health 14 (18.4) 15 (34.1) 129 (21.1) 40 (23.5)
Mod./Sev. impact on health 6 (7.9) 5 (11.4) 37 (6.1) 9 (5.3)
Hypertension
Absent 68 (88.3) 35 (79.5) 517 (84.5) 149 (88.7)
No/Min impact on health 7 (9.1) 6 (13.6) 69 (11.3) 15 (8.9)
Mod./Sev. impact on health 2 (2.6) 3 (6.8) 26 (4.2) 4 (2.4)
Cardiovascular disorders
Absent 62 (80.5) 36 (80.0) 534 (87.3) 153 (90.0)
No/Min impact on health 12 (15.6) 7 (15.6) 61 (10.0) 13 (7.6)
Mod./Sev. impact on health 3 (3.9) 2 (4.4) 17 (2.8) 4 (2.4)
Digestive disorders
Absent 57 (75.0) 31 (72.1) 456 (74.3) 140 (82.4)
No/Min impact on health 12 (15.8) 6 (14.0) 121 (19.7) 20 (11.8)
Mod./Sev. impact on health 7 (9.2) 6 (14.0) 37 (6.0) 10 (5.9)
Low back pain
Absent 21 (27.6) 10 (22.7) 196 (31.9) 58 (33.7)
Low intensity/low disability 43 (56.6) 25 (56.8) 308 (50.2) 86 (50.0)
High intensity/low disability 3 (3.9) 5 (11.4) 66 (10.7) 15 (8.7)
High disability 9 (11.9) 4 (9.1) 44 (7.2) 13 (7.5)
Headache
Absent 32 (42.1) 14 (31.8) 303 (49.5) 88 (51.5)
No/min. impact on health 32 (42.1) 16 (36.4) 235 (38.4) 63 (36.8)
Mod./Sev. impact on health 12 (15.8) 14 (31.8) 74 (12.1) 20 (11.7)
Depressive symptomatology
Absent 59 (77.6) 31 (72.1) 493 (83.4) 135 (81.3)
Present 17 (22.4) 12 (27.9) 98 (16.6) 31 (18.7)
978 Eur Spine J (2010) 19:972–981
123
Table 4 Comparison of responders and non-responders at 12 months for frequency distribution of the demographic socioeconomic charac-
teristics and comorbidities by exposure category at baseline
Characteristic Exposed to neck injury in a MVC Not exposed to neck injury in MVC
Responder Non-responder Responder Non-responder
Age (years) [mean (SD)] 45.1 (12.62) 38.8 (11.14) 46.9 (12.96) 40.8 (13.40)
Gender (no., %)
Male 23 (37.7) 22 (36.1) 259 (48.5) 147 (55.9)
Female 38 (62.3) 39 (63.9) 275 (51.5) 116 (44.1)
Marital status (no., %)
Married 42 (68.9) 44 (73.3) 417 (78.7) 188 (72.3)
Divorced 7 (11.5) 7 (11.7) 32 (6.0) 17 (6.5)
Widowed 3 (4.9) 0 (0.0) 20 (3.8) 0 (0)
Single 9 (14.8) 9 (15.0) 61 (11.5) 55 (21.2)
Location of residence (no., %)
Urban 33 (54.1) 32 (52.5) 188 (35.2) 90 (34.5)
Rural 28 (45.9) 29 (47.5) 346 (64.8) 171 (65.5)
Annual household income (no., %)
$0–20,000 9 (15.3) 18 (32.7) 75 (15.2) 65 (27.2)
$20,001–40,000 22 (37.3) 16 (29.1) 185 (37.4) 78 (32.6)
$40,001–60,000 16 (27.1) 12 (21.8) 120 (24.2) 51 (21.3)
Over $60,000 12 (16.4) 9 (16.4) 115 (23.2) 45 (18.8)
Education (no., %)
Less than grade 8 3 (4.9) 4 (6.7) 27 (5.1) 17 (6.5)
High school 12 (19.7) 17 (23.3) 112 (21.1) 59 (22.7)
High school grade 22 (36.1) 14 (27.0) 129 (24.3) 78 (30.0)
Post-secondary 16 (26.2) 20 (33.3) 172 (32.5) 76 (29.2)
University grade 8 (13.1) 5 (8.3) 90 (17.0) 30 (11.5)
Full time worker (no., %)
Yes 36 (59.0) 24 (40.7) 261 (49.4) 147 (56.5)
No 25 (41.0) 35 (59.3) 267 (50.6) 113 (43.5)
Part time worker (no., %)
Yes 14 (23.0) 8 (13.6) 82 (15.6) 36 (13.8)
No 47 (77.0) 51 (86.4) 445 (84.4) 224 (86.2)
Unemployed (no., %)
Yes 1 (1.6) 10 (16.9) 16 (3.0) 22 (8.5)
No 60 (98.4) 49 (83.1) 512 (97.0) 238 (91.5)
Retired (no., %)
Yes 2 (3.3) 1 (1.7) 90 (17.0) 16 (6.2)
No 59 (96.7) 58 (98.3) 438 (83.0) 244 (93.8)
Homemaker (no., %)
Yes 10 (16.4) 13 (22.0) 95 (18.0) 39 (15.0)
No 51 (83.6) 46 (78.0) 433 (82.0) 221 (85.0)
Student (no., %)
Yes 1 (1.6) 6 (10.2) 14 (2.7) 16 (6.2)
No 60 (98.4) 53 (89.8) 514 (97.3) 244 (93.8)
Comorbidities (no., %)
Allergy
Absent 28 (45.9) 29 (48.3) 312 (59.5) 160 (63.5)
No/Min impact on health 24 (39.3) 21 (35.0) 158 (30.2) 69 (27.4)
Mod./Sev. impact on health 9 (14.8) 10 (16.7) 54 (10.3) 23 (9.1)
Eur Spine J (2010) 19:972–981 979
123
prior studies, which mostly controlled for age and gender
[4,7,15,16,18]. In our final model, we controlled for the
effects of baseline bodily pain and the BMI. It is possible
that bodily pain was in fact a mediating variable that lies on
the causal pathway between the exposure to neck injury in
a motor vehicle collision and the outcome of troublesome
neck pain.
Our results inform the debate surrounding the etiology
of neck pain in the population. Neck pain is a recurrent
disorder characterized by the periods of the fluctuating pain
and disability [12]. To date, few studies have identified risk
factors for the recurrent episodes of the neck pain. Our
study raises the hypothesis that a past history of a neck
injury in a MVC is one of the determinants of recurrent
neck pain. Our analysis provides the public, clinicians, and
insurers with evidence that a past neck injury in a motor
vehicle collision may have a significant role in the deve-
lopment of future episodes of pain and disability. While the
causal mechanisms linking a past history of neck injury
following a motor vehicle collision and future neck pain
remain unknown, it likely involves complex relationships
between biological, psychological, and social factors.
Future research needs to focus on elucidating these
mechanisms within the biopsychosocial model of health.
Table 4 continued
Characteristic Exposed to neck injury in a MVC Not exposed to neck injury in MVC
Responder Non-responder Responder Non-responder
Arthritis
Absent 41 (68.3) 44 (74.6) 383 (73.5) 196 (78.4)
No/Min impact on health 10 (16.7) 7 (11.9) 91 (17.5) 38 (15.2)
Mod./Sev. impact on health 9 (15.0) 8 (13.6) 47 (9.0) 16 (6.4)
Breathing disorders
Absent 44 (73.3) 36 (60.0) 386 (73.5) 179 (70.2)
No/Min impact on health 11 (18.3) 18 (30.0) 108 (20.6) 61 (23.9)
Mod./Sev. impact on health 5 (8.3) 6 (10.0) 31 (5.9) 15 (5.9)
Hypertension
Absent 54 (88.5) 49 (81.7) 444 (84.3) 222 (87.7)
No/Min impact on health 5 (8.2) 8 (13.3) 60 (11.4) 24 (9.5)
Mod./Sev. impact on health 2 (3.3) 3 (5.0) 23 (4.4) 7 (2.8)
Cardiovascular disorders
Absent 50 (82.0) 48 (78.7) 465 (88.4) 222 (86.7)
No/Min impact on health 8 (13.1) 11 (18.0) 49 (9.3) 25 (9.8)
Mod./Sev. impact on health 3 (4.9) 2 (3.3) 12 (2.3) 9 (3.5)
Digestive disorders
Absent 46 (76.7) 42 (71.2) 394 (74.6) 202 (78.9)
No/Min impact on health 10 (16.7) 8 (13.6) 101 (19.1) 40 (15.6)
Mod./Sev. impact on health 4 (6.7) 9 (15.3) 33 (6.3) 14 (5.5)
Low back pain
Absent 14 (23.0) 17 (28.8) 172 (32.6) 82 (31.8)
Low intensity/low disability 39 (63.9) 29 (49.2) 263 (49.8) 131 (50.8)
High intensity/low disability 2 (3.3) 6 (10.2) 52 (9.8) 29 (11.2)
High disability 6 (9.8) 7 (11.9) 41 (7.7) 16 (6.2)
Headache
Absent 25 (42.4) 21 (34.4) 262 (49.8) 129 (50.2)
No/min. impact on health 27 (45.8) 21 (34.4) 204 (38.8) 94 (36.6)
Mod./Sev. impact on health 7 (11.9) 19 (31.1) 60 (11.4) 34 (13.2)
Depressive symptomatology
Absent 47 (78.3) 43 (72.9) 433 (84.7) 195 (79.3)
Present 13 (21.7) 16 (27.1) 78 (15.3) 51 (20.7)
980 Eur Spine J (2010) 19:972–981
123
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... Chronic pain is defined as persisting beyond "normal" injury healing (Bonnica, 1953) which can be difficult to evaluate in some cases and was therefore considered chronic when lasting or recurring more than 3 months (Treede et al., 2015). Moreover, some types of chronic pain, such as low back pain (Cassidy et al., 2005), chronic neck pain (Nolet et al., 2010), migraine (Bigal & Lipton, 2008), irritable bowel syndrome (Palsson et al., 2014), neuropathic and cancer pain (Mercadante et al., 2002), manifests as recurrent periods of pain that alternates with period of remission rather than a continuous prolonged state of pain. Those painful episodes can be triggered or intensified by acute stress (Alexander et al., 2009;Blanchard et al., 2008;Marmura, 2018). ...
... More recently, a new form of central sensitization, which silently persists following behavioral signs of pain has subsided, has been highlighted in various rodent pain models (Campillo et al., 2011;Célèrier et al., 2001;Corder et al., 2013). This so-called latent pain sensitization reproduces the episodic nature (Campillo et al., 2011) and sensitivity to stress (Rivat et al., 2007) that are characteristic for some types of human chronic pain (Bigal & Lipton, 2008;Cassidy et al., 2005;Mercadante et al., 2002;Nolet et al., 2010;Palsson et al., 2014). This phenomenon is thought to be the result of a long-lasting up-regulation of pro-nociceptive systems that outlasts hypersensitivity resolution and is actively masked by anti-nociceptive systems activity. ...
... Likewise, stress-induced hyperalgesia is still present four months after the nociceptive stimuli (Rivat et al., 2007). Latent pain sensitization is therefore a long-lasting phenomenon, which episodic nature and sensitivity to stress are reminiscent of certain types of human chronic pain (Bigal & Lipton, 2008;Cassidy et al., 2005;Mercadante et al., 2002;Nolet et al., 2010;Palsson et al., 2014). ...
Article
Chronic pain is a debilitating disorder that can occur as painful episodes that alternates with bouts of remission and occurs despite healing of the primary insult. Those episodes are often triggered by stressful events. In the last decades, a similar situation has been evidenced in a wide variety of rodent models (including inflammatory pain, neuropathy and opioid-induced hyperalgesia) where animals develop a chronic latent hyperalgesia that silently persists after behavioral signs of pain resolution. This state, referred as latent pain sensitization, is due to the compensatory activation of antinociceptive systems, such as the opioid system or NPY and its receptors. A transitory phase of hyperalgesia can then be reinstated by pharmacological or genetic blockade of these antinociceptive systems or by submitting animals to acute stress. Those observations reveal that there is a constant endogenous analgesia responsible for chronic pain inhibition that might paradoxically contribute to maintain this maladaptive state and could then participate to the transition from acute to chronic pain. Thus, demonstration of the existence of this phenomenon in humans and a better understanding of the mechanisms by which latent pain sensitization develops and maintains over long periods of time will be of particular interest to help identifying new therapeutic strategies and targets for chronic pain treatment. The present review aims to recapitulate behavioral expression, potential clinical relevance, cellular mechanisms and intracellular signaling pathways involved so far in latent pain sensitization.
... We critically appraised 8 articles and 7 articles had low to moderate risk of bias and were included in our evidence synthesis (21)(22)(23)(24)(25)(26)(27). The reviewers had perfect agreement on the admissibility of studies (8 agreements over 8 articles appraised). ...
... The studies had varied source populations: primary care and emergency department patients (3/7 articles) (23)(24)(25), insurance and injury databases (2/7 articles) (22,27), police records (1/7 articles) (21), and the general population (1/7 articles) (26) ( Table 1). The duration of time between the MVC and the outcome varied across studies: unknown (3/7 articles) (24)(25)(26), and one or more years (4/7 articles) (21-23,27) ( Table 2). ...
... Exposure to a MVC was determined by: a question on self-reported neck injury in a MVC (3/7 articles) (24)(25)(26), physician diagnosed neck injury in an emergency room of a hospital (2/7 articles) (23,27), collision reported in police records (1/7 articles) (21), and collision reported in insurance records (1/7 articles) (22). Exposure was defined as: exposure to a rear-end collision without injury and exposure to a rear-end collision with neck/shoulder injury (1/7 articles) (22), exposure to a rear-end collision where it is not known if all subjects were injured (1/7 articles) (21), and exposure to a MVC with a neck injury (5/7 articles) (23)(24)(25)(26)(27). ...
Preprint
Full-text available
ABSTRACT Objective: To summarize the literature that has examined the association between a motor vehicle collision (MVC) related neck injury and future neck pain (NP) in comparison with the population that has not been exposed to neck injury from an MVC. Literature Survey: Neck injury resulting from a MVC is associated with a high rate of chronicity. Prognosis studies indicate 50% of injured continue to experience NP a year after the collision. This is difficult to interpret due to the high prevalence of NP in the general population. Methodology: We performed a systematic review of the literature using five electronic databases, searching for risk studies on exposure to a MVC and future NP published from 1998 to 2018. The outcome of interest was future NP. Eligible risk studies were critically appraised using the modified Quality in Prognosis Studies (QUIPS) instrument. The results were summarized using best-evidence synthesis principles, a random effects meta-analysis, meta-regression and testing for publication bias was performed with the pooled data. Synthesis: Eight articles were identified of which seven were of lower risk of bias. Six studies reported a positive association between a neck injury in an MVC and future NP compared to those without a neck injury in a MVC. Pooled analysis of the six studies indicated an unadjusted relative risk of future NP in the MVC exposed population with neck injury of 2.3 (95% CI [1.8, 3.1]), which equates to a 57% attributable risk under the exposed. In two studies where exposed subjects were either not injured or injury status was unknown, there was no increased risk of future NP. Conclusions: There was a consistent positive association among studies that have examined the association between MVC-related neck injury and future NP. These findings are of potential interest to clinicians, insurers, patients, governmental agencies, and the courts.
... We critically appraised 8 articles and 7 articles had low to moderate risk of bias and were included in our evidence synthesis (21)(22)(23)(24)(25)(26)(27). The reviewers had perfect agreement on the admissibility of studies (8 agreements over 8 articles appraised). ...
... The studies had varied source populations: primary care and emergency department patients (3/7 articles) (23)(24)(25), insurance and injury databases (2/7 articles) (22,27), police records (1/7 articles) (21), and the general population (1/7 articles) (26) ( Table 1). The duration of time between the MVC and the outcome varied across studies: unknown (3/7 articles) (24)(25)(26), and one or more years (4/7 articles) (21-23,27) ( Table 2). ...
... Exposure to a MVC was determined by: a question on self-reported neck injury in a MVC (3/7 articles) (24)(25)(26), physician diagnosed neck injury in an emergency room of a hospital (2/7 articles) (23,27), collision reported in police records (1/7 articles) (21), and collision reported in insurance records (1/7 articles) (22). Exposure was defined as: exposure to a rear-end collision without injury and exposure to a rear-end collision with neck/shoulder injury (1/7 articles) (22), exposure to a rear-end collision where it is not known if all subjects were injured (1/7 articles) (21), and exposure to a MVC with a neck injury (5/7 articles) (23)(24)(25)(26)(27). ...
Article
Full-text available
Objective To summarize the literature that has examined the association between a motor vehicle collision (MVC) related neck injury and future neck pain (NP) in comparison with the population that has not been exposed to neck injury from an MVC. Literature Survey Neck injury resulting from a MVC is associated with a high rate of chronicity. Prognosis studies indicate 50% of injured continue to experience NP a year after the collision. This is difficult to interpret due to the high prevalence of NP in the general population. Methodology We performed a systematic review of the literature using five electronic databases, searching for risk studies on exposure to a MVC and future NP published from 1998 to 2018. The outcome of interest was future NP. Eligible risk studies were critically appraised using the modified Quality in Prognosis Studies (QUIPS) instrument. The results were summarized using best‐evidence synthesis principles, a random effects meta‐analysis, meta‐regression and testing for publication bias was performed with the pooled data. Synthesis Eight articles were identified of which seven were of lower risk of bias. Six studies reported a positive association between a neck injury in an MVC and future NP compared to those without a neck injury in a MVC. Pooled analysis of the six studies indicated an unadjusted relative risk of future NP in the MVC exposed population with neck injury of 2.3 (95% CI [1.8, 3.1]), which equates to a 57% attributable risk under the exposed. In two studies where exposed subjects were either not injured or injury status was unknown, there was no increased risk of future NP. Conclusions There was a consistent positive association among studies that have examined the association between MVC‐related neck injury and future NP. These findings are of potential interest to clinicians, insurers, patients, governmental agencies, and the courts.
... The self-perceived impact of each comorbidity on one's health is rated on a four point ordinal scale as: (1) not (4) severe. The questionnaire has been shown to have good test-retest reliability (ICC = 0.93) and adequate face, concurrent and convergent validity [23,24]. ...
... The CES-D was used as a continuous variable in this analysis. The questionnaire has been shown to be reliable and valid in various populations with good internal consistency (alpha coefficients [0.85) [23,25,27,28]. ...
Article
Abstract Purpose This population-based cohort study investigated the association between a lifetime history of a work-related low back injury, in those who had recovered to have no or mild low back pain, and the development of troublesome low back pain (LBP). A secondary analysis explored the possible effects of misclassification of the exposure by examining the association between a lifetime history of having taken time off work or performed light duties at work because of a work-related low back injury. Current evidence from cross-sectional studies suggests that individuals with a history of a work-related low back injury are more likely to experience future LBP. However, there is a need to examine this association prospectively in a large population-based cohort with adequate control of known confounders. Methods We formed a cohort of 810 randomly sampled Saskatchewan adults with no or mild LBP in September 1995. At baseline, participants were asked if they had ever injured their low back at work. The secondary analysis asked if they had ever had to take time off work or perform light duties at work because of a work-related low back injury. Prospective follow-up 6 and 12 months later, asked about the presence of troublesome LBP (grade II–IV) on the Chronic Pain Grade Questionnaire. Multivariable Cox proportional hazards regression analysis was used to estimate these associations while controlling for known confounders. Results The proportion followed up at 6 and 12 months was 76 and 65 %, respectively. We found an association between a history of work-related low back injury and the onset of troublesome LBP after controlling for gender (adjusted HRR = 2.24; 95 % CI 1.41–3.56).When covariates that may also be mediators of the association were added to the model, the effect estimate was attenuated (adjusted HRR = 1.37; 95 %CI 1.41–3.56).We found a similar association between a lifetime history of having taken time off work or had to work light duties at work because of a work-related low back injury, djusted for gender (adjusted HRR = 2.31; 95 % CI 1.39– 3.85) which was also diluted by the further adjustment for covariates that may also be mediators of the association (adjusted HRR = 1.80; 95 % CI 1.08–3.01). Conclusion Our study suggests that a history of work-related low back injury or taking time off work or having to perform light duties at work due to a work-related low back injury may be a risk factor for the development of troublesome LBP. Residual confounding may account for some of the observed associations, but this was less in the group who took time off work or had to work light duties due to a work-related low back injury.
... There is limited preliminary evidence that having a prior compensation claim (possibly a proxy for prior WAD) is associated with poorer disability recovery and longer time to claim closure [52,74]. There is also limited evidence that a history of WAD increases the risk of future prevalent and incident episodes of neck pain [26,58,83]. ...
Article
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
... Table 2 summarizes predictive factors of psychological and functional outcomes post an RTC. Anxiety (Alghnam et al., 2015;Mayou and Bryant, 2002;Seethalakshmi et al., 2006), depression (Mayou and Bryant, 2002;Seethalakshmi et al., 2006), PTSD (Barth et al., 2005;Koren et al., 2001;Matthews, 2005;Seethalakshmi et al., 2006), limitations in daily life activity (Alghnam et al., 2015;Kelley-Quon et al., 2010), and pain (Alghnam et al., 2015;Nolet et al., 2010) have been associated with poor recovery following a crash. Further, physical injury, depression, over concern, anxiety, and reduced time management ability were barriers to gaining employment after an RTC (Matthews, 2005). ...
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Objective: Road Traffic Crashes (RTCs) are a major cause of disability globally, with millions of people being injured or disabled each year. This study aims to identify the factors reported in the literature that are associated with physical, psychological and functional outcomes of adult trauma patients following an RTC. Methods: A scoping literature review was conducted. Peer-reviewed articles were retrieved from MEDLINE, EMBASE, and CINAHL. These databases were chosen as the MeSH and Emtree thesauri allow for high specificity searches. More- over, these databases index the major biomedical/health journals in the field. Results: Thirty-one studies from 10 countries are reported in a PRISMA chart and summarized in a matrix. This review identified a number of factors that are clustered into six categories; (i.) injury characteristics and hospital predictive factors; (ii.) demographic factors; (iii.) family and social support; (iv.); compensation system process and fault in the RTC (v.); pre-injury health status. A final category was used to represent the range of (vi.) psychological and functional outcomes. Conclusion: These findings highlight the multiple and diverse contributors that influence a person's outcomes following an RTC. These factors are intrinsic and extrinsic and commence from the time of injury as well as highlighting the importance for ongoing support after acute care discharge to enable a quick return to optimal wellbeing. Research examining RTC outcomes must integrate information about the crash response and health care system while simulta- neously measuring other factors to appropriately quantify the relative contribution of each variable to psychological and functional outcomes.
... The main cost from traffic crash-related injury is in workplace output losses [4], including loss in contributions to the economy, replacing staff who do not return to work, and staff returning to work at reduced hours [4]. Musculoskeletal injuries from a road traffic crash, even those classed as 'mild' [5], can result in persistent pain [6][7][8] which may impact on staying and returning to work and working optimally. This is evidenced in studies reporting extended periods of sick leave [9] and return to work rates as low as 18% after 26 weeks [10] in people with whiplash-associated disorder. ...
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Background: Musculoskeletal injuries are the most common non-fatal injury from road traffic crashes. Even when the injuries are mild, they can cause pain which can affect return to work rates and work ability post-crash. Workplace output losses are the biggest cost from traffic crash-related injuries. There is a need to identify effective interventions that can improve work-related outcomes (e.g. time to return to work, sick leave, and work ability) in this group and a need to understand the intervention components, external factors, and participant characteristics that may be associated with improvement. Methods: A systematic review will be conducted using seven databases and search terms related to road traffic crash, musculoskeletal injury, work-related outcomes, and study design. Intervention studies will be eligible if they report on at least one work-related outcome, include adults with a traffic crash-related musculoskeletal injury (e.g. fracture or whiplash), include a comparison group, and are written in English. Interventions can be medical, therapeutic, work-based, multicomponent, or other. Two researchers will independently screen titles and abstracts, review full texts for inclusion in the review, and perform the data extraction. The main outcomes of the review will be time until return to work and duration of sick leave. The results will be narratively described, with meta-analyses conducted where possible. Discussion: This review will explore the effectiveness of interventions in individuals with traffic crash-related musculoskeletal injury on work-related outcomes and will act as a useful source for researchers, policy makers, and stakeholders when developing and implementing interventions in this group. Systematic review registration: PROSPERO CRD42018103746.
... The self-perceived health impact of each comorbidity was rated on a four-point ordinal scale as: (1) not at all, (2) mild, (3) moderate and (4) severe. The Comorbidity Questionnaire has good test-retest reliability (ICC = 0.93) and adequate face, concurrent and convergent validity [23,24]. ...
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Purpose: This population-based cohort study investigated the association between a lifetime history of a low back injury in a motor vehicle collision (MVC) and future troublesome low back pain. Participants with a history of a low back injury in a motor vehicle collision who had recovered (no or mild low back pain) were compared to those without a history of injury. Current evidence from two cross-sectional and one prospective study suggests that individuals with a history of a low back injury in a MVC are more likely to experience future LBP. There is a need to test this association prospectively in population-based cohorts with adequate control of known confounders. Methods: We formed a cohort of 789 randomly sampled Saskatchewan adults with no or mild LBP. At baseline, participants were asked if they had ever injured their low back in a MVC. Six and 12 months later, participants were asked about the presence of troublesome LBP (grade II-IV) on the Chronic Pain Grade Questionnaire. Multivariable Cox proportional hazards regression analysis was used to estimate the association while controlling for known confounders. Results: The follow-up rate was 74.8% (590/789) at 6 months and 64.5% (509/789) at 12 months. There was a positive crude association between a history of low back injury in a MVC and the development of troublesome LBP over a 12-month period (HRR = 2.76; 95% CI 1.42-5.39). Controlling for arthritis reduced this association (HRR = 2.25; 95% CI 1.11-4.56). Adding confounders that may be on the casual pathway (baseline LBP, depression and HRQoL) to the multivariable model further reduced the association (HRR = 2.20; 95% CI 1.04-4.68). Conclusion: Our analysis suggests that a history of low back injury in a MVC is a risk factor for developing future troublesome LBP. The consequences of a low back injury in a MVC can predispose individuals to experience recurrent episodes of low back pain.
... Clinically, the Cervical Spine Injury Severity Score (CSISS) [3] and Sub-axial Injury Classification (SIC) [4] have been developed to organize and guide treatment, but there is still controversy over how to treat traumatic injuries [5][6][7]. More generally, neck injuries and associated neck pain [8,9] are a leading cause of chronic pain and disability [10,11]. ...
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Purpose To quantify the mechanical role of posterior column components in human cervical spine segments. Methods Twelve C6-7 segments were subjected to resection of (1) suprasinous/interspinous ligaments (SSL/ISL), (2) ligamenta flavum (LF), (3) facet capsules, and (4) facets. A robot-based testing system performed repeated flexibility testing of flexion–extension (FE), axial rotation (AR), and lateral bending (LB) to 2.5Nm and replayed kinematics from intact flexibility tests for each state. Range-of-motion, stiffness, moment resistance and resultant forces were calculated. Results The LF contributes largely to moment resistance, particularly in flexion. Facet joints were primary contributors to AR and LB mechanics. Moment/force responses were more sensitive and precise than kinematic outcomes. Conclusions The LF is mechanically important in the cervical spine; its injury could negatively impact load distribution. Damage to facets in a flexion injury could lead to AR or LB hypermobility. Quantifying the contribution of spinal structures to moment resistance is a sensitive, precise process for characterizing structural mechanics.
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Objective To evaluate the effectiveness of a government-regulated rehabilitation guideline compared with education and activation by general practitioners, and to a preferred-provider insurance-based rehabilitation programme on self-reported global recovery from acute whiplash-associated disorders (WAD) grade I–II. Design Pragmatic randomised clinical trial with blinded outcome assessment. Setting Multidisciplinary rehabilitation clinics and general practitioners in Ontario, Canada. Participants 340 participants with acute WAD grade I and II. Potential participants were sampled from a large automobile insurer when reporting a traffic injury. Interventions Participants were randomised to receive one of three protocols: government-regulated rehabilitation guideline, education and activation by general practitioners or a preferred-provider insurance-based rehabilitation. Primary and secondary outcome measures Our primary outcome was time to self-reported global recovery. Secondary outcomes included time on insurance benefits, neck pain intensity, whiplash-related disability, health-related quality of life and depressive symptomatology at 6 weeks and 3, 6, 9 and 12 months postinjury. Results The median time to self-reported global recovery was 59 days (95% CI 55 to 68) for the government-regulated guideline group, 105 days (95% CI 61 to 126) for the preferred-provider group and 108 days (95% CI 93 to 206) for the general practitioner group; the difference was not statistically significant (Χ ² =3.96; 2 df: p=0.138). We found no clinically important differences between groups in secondary outcomes. Post hoc analysis suggests that the general practitioner (hazard rate ratio (HRR)=0.51, 95% CI 0.34 to 0.77) and preferred-provider groups (HRR=0.67, 95% CI 0.46 to 0.96) had slower recovery than the government-regulated guideline group during the first 80 days postinjury. No major adverse events were reported. Conclusions Time-to-recovery did not significantly differ across intervention groups. We found no differences between groups with regard to neck-specific outcomes, depression and health-related quality of life. Trial registration number NCT00546806 .
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Psychometric properties of the Center for Epidemiologic Studies Depression (CES-D) scale were examined among five groups that vaned in physical health and illness. Participants included 175 healthy undergraduates, 176 individuals attending family physicians, 107 progressive renal disease, 135 end-stage renal disease, and 120 cancer patients. Individual item and total CES-D scores were relatively symmetrically distributed and varied across the entire range of potentially obtainable scores. Reliability analyses yielded internal consistency (alpha) coefficients ranging from 0.63 to 0.93 across the groups. Test-retest reliability (3-month lag) was 0.61. The CES-D's factorial composition was highly similar to that observed among community volunteers. Varimax-rotated principal-components analyses extracted four factors, corresponding to “depressive affect”, “positive affect”, “somatic and retarded activity”, and “interpersonal”. Moreover, this pattern did not change despite differences in physical health-illness across the groups. although a significant Groups X Items (repeated measures) interaction indicated that “positive affect” items were lower among progressive renal failure patients than among the other groups. The psychometric characteristics of the CES-D scale, thus, appear to be relatively constant across the five health-illness populations.
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Study DesignBest evidence synthesis. ObjectiveTo undertake a best evidence synthesis of the published evidence on the burden and determinants of neck pain and its associated disorders in the general population. Summary of Background DataThe evidence on burden and determinants of neck has not previously been summarized. MethodsThe Bone and Joint Decade 2000−2010 Task Force on Neck Pain and Its Associated Disorders performed a systematic search and critical review of literature published between 1980 and 2006 to assemble the best evidence on neck pain. Studies meeting criteria for scientific validity were included in a best evidence synthesis. ResultsWe identified 469 studies on burden and determinants of neck pain, and judged 249 to be scientifically admissible; 101 articles related to the burden and determinants of neck pain in the general population. Incidence ranged from 0.055 per 1000 person years (disc herniation with radiculopathy) to 213 per 1000 persons (self-reported neck pain). Incidence of neck injuries during competitive sports ranged from 0.02 to 21 per 1000 exposures. The 12-month prevalence of pain typically ranged between 30% and 50%; the 12-month prevalence of activity-limiting pain was 1.7% to 11.5%. Neck pain was more prevalent among women and prevalence peaked in middle age. Risk factors for neck pain included genetics, poor psychological health, and exposure to tobacco. Disc degeneration was not identified as a risk factor. The use of sporting gear (helmets, face shields) to prevent other types of injury was not associated with increased neck injuries in bicycling, hockey, or skiing. ConclusionNeck pain is common. Nonmodifiable risk factors for neck pain included age, gender, and genetics. Modifiable factors included smoking, exposure to tobacco, and psychological health. Disc degeneration was not identified as a risk factor. Future research should concentrate on longitudinal designs exploring preventive strategies and modifiable risk factors for neck pain.
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The aim of this study was to examine the association between grades of neck pain severity and health-related quality of life (HRQoL), using a population-based, cross-sectional mailed survey. The literature suggests that physical and mental HRQoL is worse for individuals with neck pain compared to those without neck pain. However, the strength of the association varies across studies. Discrepancies in study results may be attributed to the use of different definitions and measures of neck pain and differences in the selection of covariates used as control variables in the analyses. The Saskatchewan Health and Back Pain Survey was mailed to 2,184 randomly selected Saskatchewan adults of whom 1,131 returned the questionnaire. Neck pain was measured with the Chronic Pain Questionnaire and categorized into four increasing grades of severity. We measured HRQoL with the SF-36 Health Survey and computed the physical and mental component summary scores. We built separate multiple linear regression models to examine the association between grades of neck pain and physical and mental summary scores while controlling for sociodemographic, general health and comorbidity covariates. Our crude analysis suggests that a gradient exists between the severity of neck pain and HRQoL. Compared to individuals without neck pain, those with Grades III-IV neck pain have significantly lower physical (mean difference = -13.9/100; 95% CI = -16.4, -11.3) and mental (mean difference = -10.8/100; 95% CI = -13.6, -8.1) HRQoL. Controlling for covariates greatly reduced the strength of association between neck pain and physical HRQoL and accounted for the observed association between neck pain and mental HRQoL. In the comorbidity model, the strength of association between Grades III-IV neck pain and PCS decreased by more than 50% (mean difference = -4.5/100; 95% CI = -6.9, -2.0). In the final PCS model, Grades III-IV neck pain coefficients changed only slightly from the comorbidity model (mean difference = -4.4/100; 95% CI = -6.9, -1.9). This suggests that comorbid conditions account for most of the association between neck pain and PCS score. It was concluded that prevalent neck pain is weakly associated with physical HRQoL, and that it is not associated with mental HRQoL. Our cross-sectional analysis suggests that most of the observed association between prevalent neck pain and HRQoL is attributable to comorbidities.
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• Discrepancies between the symptoms of depression, as found in a self-report questionnaire (Center for Epidemiologic Studies-Depression Scale [CES-D]), and the diagnosis of major depression as made by the Research Diagnostic Criteria (RDC) occurred in a community survey. The discrepancies can be explained by the subject's psychiatric or medical disorders other than depression, by nay saying during the interview, or by the exclusion criteria of the RDC (duration of symptoms, role impairment, or help seeking) that are not part of the CES-D. Results show that the discrepancies can be readily explained.
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The Center for Epidemiologic Studies Depression scale (CES-D) has been widely used in studies of late-life depression. Psychometric properties are generally favourable, but data on the criterion validity of the CES-D in elderly community-based samples are lacking. In a sample of older (55-85 years) inhabitants of the Netherlands, 487 subjects were selected to study criterion validity of the CES-D. Using the 1-month prevalence of major depression derived from the Diagnostic Interview Schedule (DIS) as criterion, the weighted sensitivity of the CES-D was 100%; specificity 88%; and positive predictive value 13 . 2%. False positives were not more likely among elderly with physical illness, cognitive decline or anxiety. We conclude that the criterion validity of the CES-D for major depression was very satisfactory in this sample of older adults.
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The CES-D scale is a short self-report scale designed to measure depressive symptomatology in the general population. The items of the scale are symptoms associated with depression which have been used in previously validated longer scales. The new scale was tested in household interview surveys and in psychiatric settings. It was found to have very high internal consistency and adequate test- retest repeatability. Validity was established by pat terns of correlations with other self-report measures, by correlations with clinical ratings of depression, and by relationships with other variables which support its construct validity. Reliability, validity, and factor structure were similar across a wide variety of demographic characteristics in the general population samples tested. The scale should be a useful tool for epidemiologic studies of de pression.
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The objective of this study is to determine whether independent associations exist between a history of neck injury related to a motor vehicle collision and: (1) graded neck pain in the past 6 months; (2) headaches in the past 6 months and; (3) depressive symptomatology during the past week. We used data from the Saskatchewan Health and Back Pain Survey, a population-based cross-sectional survey mailed to a stratified random sample of 2184 Saskatchewan adults aged 20–69 years. Fifty-five percent of the eligible population participated. The exposure was collected by asking subjects whether they had ever injured their neck in a motor vehicle collision. The outcomes: 6-month prevalence of graded neck pain, 6-month prevalence headache and depressive symptomatology during the past week were measured with valid and reliable questionnaires. Sixteen percent of the study sample reported a lifetime history of neck injury in a traffic collision. The association between neck injury and the outcomes was determined from polytomous and binary multivariate logistic regression with adjustment for age, gender and other covariates. A history of neck injury was positively associated with low intensity/low disability neck pain (OR=2.81; 95% CI 1.81–4.37), positively associated with high intensity/low disability neck pain (OR=4.46; 95% CI 2.49–4.99) and with disabling neck pain (OR=3.30; 95% CI 1.48–7.39). Similarly, we found a positive association between a history of neck injury in a motor vehicle collision and headaches that moderately/severely impact on one’s health (OR=2.09; 95% CI 1.27–3.44). No association was found between neck injury and depressive symptomatology (OR=0.84; 95% CI 0.50–1.40). Our cross-sectional analysis suggests that neck pain and severe headaches are more prevalent in individuals with a history of neck injury from a car collision. However, the results should not be used to infer a causal relationship between whiplash and chronic neck pain and headaches.
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Best evidence synthesis. To undertake a best evidence synthesis of the published evidence on the burden and determinants of neck pain and its associated disorders in the general population. The evidence on burden and determinants of neck has not previously been summarized. The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders performed a systematic search and critical review of literature published between 1980 and 2006 to assemble the best evidence on neck pain. Studies meeting criteria for scientific validity were included in a best evidence synthesis. We identified 469 studies on burden and determinants of neck pain, and judged 249 to be scientifically admissible; 101 articles related to the burden and determinants of neck pain in the general population. Incidence ranged from 0.055 per 1000 person years (disc herniation with radiculopathy) to 213 per 1000 persons (self-reported neck pain). Incidence of neck injuries during competitive sports ranged from 0.02 to 21 per 1000 exposures. The 12-month prevalence of pain typically ranged between 30% and 50%; the 12-month prevalence of activity-limiting pain was 1.7% to 11.5%. Neck pain was more prevalent among women and prevalence peaked in middle age. Risk factors for neck pain included genetics, poor psychological health, and exposure to tobacco. Disc degeneration was not identified as a risk factor. The use of sporting gear (helmets, face shields) to prevent other types of injury was not associated with increased neck injuries in bicycling, hockey, or skiing. Neck pain is common. Nonmodifiable risk factors for neck pain included age, gender, and genetics. Modifiable factors included smoking, exposure to tobacco, and psychological health. Disc degeneration was not identified as a risk factor. Future research should concentrate on longitudinal designs exploring preventive strategies and modifiable risk factors for neck pain.