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Reverse Causality in the Association Between Whiplash and Symptoms of Anxiety and Depression
Abstract
Longitudinal population-based cohort study.
The aim of this study was to examine the possibility of reverse causality, that is, if symptoms of anxiety and depression are associated with incident self-reported whiplash injury. The clinical relevance of self-reported whiplash injury was evaluated by its association with subsequent disability pension award.
Whiplash is associated with an increased level of anxiety and depressive symptoms. This increase in psychological distress is generally understood as the consequence of the accident and related whiplash.
Longitudinal data from the HUNT study was used. Baseline measures of symptoms of anxiety and depression were used in prediction of incident whiplash injury self-reported at follow-up 11 years later. Incident disability pension award was obtained from a comprehensive national registry during 2-year follow-up after self-reported whiplash injury.
Case-level symptom load of anxiety and depression at baseline increased the likelihood of reporting incident whiplash at follow-up (odds ratio [OR] = 1.60, 95% confidence interval = 1.22-2.11). Self-reported whiplash increased the chances of a subsequent disability pension award (OR = 6.54), even in the absence of neck pain (OR = 3.48).
This is the first published study with a prewhiplash prospective evaluation of psychological status. Our findings are in conflict with previous research suggesting whiplash to be the cause of associated psychological symptoms rather than their consequence. Self-reported whiplash injury was clinically relevant as it independently increased subsequent disability pension award. The strength of this effect, even in the absence of neck pain, suggests the ascertainment of this diagnostic label, or factors associated with this, are important predictors of disability.
... As in previous studies [13,35], self-reported incident whiplash was assessed using the question "Have you ever experienced whiplash?", together with a follow-up question on how old the person was at the time of the injury. ...
... For instance, somatic symptoms and symptoms of anxiety and depression might have been present before the accident. Increased preinjury levels of symptoms of anxiety and depression have been found [35], and reporting low pre-injury physical and mental health predicts whiplash [54]. ...
... Previous studies have used self-reported data and similar methods of classification when investigating chronic whiplash [13,21]. A recent study found self-reported whiplash to strongly predict a subsequent allowance of disability benefits [35], indicating clinical relevance of self-reported whiplash, whether it is picking up true whiplash sufferers or not. The lack of a medical confirmation is truly a limitation if to be regarded a study of true whiplash victims. ...
Background:
Chronic whiplash leads to considerable patient suffering and substantial societal costs. There are two competing hypothesis on the etiology of chronic whiplash. The traditional organic hypothesis considers chronic whiplash and related symptoms a result of a specific injury. In opposition is the hypothesis that chronic whiplash is a functional somatic syndrome, and related symptoms a result of society-induced expectations and amplification of symptoms. According to both hypotheses, patients reporting chronic whiplash are expected to have more neck pain, headache and symptoms of anxiety and depression than the general population. Increased prevalence of somatic symptoms beyond those directly related to a whiplash neck injury is less investigated. The aim of this study was to test an implication derived from the functional hypothesis: Is the prevalence of somatic symptoms as seen in somatization disorder, beyond symptoms related to a whiplash neck injury, increased in individuals self-reporting chronic whiplash? We further aimed to explore recall bias by comparing the symptom profile displayed by individuals self-reporting chronic whiplash to that among those self-reporting a non-functional injury: fractures of the hand or wrist. We explored symptom load, etiologic origin could not be investigated in this study.
Methods:
Data from the Norwegian population-based "Hordaland Health Study" (HUSK, 1997-99); N = 13,986 was employed. Chronic whiplash was self-reported by 403 individuals and fractures by 1,746. Somatization tendency was measured using a list of 17 somatic symptoms arising from different body parts and organ systems, derived from the research criteria for somatization disorder (ICD-10, F45).
Results:
Chronic whiplash was associated with an increased level of all 17 somatic symptoms investigated (p<0.05). The association was moderately strong (group difference of 0.60 standard deviation), only partly accounted for by confounding. For self-reported fractures symptoms were only slightly elevated. Recent whiplash was more commonly reported than whiplash-injury a long time ago, and the association of interest weakly increased with time since whiplash (r = 0.016, p = 0.032).
Conclusions:
The increased prevalence of somatic symptoms beyond symptoms expected according to the organic injury model for chronic whiplash, challenges the standard injury model for whiplash, and is indicative evidence of chronic whiplash being a functional somatic syndrome.
... Poor somatic and mental health and poor self-rated health have been found to predict onset of whiplash [29][30][31]. Less is known about the importance of such factors on the maintenance of chronic whiplash, and a roundtable discussion published in Spine 2011 stated the need for clarification regarding which factors are involved in the initiation versus factors involved in the maintenance of whiplash [32]. In this study, we used data from two waves of a large population-based Norwegian study to investigate how somatic health, mental health and health-related measures predict a chronic course after whiplash injuries. ...
... Previous studies have found individuals self-reporting whiplash to suffer by increased symptom loads [16,18]. A recent study found selfreported whiplash to strongly predict a subsequent allowance of disability benefits [30], indicating clinical relevance of selfreported whiplash, whether it is picking up "true" whiplash sufferers or not. ...
Whiplash injuries show a variable prognosis which is difficult to predict. Most individuals experiencing whiplash injuries rapidly recover but a significant proportion develop chronic symptoms and ongoing disability.
By employing longitudinal data, we investigated how psychological and physical symptoms, self-rated health, use of health services and medications, health behavior and demographic factors predict recovery from whiplash.
Data from two waves of a large, Norwegian, population-based study (The Nord-Trøndelag Health Study: HUNT2 and HUNT3) were used. Individuals reporting whiplash in HUNT2 (baseline) were identified in HUNT3 11 years later. The characteristics of individuals still suffering from whiplash in HUNT3 were compared with the characteristics of individuals who had recovered using Pearson's chi-squared test, independent sample t-tests and logistic regression.
At follow-up, 31.6 % of those reporting whiplash at baseline had not recovered. These individuals (n = 199) reported worse health at baseline than recovered individuals (n = 431); they reported poorer self-rated health (odds ratio [OR] = 3.12; 95 % confidence interval [CI], 2.20-4.43), more symptoms of anxiety (OR = 1.70; 95 % CI, 1.15-2.50), more diffuse somatic symptoms (OR = 2.38; 95 % CI, 1.61-3.51) and more musculoskeletal symptoms (OR = 1.21; 95 % CI, 1.13-1.29). Individuals still suffering from whiplash also visited more health practitioners at baseline (OR = 1.18; 95 % CI, 1.06-1.32) and used more medications (OR = 1.24; 95 % CI, 1.09-1.40).
Poor self-rated health seems to be a strong risk factor for whiplash injuries becoming chronic. Diffuse somatic symptoms, musculoskeletal symptoms and symptoms of anxiety at baseline are important prognostic risk factors. Knowledge of these maintaining risk factors enables identification of individuals at risk of non-recovery, facilitating adequate treatment for this vulnerable group.
... [17][18][19] Recent studies have reported links between preinjury and postinjury selfreported healthcare consultation and health status. [28][29][30] From the perspective of the society, healthcare consumption and return to work are important outcomes. 31 32 In Region Skåne, located in southern Sweden, there is a possibility to study patients' actual healthcare consultations and sick leave episodes using longitudinal data from independent sources both before and after neck-injury diagnosis. ...
... 28 29 The explanation would be that poor health, especially mental conditions in combination with pharmaceuticals, would increase the risk of a car accident. 28 Our results indicate that psychological distress is a common reason for physician healthcare consultation even before a diagnosis of acute neck injury. This tendency was maintained and even increased after injury. ...
Recent studies based on self-assessed data on exposure and outcome suggest a negative association between poor health before neck injury and recovery. Our aim was to study actual healthcare consultation and work disability before and after neck injury (whiplash).
Cohort study with matched references studied prospectively and retrospectively via regional and national held registers.
Population-based study in Region Skåne, Sweden (population=1.21 million) including all levels of healthcare.
1443 participants aged ≥18 (54% women) with acute neck injury, Whiplash, (International Classification of Diseases-10-SE code S13.4*) in 2007 or 2008 and no such diagnosis since 1998. Each patient with a neck injury was assigned four randomly selected population references matched for age, sex and area of residence (97% of the patients and 94% of the references were followed during the whole study period).
We studied changes in healthcare consultations 3 years before to 3 years after diagnosis as well as sick leave episodes. Analyses were also stratified by preinjury frequency of consultation.
Before the injury, the mean number of total consultations over 36 months among the neck injured (n=1443) and references (n=5772) was 9.3 vs 7.2 (p<0.0001) and postneck injury 12.7 vs 7.8 (p<0.0001). In the group of high-frequent consulters, there were more women compared with frequent and low-frequent consulters (70.6% vs 32.8%; p<0.0001). Among low-frequent and frequent consulters preinjury (n=967, 67% of the cohort), 16% became high-frequent consulters attributable to the injury. The number of days of sick leave preinjury was correlated with the number of preinjury and postinjury consultations (r=0.47 (99% CI 0.38 to 0.49), r=0.32 (99% CI 0.25 to 0.37)).
People with a neck injury constitute a heterogeneous group. The preinjury level of healthcare consultation is associated with the postinjury level of consultation.
... How physical activity reduces the risk of chronic whiplash is not possible to investigate in this study, although it seems plausible that physically active individuals are more likely to remain active and not adapt a passive coping strategy or fear avoidance after whiplash accidents. Further, physical activity reduces the risk of experiencing depressive symptoms [54][55][56] and mental health problems have been found to be strong risk factors for the development of chronic whiplash [29,57]. ...
... This can increase the risk of reattribution of pre-existing symptoms to the injury, and further amplification of these. The importance of reattribution and amplification in chronic whiplash has been emphasized in previous studies [9,24,57,61]. ...
... However, worse mental health might not only be a consequence of injury. Longitudinal research has shown that the relation may be bidirectional (Patten et al., 2010) and that psychiatric disorders such as anxiety and depression might be associated with increased odds for future injuries (Mykletun et al., 2011), with injury possibly being common in groups such as outpatients with major depressive disorder (Hung et al., 2016). ...
Psychotic experiences (PEs) have been linked to an increased risk for accidents and injuries. However, this association remains little researched in many countries. To address this research gap, the current study used cross-sectional data from the United States to examine the association between PEs and accidents, injuries, and poisoning in a general population sample. Data were analyzed from 2274 individuals who completed the psychosis screen as part of the National Comorbidity Survey Replication (NCS-R). Information was obtained on PEs (hallucinations and delusions) and the experience of past 12-month accidents, injuries, and poisoning. Logistic regression analysis was used to examine the association while adjusting for demographic variables and common mental disorders (CMDs). In a fully adjusted model past 12-month PEs were associated with almost three times higher odds for reporting accidents, injuries, and poisoning (odds ratio [OR]: 2.97, 95% confidence interval [CI]: 1.13-7.74). The results of this study indicate that PEs are associated with higher odds for accidents and injuries among adults in the United States. Research is now needed to determine the direction of this association and the factors linked to it.
... The biopsychosocial review of the literature on pain and emotion by Lumley et al. (2011) shows that psychological distress plays a large role in the experience of pain (Lumley et al., 2011). In fact, while tissue damage from injury or disease often precedes pain, a large literature finds that pain is also often preceded by psychological distress (Currie and Wang, 2005;Mykletun et al., 2011;Knaster et al., 2012;Afari et al., 2014;Phyomaung et al., 2014;Aro et al., 2015;Tegethoff et al., 2015). ...
We examine the hypothesis that psychological distress due to perceived discrimination can result in chronic pain, where perceived discrimination is based on age, gender, race, ethnicity, disability, sexual orientation, height/weight, religion, and other characteristics. Using a sample of 1908 individuals from the two most recent waves (2004-2006 and 2013-2014) of panel data from the National Survey of Midlife Development in the United States, we apply instrumental variables regression where measures of daily and lifetime perceived discrimination are instruments whose effects on chronic pain are mediated by psychological distress. We find statistically significant dose-response relationships between daily perceived discrimination and psychological distress, between lifetime perceived discrimination and psychological distress, and between psychological distress and chronic pain. Based on our instrumental variables regression model, we estimate that 4.1 million people in the US in 2016, aged 40 and older, experience chronic pain that is caused by increased psychological distress, where psychological stress has increased due to perceived discrimination.
... It should, however, also be noted that psychosocial factors might affect pain and outcome after whiplash injuries (Sterling et al., 2011b)as in other pain conditions (Pincus et al., 2002). Previous research has found increased risk of developing WAD among individuals reporting symptoms of anxiety (Myrtveit et al., 2013), anxiety and depression (Mykletun et al., 2011) and mental impairment before the injury. Symptoms of anxiety is also associated with non-recovery from WAD (Myrtveit et al., 2014). ...
Background:
Pain is a cardinal symptom in individuals with whiplash-associated disorders (WAD). We aimed to compare pain characteristics between individuals with WAD and individuals reporting chronic pain from other causes, and to determine whether potential differences were accounted for by experimental pain tolerance.
Methods:
Data from the 6th Tromsø Study (2007-2008, n = 12,981) were analysed. The number of painful locations was compared between individuals with WAD and individuals reporting chronic pain from other causes using negative binomial regression, pain frequency using multinomial logistic regression and pain intensity using multiple linear regression. Differences in experimental pain tolerance (cold pressor test) were tested using Cox regression; one model compared individuals with WAD to those with chronic pain from other causes, one compared the two groups with chronic pain to individuals without chronic pain. Subsequently, regression models investigating clinical pain characteristics were adjusted for pain tolerance.
Results:
Of individuals with WAD, 96% also reported other causes for pain. Individuals with WAD reported a higher number of painful locations [median (inter-quartile range): 5 (3.5-7) vs. 3 (2-5), p < 0.001] and higher pain intensity (crude mean difference = 0.78, p < 0.001) than individuals with chronic pain from other causes. Pain tolerance did not differ between these two groups. Compared to individuals without chronic pain, individuals with WAD and individuals with chronic pain from other causes had reduced pain tolerance.
Conclusions:
Individuals with WAD report more additional causes of pain, more painful locations and higher pain intensity than individuals with chronic pain from other causes. The increased pain reporting was not accounted for by pain tolerance.
... In spinal cord injury patients, pre-injury history of depression is a risk factor for depression following spinal cord injury [6]. Pre-injury anxiety and depression increase the likelihood of incident self-reported whiplash [7]. Self-reported prior mental health problems have also been identified as a risk factor for developing depression after whiplash [8,9]. ...
... It should, however, also be noted that psychosocial factors might affect pain and outcome after whiplash injuries (Sterling et al., 2011b)as in other pain conditions (Pincus et al., 2002). Previous research has found increased risk of developing WAD among individuals reporting symptoms of anxiety (Myrtveit et al., 2013), anxiety and depression (Mykletun et al., 2011) and mental impairment before the injury. Symptoms of anxiety is also associated with non-recovery from WAD (Myrtveit et al., 2014). ...
Aim
Among individuals who experience whiplash accidents, around 20% develop chronic pain. We aimed to compare number of painful locations and pain intensity between individuals with chronic whiplash and individuals with other chronic pain, and to investigate whether differences could be explained by pain tolerance.
Methods
Employing data from the sixth wave of the Tromsø Study, individuals reporting whiplash were compared to individuals with other chronic pain. Number of pain locations was compared using Poisson regression, pain intensity using linear regression. Pain tolerance (cold-pressor test) was compared using cox regression; one model compared individuals with whiplash to those with other chronic pain, another model compared the two groups with chronic pain to pain-free controls. In order to investigate whether pain tolerance could account for differences in pain, the regression models were adjusted for time-till-failure in the cold-pressor test.
Results
Individuals with whiplash reported a higher number of painful locations (IRR = 5.23, 95%CI: 4.93–5.53 versus IRR = 3.57, 95%CI: 3.50–3.65) and higher pain intensity (mean: 7.80, 95%CI: 7.58–8.02 versus mean: 7.14, 95%CI: 7.08–7.21) than individuals with other chronic pain. Pain tolerance did not differ between these two groups, but compared to pain-free controls individuals in both groups had reduced pain tolerance.
Conclusions
Individuals with chronic whiplash had reduced pain tolerance compared to individuals without chronic pain, but not compared to individuals with other chronic pain. Reduced pain tolerance can account for some of the increased pain reported by individuals with chronic whiplash compared to controls but not compared to individuals with other chronic pain.
... Diagnostiske merkelapper kan gi en viss legitimitet. For eksempel innvilges uførepensjon like hyppig for whiplashdiagnose uten nakkesmerter som for nakkesmerter uten whiplashdiagnose (2). ...
... Pre-collision factors such as health-seeking behaviour and somatisation cause a greater vulnerability towards nonrecovery (Wynne- Jones et al., 2006) and might explain increased cold pain threshold via increased vigilance to painful stimuli. One prospective study has demonstrated that pre-collision anxiety and depression are prognostic factors for whiplash-related compensation (Mykletun et al., 2011). ...
To review and critically evaluate the existing literature for the prognostic value of cold hyperalgesia in Whiplash Associated Disorders (WAD).
Embase, PsycINFO, and Medline databases were systematically searched (from inception to 20th September 2011) for prospective studies investigating a prognostic ability for cold hyperalgesia in WAD. Reference lists and lead authors were cross-referenced. Two independent reviewers selected studies, and consensus was achieved via a third reviewer. The risk of bias in identified studies was systematically evaluated by two reviewers using previously published guidance. The influences of seven potential covariates of cold hyperalgesia were considered. Quantitative synthesis was planned and homogeneity assessed. A modified Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to qualitatively assess trials.
The review screened 445 abstracts, from these 20 full text studies were retrieved and assessed for eligibility. Six prospective studies on four cohorts were identified and reviewed. Findings from all four cohorts supported cold hyperalgesia as a prognostic factor in WAD.
There is moderate evidence supporting cold hyperalgesia as a prognostic factor for long-term pain and disability outcome in WAD. Further validation of the strength of this relationship and the influence of covariates are required. The mechanism for this relationship is unknown.
... These expectations have been found to be associated with poor recovery after whiplash injury. 86 Although less well investigated, psychological factors present before the injury may also be associated with poor functional recovery 87 and this requires further investigation. ...
Nonsystematic review and discussion of the etiological processes involved in whiplash-associated disorders (WAD).
To summarize the research and identify priorities for future research.
Although there is convergent evidence of a peripheral lesion in some individuals after whiplash injury, in the majority of injured people, a lesion cannot be established with current imaging technology. Therefore, it is important to consider processes that underlie the initiation and maintenance of whiplash pain as this may allow for the development and testing of interventions to target these processes and improve outcomes.
A nonsystematic review was performed to summarize current knowledge regarding potential etiological processes involved in the initiation and maintenance of WAD and to identify future research priorities.
There are several etiological processes potentially involved in the initiation and maintenance of WAD. These include augmented nociceptive processing, stress system responses, and psychosocial and sociocultural factors. Recent findings also indicate that morphological changes in the neck muscles of injured people show some association with poor recovery, but the mechanisms underlying these changes are not clear. Preliminary evidence indicates associations between these processes. Future research priorities include the following: more sophisticated investigation and analysis of interactions between the various processes; whether the modification of these processes is achievable and if modification can improve health outcomes; and to clarify factors involved in the initiation of whiplash pain versus those involved in symptom maintenance.
Research to date indicates that there are several physiological and psychological etiological processes that may underlie the initiation and maintenance of whiplash-related pain and disability. Further research is required to determine relationships and interactions between these factors and to determine whether their modification is possible and will improve outcomes after injury.
... The present results are in accordance with previous cross-sectional studies, reporting a wide variety of health complaints among persons with self-reported whiplash injury [20,21] and a Swedish cohort study showed that persons with chronic pain after a whiplash injury had an increased risk for pain from different anatomical sites [32]. There are some that argue that these symptoms might reflect central sensitization [33] but there is also a strong association between whiplash injury and psychiatric disorders [23], which might reflect a reversed causality, that is, increased risk of future self-reported whiplash injury in individuals who already have anxiety and depression [34]. Thus, the strong relationship between whiplash injury and the combination of headache and chronic MSC in the present study may, at least in part, reflect personality traits rather than biological mechanisms [35]. ...
To evaluate the life-time prevalence of self reported whiplash injury and the relationship to chronic musculoskeletal complaints (MSCs) and headache in a large unselected adult population.
Between 1995 and 1997, all inhabitants 20 years and older in Nord-Trondelag county in Norway were invited to a comprehensive health survey. Out of 92,936 eligible for participation, a total of 59,104 individuals (63.6%) answered the question about whiplash injury (whiplash). Among these, 46,895 (79.3%) responded to the questions of musculoskeletal complaints and headache.
The total life-time prevalence of self reported whiplash injury was 2.9%, for women 2.7% and for men 3.0%. There was a significant association between self reported whiplash injury and headache (OR = 2.1; 95% CI 1.8-2.4), and chronic MSCs (OR = 3.3; 95% CI 2.8-3.8), evident for all ten anatomical sites investigated. The association was most pronounced for those with a combination of headache and chronic MSC for both men (OR = 4.8; 95% CI 3.6-6.2) and women (OR = 5.2; 95% CI 3.7-7.1).
Subjects with self reported whiplash injury had significantly more headache and musculoskeletal complaints than those without, and may in part be due to selective reporting. The causal mechanism remains unclear and cannot be addressed in the present study design.
Scientific findings have indicated that psychological and social factors are the driving forces behind most chronic benign pain presentations, especially in a claim context, and are relevant to at least three of the AMA Guides publications: AMA Guides to Evaluation of Disease and Injury Causation, AMA Guides to Work Ability and Return to Work, and AMA Guides to the Evaluation of Permanent Impairment. The author reviews and summarizes studies that have identified the dominant role of financial, psychological, and other non–general medicine factors in patients who report low back pain. For example, one meta-analysis found that compensation results in an increase in pain perception and a reduction in the ability to benefit from medical and psychological treatment. Other studies have found a correlation between the level of compensation and health outcomes (greater compensation is associated with worse outcomes), and legal systems that discourage compensation for pain produce better health outcomes. One study found that, among persons with carpal tunnel syndrome, claimants had worse outcomes than nonclaimants despite receiving more treatment; another examined the problematic relationship between complex regional pain syndrome (CRPS) and compensation and found that cases of CRPS are dominated by legal claims, a disparity that highlights the dominant role of compensation. Workers’ compensation claimants are almost never evaluated for personality disorders or mental illness. The article concludes with recommendations that evaluators can consider in individual cases.
Vel 75 % av alle voksne i Norge opplever smerter eller plager fra muskel- og skjelettsystemet i en eller annen form i løpet av en måned. Det meste av dette er lette plager, som ikke krever behandling. Det er imidlertid en betydelig del av befolkningen som har kroniske smerter. Det er vanligst å ha plager fra korsryggen, nakken og skuldrene. Det er også mange som har smerter i hofter, bekken og knær. Ofte er det ikke mulig å stille spesifikke diagnoser på slike plager, og mange har symptomdiagnoser. De fleste som har plager fra muskel- og skjelettsystemet har plager fra flere områder og ofte mange symptomer fra andre organer og kropsdeler. Korsryggsplager er den hyppigste årsaken til sykefravær (11 %) og uførhet (9 %) blant muskel- og skjelettplagene. Nakke- og skulderplager er også vanlige årsaker til sykefravær. Utbredte og uspesifikke muskel- og skjelettsmerter, ofte sammen med andre symptomer, er en viktig risikofaktor for uførhet.
Background:
It is unknown whether living with neck and back pain, disability, and mental disorders influences the perception of psychological and social factors at work among sick-listed patients.
Objectives:
The primary aim of the present study was to examine the associations between pain, disability, anxiety, depression, and perceived psychological and social factors at work among sick-listed patients with neck and back pain.
Methods:
We performed a cross-sectional study of 380 sick-listed patients with neck and low-back pain who were referred to spine clinics at two Norwegian university hospitals. Ordinal regression was applied, with psychological and social factors at work as the dependent variable.
Results:
Pain was not associated with psychological and social factors at work. Disability was associated with a minor increase in the perception of demands among women, but not men. Women with high anxiety or depression scores experienced less control over work situations and less positive challenges at work. Men with high depression scores perceived low support.
Conclusions:
Sick-listed patients with neck and back pain who had concurrent anxiety or depression reported increased psychological and social challenges at work. To provide suitable treatment in the clinical setting, further attention should be paid to the interaction between anxiety or depression and perceived job strain.
Whiplash is an acceleration-deceleration mechanism of energy transfer to the neck which may result mainly from rear-end or side-impact motor vehicle collisions but also from diving or other mishaps [1]. Whiplash-associated disorder (WAD) is generally considered to be a soft tissue injury of the neck with symptoms such as neck pain and stiffness, headaches, cognitive and psychiatric disorders, dizziness, visual symptoms, paresthesias, and weakness. It is estimated that the incidence of whiplash injury is approximately 4 per 1,000 persons [2]. Although many persons involved in whiplash injuries recover quickly, between 4 and 42 % of patients report symptoms several years later [2, 3]. According to Quebec Task Force, late whiplash syndrome has been defined by the symptoms persistence for more than 6 months after the injury. Patients with neurological symptoms caused by whiplash syndrome are frequently referred to neurologists in everyday clinical practice.
This book is suitable for all manual and physical therapists, sports and personal trainers, athletes who require special movement ranges and individuals who would like to recover or improve their range and ease of movement.
The lack of efficacy of rehabilitative approaches to the management of chronic whiplash associated disorders (WAD) may be in part due to heterogeneity of the clinical presentation of this patient population. The aim of this study was to identify homogeneous subgroups of patients with chronic WAD based on symptoms of PTSD and sensory hypersensitivity and to compare the clinical presentation of these sub-groups. Successive k-means cluster analyses using 2, 3 and 4 cluster solutions were performed using data for 331 (221 female) patients with chronic (> 3 months) WAD. The 4 cluster solution was identified as the most clinically relevant yielding 4 distinct clusters: no to mild post-traumatic stress symptoms and no sensory hypersensitivity (nPnH), no to mild post-traumatic stress symptoms and sensory hypersensitivity (nPH), moderate to severe post-traumatic stress and no sensory hypersensitivity (PnH) and moderate to severe post-traumatic stress and sensory hypersensitivity (PH). The nPnH cluster was the largest cluster comprising 43.5% of the sample. The PH cluster had significantly worse disability, pain intensity, self report mental health status and cervical ROM in comparison to the nPnH and nPH clusters. These data provide further evidence of the heterogeneity of the chronic WAD population and the association of a more complex clinical presentation with higher disability and pain in this patient group.
Objectives:
To estimate the direct and indirect factual costs of polyneuropathy in a national sample of patients and their spouses based on a national register-based cohort study with matched controls.
Methods:
Using records from the Danish National Patient Registry (1997-2009) all patients with a diagnosis of polyneuropathy and their partners were identified and compared with randomly chosen controls matched for age, gender, geographic area and civil status. Direct costs included frequencies of primary and secondary sector contacts and procedures, and medication. Indirect costs included the effect on labor supply. Social-transfer payments were included to illustrate the effect on national accounts. All cost data were extracted from national databases.
Results:
13,758 unspecified polyneuropathy patients were registered. They were compared with 54,900 matched controls identified from the National Danish Patient Registry. In addition, partners of patients in the case group were matched with partners in the corresponding control group. Almost half of the patients in the patient group had a partner. Patients had significantly higher rates of health-related contacts, medication use and greater socioeconomic costs than controls. They had very marginally lower employment rates, and those who were employed generally had lower incomes. The sum of direct net healthcare costs after the injury (general practitioner services, hospital services and medication) and indirect costs (loss of labor market income) was €12,647 for patients and €2,984 for their partners over and above that of controls. Social-transfer payments were all significantly larger in patients than in control subjects. Furthermore, the patients already exhibited a negative social- and health-related status up to eleven years before the first diagnosis, particularly for those with the highest costs. The health effects were present in all age groups and in both genders.
Conclusions:
Patients with a diagnosis of polyneuropathy experience increased mortality, morbidity and socioeconomic consequences.
To examine if pre-injury health-related factors are associated with the subsequent report of whiplash, and more specifically, both whiplash and neck pain.
Longitudinal population study of 40,751 persons participating in two consecutive health surveys with 11 years interval. We used logistic regression to estimate odds ratio (OR) for reporting whiplash or whiplash with neck pain lasting at least 3 months last year, related to pre-injury health as indicated by subjective health, mental and physical impairment, use of health services, and use of medication. All associations were adjusted for socio-demographic factors.
The OR for reporting whiplash was increased in people reporting poor health at baseline. The ORs varied from 1.47 (95% CI 1.13-1.91) in people visiting a general practitioner (GP) last year to 3.07 (95% CI 2.00-4.73) in people who reported poor subjective health. The OR associated with physical impairment and mental impairment was 2.69 (95% CI 1.75-4.14) and 2.49 (95% CI 1.31-4.74), respectively. Analysis of reporting both whiplash and neck pain gave somewhat stronger association, with ORs varying from 1.50 (95% CI 1.07-2.09) in people visiting a GP last year to 5.70 (95% CI 3.18-10.23) in people reporting poor subjective health. Physical impairment was associated with an OR of 3.48 (95% CI 2.12-5.69) and mental impairment with an OR of 3.02 (95% CI 1.46-6.22).
Impaired self-reported pre-injury health was strongly associated with the reporting of a whiplash trauma, especially in conjunction with neck pain. This may indicate that individuals have, already before the trauma, adopted an illness role or behaviour which is extended into and influence the report of a whiplash injury. The finding is in support of a functional somatic disorder model for whiplash.
Meta-analytic procedures were used to determine the relation between disability compensation and pain. Of the 157 relevant identified studies, only 32 contained quantifiable data from treatment and control groups. The majority of these exclusively examined chronic low back pain patients (72%). Overall, 136 comparisons were obtained, on the basis of 3,802 pain patients and 3,849 controls. Liberal procedures for estimating effect sizes (ESs) yielded an ES of .60 (p < .0002). Conservative procedures yielded an ES of .48 (p < .0005). Both ESs differed from zero, indicating that compensation is related to increased reports of pain and decreased treatment efficacy. These results are interpreted in light of current models of pain. Health policy implications are also discussed.
To examine the hypothesized effect of health anxiety on subsequent disability pension award. Mental disorders are consistently underrecognized in general health care, leading to underestimation of its effects on related social security expenditures. According to medicolegal diagnoses for disability pension award, there are almost no awards of disability benefits for health anxiety or hypochondriasis. There are no empirical longitudinal population-based studies on occupational disability in health anxiety or the extreme of hypochondriasis.
Using a historical cohort design, we utilized a unique link between a large epidemiological cohort study (n = 6819) and a comprehensive national database of disability benefits to examine the effect of health anxiety on subsequent disability pension award (n = 277) during 1.0 to 6.6 years of follow-up. The data sources were merged after informed consent, using the national personal identification number.
Health anxiety was a strong predictor of disability pension award, exceeding the effect of general anxiety, and comparable to the effect of depression. This effect was partly accounted for by adjustment for income and level of education, and comorbid mental, psychosomatic, or physical conditions. The effect was not limited to high symptom levels, but followed a dose-response association. Despite the robust effect in this prospective study, health anxiety or hypochondriasis was not recognized as medicolegal diagnosis for any awards of disability pension, and was not accounted for by other mental disorders.
Health anxiety is a strong, independent, and yet underrecognized risk factor for disability pension award.
The recent drive within the UK National Health Service to improve psychosocial care for people with mental illness is both understandable and welcome: evidence-based psychological and social interventions are extremely important in managing psychiatric illness. Nevertheless, the accompanying downgrading of medical aspects of care has resulted in services that often are better suited to offering non-specific psychosocial support, rather than thorough, broad-based diagnostic assessment leading to specific treatments to optimise well-being and functioning. In part, these changes have been politically driven, but they could not have occurred without the collusion, or at least the acquiescence, of psychiatrists. This creeping devaluation of medicine disadvantages patients and is very damaging to both the standing and the understanding of psychiatry in the minds of the public, fellow professionals and the medical students who will be responsible for the specialty's future. On the 200th birthday of psychiatry, it is fitting to reconsider the specialty's core values and renew efforts to use psychiatric skills for the maximum benefit of patients.
The concordance between self-report and clinical rating scales of depression increases during progress from the acute depressive episode to recovery or improvement of symptoms. We investigated this convergence in a group of 52 outpatients with DSM-III major depression disorders using three widely employed depression scales and their parallel formats (i.e., alternative modes of administering the scales). The six instruments were applied at admission and after 12 and 24 weeks' treatment. The results indicate that the increase in the global concordance between scales may be a statistical effect deriving from broadening of the range of scores.
The authors evaluated the impact of financial incentives on disability, symptoms, and objective findings after closed-head injury.
Meta-analysis was used to review the literature. Seventeen reports, covering 18 study groups and a total of 2,353 subjects, contained data from which effect sizes could be calculated. Effect sizes were aggregated after weighting for group size. After discussion, there was 100% agreement between the authors on all calculations.
A moderate overall effect size, 0.47, was found. The effect was particularly strong for mild head trauma. The data showed more abnormality and disability in patients with financial incentives despite less severe injuries.
Clinical evaluation of patients after closed-head injury, particularly mild head trauma, must include consideration of the effect of financial incentives on symptoms and disability.
Meta-analytic procedures were used to determine the relation between disability compensation and pain. Of the 157 relevant identified studies, only 32 contained quantifiable data from treatment and control groups. The majority of these exclusively examined chronic low back pain patients (72%). Overall, 136 comparisons were obtained, on the basis of 3,802 pain patients and 3,849 controls. Liberal procedures for estimating effect sizes (ESs) yielded an ES of .60 (p < .0002). Conservative procedures yielded an ES of .48 (p < .0005). Both ESs differed from zero, indicating that compensation is related to increased reports of pain and decreased treatment efficacy. These results are interpreted in light of current models of pain. Health policy implications are also discussed.
In Lithuania, there is little awareness of the notion that chronic symptoms may result from rear end collisions via the so-called whiplash injury. After most such collisions no contact with the health service is established. An opportunity therefore exists to study post-traumatic pain without the confounding factors present in western societies.
In a prospective, controlled inception cohort study, 210 victims of a rear end collision were consecutively identified from the daily records of the Kaunas traffic police. Neck pain and headache were evaluated by mailed questionnaires shortly after the accident, after 2 months, and after 1 year. As controls, 210 sex and age matched subjects were randomly taken from the population register of the same geographical area and evaluated for the same symptoms immediately after their identification and after 1 year.
Initial pain was reported by 47% of accident victims; 10% had neck pain alone, 18% had neck pain together with headache, and 19% had headache alone. The median duration of the initial neck pain was 3 days and maximal duration 17 days. The median duration of headache was 4.5 hours and the maximum duration was 20 days. After 1 year, there were no significant differences between the accident victims and the control group concerning frequency and intensity of these symptoms.
In a country were there is no preconceived notion of chronic pain arising from rear end collisions, and thus no fear of long term disability, and usually no involvement of the therapeutic community, insurance companies, or litigation, symptoms after an acute whiplash injury are self limiting, brief, and do not seem to evolve to the so-called late whiplash syndrome.
The term functional somatic syndrome has been applied to several related syndromes characterized more by symptoms, suffering, and disability than by consistently demonstrable tissue abnormality. These syndromes include multiple chemical sensitivity, the sick building syndrome, repetition stress injury, the side effects of silicone breast implants, the Gulf War syndrome, chronic whiplash, the chronic fatigue syndrome, the irritable bowel syndrome, and fibromyalgia. Patients with functional somatic syndromes have explicit and highly elaborated self-diagnoses, and their symptoms are often refractory to reassurance, explanation, and standard treatment of symptoms. They share similar phenomenologies, high rates of co-occurrence, similar epidemiologic characteristics, and higher-than-expected prevalences of psychiatric comorbidity. Although discrete pathophysiologic causes may ultimately be found in some patients with functional somatic syndromes, the suffering of these patients is exacerbated by a self-perpetuating, self-validating cycle in which common, endemic, somatic symptoms are incorrectly attributed to serious abnormality, reinforcing the patient's belief that he or she has a serious disease. Four psychosocial factors propel this cycle of symptom amplification: the belief that one has a serious disease; the expectation that one's condition is likely to worsen; the "sick role," including the effects of litigation and compensation; and the alarming portrayal of the condition as catastrophic and disabling. The climate surrounding functional somatic syndromes includes sensationalized media coverage, profound suspicion of medical expertise and physicians, the mobilization of parties with a vested self-interest in the status of functional somatic syndromes, litigation, and a clinical approach that overemphasizes the biomedical and ignores psychosocial factors. All of these influences exacerbate and perpetuate the somatic distress of patients with functional somatic syndromes, heighten their fears and pessimistic expectations, prolong their disability, and reinforce their sick role. A six-step strategy for helping patients with functional somatic syndromes is presented here.
Non-medical factors may be important determinants for granting disability pension (DP) even though disability is medically defined, as in Norway. The aim of this analysis was to identify determinants of DP in a total county population in a 10-year follow-up study.
Participants were people without DP, 20- to 66-years-old in 1984-1986. The baseline data were obtained in the Nord-Trøndelag Health Study (HUNT): 90 000 people were invited to answer questionnaires on health, disease, social, psychological, occupational, and lifestyle factors. Information on those who later received DP was obtained from the National Insurance Administration database in 1995. Data analyses were performed using Cox regression analyses.
The incidence of DP showed great variation with regards to age and gender, accounting for an overall increase in the follow-up period. Low level of education, low self-perceived health, occupation-related factors and any long-standing health problem were found to be the strongest independent determinants of DP. Low level of education and socioeconomic factors contributed more to younger people's risk compared to those over 50 years. For people under 50 years of age with a low level of education compared to those with a high level of education, the age-adjusted relative risk for DP was 6.35 for men and 6.95 for women. The multivariate-adjusted relative risk was 2.91 and 4.77, respectively.
Even for a medically based DP, low socioeconomic status, low level of education and occupational factors might be strong determinants when compared to medical factors alone. These non-medical determinants are usually not addressed by individual based health or rehabilitation programmes.
To examine the relationship between anxiety disorders and depression and various somatic health problems in the general population.
Cross-sectional study with survey methods and clinical examinations.
The Health Study of Nord-Trøndelag, Norway (the HUNT study).
60869 individuals aged 20-89 years.
Anxiety disorder, depression and their comorbidity are categorized based on scores on the Hospital Anxiety and Depression Scale. All somatic health variables are self-reported, while blood pressure, height and weight are measured. Multivariate nominal logistic regression analyses are used to investigate the relationship between somatic variables and the anxiety/depression categories.
Most somatic health variables show a stronger association with comorbid anxiety disorder/depression than with anxiety disorder or depression alone. About one-third of individuals reporting somatic health problems also have anxiety disorder and/or depression.
Somatic health problems carry a high risk of both anxiety disorder and depression. Active identification and treatment of these co-occurring mental disorders are of practical importance.
To determine prognostic factors for the duration and severity of acute symptoms in subjects with grade 1 or 2 whiplash injuries.
Collision victims presenting to a trauma centre with spinal pain or stiffness were assessed clinically (including a visual analogue scale (VAS)), radiologically, and psychologically (short form 36 (SF36), everyday life quality (EDLQ), pain control questionnaire (FSR)). Collision type and estimated DeltaV (change in velocity of the occupant's vehicle) were also assessed. Assessment at six months involved VAS symptom rating, SF36, EDLQ, depression scale (CES-D), and impact of event scale (IES).
43 consecutive collision victims (22 male, 21 female; mean age 29 years (range 19 to 72) with grade 1 or 2 whiplash associated disorders were assessed. Mean DeltaV, available for 36 of 43 collisions, was 13.9 (5 to 30) km/h. Thirty two (74%) of the subjects were available for follow up at six months. The mean duration of symptoms was 28 (1 to 180) days in this group. No correlation was found between severity and duration of symptoms and the DeltaV of collision or other collision parameters. Patients with initial pain VAS >5 or with duration of symptoms more than 28 days had significant changes in SF36, EDLQ, CES-D, and IES scores at six months, and had initial scores that were predictive of these outcomes.
Psychological factors were found to be more relevant than collision severity in predicting the duration and severity of symptoms in collision victims with grade 1 or 2 whiplash associated disorders.
The objective of our prospective inception cohort study was to identify prognostic factors for poor recovery in patients with whiplash-associated disorders grade 1 or 2 who still had neck pain and accompanying complaints 2 weeks after the accident. The study was carried out in a primary health care setting in The Netherlands and included 125 patients. The primary outcome measure was functional recovery defined in terms of neck pain intensity or work disability without medication use. The secondary outcome measures included neck pain intensity, work disability and sick leave. The outcomes were assessed at 4, 12 and 52 weeks after the accident. Prognostic factors were identified by logistic regression analyses. One year after the injury, 64% of the patients were recovered. Factors related to poor recovery were female gender, a low level of education, high initial neck pain, more severe disability, higher levels of somatisation and sleep difficulties. Neck pain intensity and work disability proved to be the most consistent predictors for poor recovery. The accuracy of the predictions of the prognostic models was high, meaning that the models adequately distinguished patients with poor recovery from those regarded as recovered. These findings add to the growing body of evidence, indicating that socio-demographic, physical and psychological factors affect short- and long-term outcome after whiplash injury. Our findings also indicate that care providers can easily identify patients at risk for poor recovery with a visual analogue scale for initial pain intensity and work-related activities.
Compensation, whether through workers' compensation or through litigation, has been associated with poor outcome after surgery; however, this association has not been examined by meta-analysis.
To investigate the association between compensation status and outcome after surgery.
We searched MEDLINE (1966-2003), EMBASE (1980-2003), CINAHL, the Cochrane Controlled Trials Register, and reference lists of retrieved articles and textbooks, and we contacted experts in the field.
The review included any trial of surgical intervention in which compensation status was reported and results were compared according to that status. No restrictions were placed on study design, language, or publication date. Studies were selected by 2 unblinded independent reviewers.
Two reviewers independently extracted data on study type, study quality, surgical procedure, outcome, country of origin, length and completeness of follow-up, and compensation type.
Two hundred eleven studies satisfied the inclusion criteria. Of these, 175 stated that the presence of compensation (workers' compensation with or without litigation) was associated with a worse outcome, 35 found no difference or did not describe a difference, and 1 described a benefit associated with compensation. A meta-analysis of 129 studies with available data (n = 20,498 patients) revealed the summary odds ratio for an unsatisfactory outcome in compensated patients to be 3.79 (95% confidence interval, 3.28-4.37 by random-effects model). Grouping studies by country, procedure, length of follow-up, completeness of follow-up, study type, and type of compensation showed the association to be consistent for all subgroups.
Compensation status is associated with poor outcome after surgery. This effect is significant, clinically important, and consistent. Because data were obtained from observational studies and were not homogeneous, the summary effect should be interpreted with caution. Compensation status should be considered a potential confounder in all studies of surgical intervention. Determination of the mechanism for this association requires further study.
To examine the association between depression and/or anxiety and cognitive function in the elderly general population.
Non-demented participants from the general population (n = 1,930) aged 72-74 years.
Symptoms and caseness of depression and anxiety disorder were assessed using the Hospital Anxiety and Depression Scale (HADS). Cognitive function was assessed by the Digit Symbol Test (modified version), the Kendrick Object Learning Test, and the 'S'-task from the Controlled Oral Word Association Test.
There was a significant association between depression and reduced cognitive function. The inverse association between anxiety and reduced cognitive performance was explained by adjustment for co-morbid depression. The inverse association between depressive symptoms and cognitive function was found to be close to linear, and was also present in the sub-clinical symptom range. Males were more affected cognitively by depressive symptoms than females.
The inverse association between depression and cognitive function is not only a finding restricted to severely ill patient samples, but it can also be found in the elderly general population.
Mental illness is consistently underrecognized in general health care, which may lead to underestimation of its effects on awards for social security payments. The authors investigated empirically the contribution of psychiatric morbidity to the award of disability pensions, in particular those awarded for physical diagnoses.
Using a historical cohort design, the authors utilized a unique link between a large epidemiological cohort study and a comprehensive national database. Baseline information on mental and physical health was gathered from a 1995-1997 population-based health study of those of working age (20-66 years) in Nord-Trøndelag County, Norway, who were not recipients of disability pension (N=45,782). The outcome assessed was the awarding of disability pensions ascribed to specific ICD-10 diagnoses within 6 to 30 months as registered in the National Insurance Administration.
Anxiety and depression were robust predictors of disability pension awards in general, even when disability pensions awarded for any mental disorder were excluded. These effects were only partly explained by baseline somatic symptoms and diagnoses and were stronger in individuals aged 20-44 than in those aged 45-66. Somatic symptoms accounted for far more disability pension awards than did somatic diagnoses.
The cost of common mental disorders in terms of disability pensions and lost productivity may have been considerably underestimated by official statistics, particularly for younger claimants. The results suggest this might be due both to overuse of physical diagnoses and underrecognition of common mental disorders in primary care.
Psychomotor disturbances can frequently be found in depressed patients and may have an important influence on the ability to drive. Additionally, effects of sedation, as seen with some antidepressants, probably impair driving performance. The present study was designed to evaluate the effects of antidepressant monotherapy on psychomotor functions related to car-driving skills in depressive patients in a routine clinical setting.
Inpatients (N = 100) who met the ICD-10 and DSM-IV criteria for major depressive disorder were tested under steady-state plasma level conditions prior to being discharged to out-patient treatment. The study ran from January 2004 through March 2005. All patients participated voluntarily and gave informed consent. According to the German guidelines for road and traffic safety, data were collected with the computerized Act & React Testsystem ART-90 and the Wiener Testsystem, measuring visual perception, reaction time, selective attention, vigilance, and stress tolerance. Psychopathologic symptoms were rated with the Hamilton Rating Scale for Depression.
Before discharge to outpatient treatment, 24% of the patients tested were without clinically relevant psychomotor disturbances. In 60% of the cases, mild to moderate impairments could be seen, and about 16% of the patients were considered as severely impaired in psychomotor functions related to car-driving abilities. Data show that patients treated with selective serotonin reuptake inhibitors (SSRIs) or the noradrenergic and specific serotonergic antidepressant (NaSSA) mirtazapine had an altogether better test performance in comparison with patients receiving tricyclic antidepressants (TCAs). Differences were most pronounced in measures of reactivity, stress tolerance, and selective attention. Statistically significant differences between patients treated with TCAs or the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine could not be found. Among the newer antidepressants there is an advantage for patients treated with mirtazapine, especially in tasks with high multi-channel perception and output demands.
About 16% of depressive patients discharged from hospital to outpatient treatment must be considered unfit to drive. In 60% of the cases, patients performed at a questionable level of fitness for driving, and it seems justified to counsel patients individually, taking into account compensational factors. Data point to an advantage for patients treated with SSRIs or mirtazapine when compared with TCAs or venlafaxine. However, causal relationships cannot be drawn from our data.
Objective: Mental illness is consistently underrecognized in general health care, which may lead to underestimation of its effects on awards for social security payments. The authors investigated empirically the contribution of psychiatric morbidity to the award of disability pensions, in particular those awarded for physical diagnoses. Method: Using a historical cohort design, the authors utilized a unique link between a large epidemiological cohort study and a comprehensive national database. Baseline information on mental and physical health was gathered from a 1995-1997 population-based health study of those of working age (20-66 years) in Nord-Trøndelag County, Norway, who were not recipients of disability pension (N=45,782). The outcome assessed was the awarding of disability pensions ascribed to specific ICD-10 diagnoses within 6 to 30 months as registered in the National Insurance Administration. Results: Anxiety and depression were robust predictors of disability pension awards in general, even when disability pensions awarded for any mental disorder were excluded. These effects were only partly explained by baseline somatic symptoms and diagnoses and were stronger in individuals aged 20-44 than in those aged 45-66. Somatic symptoms accounted for far more disability pension awards than did somatic diagnoses. Conclusions: The cost of common mental disorders in terms of disability pensions and lost productivity may have been considerably underestimated by official statistics, particularly for younger claimants. The results suggest this might be due both to overuse of physical diagnoses and underrecognition of common mental disorders in primary care.
The term functional somatic syndrome has been applied to several related syndromes characterized more by symptoms, suffering, and disability than by consistently demonstrable tissue abnormality. These syndromes include multiple chemical sensitivity, the sick building syndrome, repetition stress injury, the side effects of silicone breast implants, the Gulf War syndrome, chronic whiplash, the chronic fatigue syndrome, the irritable bowel syndrome, and fibromyalgia. Patients with functional somatic syndromes have explicit and highly elaborated self-diagnoses, and their symptoms are often refractory to reassurance, explanation, and standard treatment of symptoms. They share similar phenomenologies, high rates of co-occurrence, similar epidemiologic characteristics, and higher-than-expected prevalences of psychiatric comorbidity. Although discrete pathophysiologic causes may ultimately be found in some patients with functional somatic syndromes, the suffering of these patients is exacerbated by a self-perpetuating, self-validating cycle in which common, endemic, somatic symptoms are incorrectly attributed to serious abnormality, reinforcing the patient's belief that he or she has a serious disease. Four psychosocial factors propel this cycle of symptom amplification: the belief that one has a serious disease; the expectation that one's condition is likely to worsen; the "sick role," including the effects of litigation and compensation; and the alarming portrayal of the condition as catastrophic and disabling. The climate surrounding functional somatic syndromes includes sensationalized media coverage, profound suspicion of medical expertise and physicians, the mobilization of parties with a vested self-interest in the status of functional somatic syndromes, litigation, and a clinical approach that overemphasizes the biomedical and ignores psychosocial factors. All of these influences exacerbate and perpetuate the somatic distress of patients with functional somatic syndromes, heighten their fears and pessimistic expectations, prolong their disability, and reinforce their sick role. A six-step strategy for helping patients with functional somatic syndromes is presented here.
FEW CONDITIONS rouse emotions as quickly as a discussion of whiplash, and yet plausible explanations for the phenomenon are slowly beginning to emerge.
Neck pain is second only to low back pain as the most common musculoskeletal disorder in population surveys and primary care, and, like low back pain, it poses a significant health and economic burden, being a frequent source of disability. While most individuals with acute neck pain do not seek health care, those that do account for a disproportionate amount of health care costs. Furthermore, in the setting of the whiplash syndrome, neck pain accounts for significant costs to society in terms of insurance and litigation, and days lost from work. Much neck pain is not attributable to a specific disease or disorder and is labelled as 'soft-tissue' rheumatism or muscular/mechanical/postural neck pain. Most chronic neck pain is attributed to whiplash injury, another enigmatic diagnosis. Despite decades of research and posturing to explain chronic neck pain on the basis of a specific disease or injury, and despite increasingly sophisticated radiological assessment, little advance has been made in either achieving a specific structural diagnosis or, more importantly, in reducing the health and economic burden of chronic neck pain. There is some evidence, however, that measures which address the psychosocial factors that promote pain chronicity, and shift the patient's view away from injury and disease to more benign perspectives on their condition, may be helpful. This chapter considers briefly the magnitude of the neck pain problem, our limitations in understanding it from a traditional medical perspective, and suggestions for therapeutic and societal approaches that appear more likely to be helpful.
With the increased incidence of whiplash injury following the introduction of compulsory car seat belts, a large number of reports have dealt with the aftermath of this condition. Previous studies, however, focused on somatic symptoms on the one hand or considered only psychological or neuropsychological variables on the other hand, often in loosely defined or selected groups of patients. No study so far has analyzed the long-term outcome in a nonselected group of patients using a clear injury definition considering patient history; somatic, radiologic, and neuropsychological findings; and features of the injury mechanisms assessed soon after trauma and during follow-up. the present investigation was designed to assess these combined factors. According to a strict definition of whiplash injury, we assessed a consecutive nonselected sample of 117 patients with recent injury who had similar sociocultural and educational backgrounds. The patients had been in automobile crashes and were all equally covered by accident insurance according to the country-wide scheme. Initial examination was performed 7.2 +/- 4.2 days after trauma, and follow-up examinations 3, 6, 12, and 24 months later. At baseline, features of injury mechanism, subjective complaints, and different aspects of patient history were documented and cervical spine X rays performed. At all examinations patients underwent neurologic examination and cognitive and psychosocial factor assessment. At 2 years, patients were divided into symptomatic and asymptomatic groups and then compared with regard to the initial findings. In addition, symptomatic patients who were disabled at the 2-year follow-up examination and symptomatic patients not disabled (that is, they were able to work at the pretraumatic level) were compared regarding initial and 2-year findings. At 2 years, 18% of patients still had injury-related symptoms. With regard to baseline findings the following significant differences were found: Symptomatic patients were older, had higher incidence of rotated or inclined head position at the time of impact, had higher prevalence of pretraumatic headache, showed higher intensity of initial neck pain and headache, complained of a greater number of symptoms, had a higher incidence of symptoms of radicular deficit and higher average scores on a multiple symptom analysis, and displayed more degenerative signs (osteoarthrosis) on X ray. In addition, symptomatic patients scored higher with regard to impaired well-being and performed worse on tasks of attentional functioning and showed more concern with regard to long-term suffering and disability.(ABSTRACT TRUNCATED AT 400 WORDS) Language: en
Physicians and other therapists continue to grapple in daily practice with the controversies of the late whiplash syndrome. For decades much of the debate and the approach to this controversial syndrome has centred on the natural history of and progression to chronic pain after acute whiplash injury. Recognising that there is recent epidemiological data that defines the natural history of the acute whiplash injury outside of many of the confounding factors occurring in many western countries, and the lack of evidence for a ('chronic whiplash injury)), this article will thus introduce the biopsychosocial model, its elements, its advantages over the traditional model, and the practical application of this model. The biopsychosocial model recognises physical and psychological souces of somatic symptoms, but fundamentally recognises that the late whiplash syndrome is not the result of a "chronic injury".
Study DesignBest evidence synthesis.
ObjectiveTo perform a best evidence synthesis on the course and prognostic factors for neck pain and its associated disorders in Grades
I–III whiplash-associated disorders (WAD).
Summary of Background DataKnowledge of the course of recovery of WAD guides expectations for recovery. Identifying prognostic factors assists in planning
management and intervention strategies and effective compensation policies to decrease the burden of WAD.
MethodsThe Bone and Joint Decade 2000–2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) conducted
a critical review of the literature published between 1980 and 2006 to assemble the best evidence on neck pain and its associated
disorders. Studies meeting criteria for scientific validity were included in a best evidence synthesis.
ResultsWe found 226 articles related to course and prognostic factors in neck pain and its associated disorders. After a critical
review, 70 (31%) were accepted on scientific merit; 47 of these studies related to course and prognostic factors in WAD. The
evidence suggests that approximately 50% of those with WAD will report neck pain symptoms 1year after their injuries. Greater
initial pain, more symptoms, and greater initial disability predicted slower recovery. Few factors related to the collision
itself (for example, direction of the collision, headrest type) were prognostic; however, postinjury psychological factors
such as passive coping style, depressed mood, and fear of movement were prognostic for slower or less complete recovery. There
is also preliminary evidence that the prevailing compensation system is prognostic for recovery in WAD.
ConclusionThe Neck Pain Task Force undertook a best evidence synthesis to establish a baseline of the current best evidence on the course
and prognosis for WAD. Recovery of WAD seems to be multifactorial.
It is well recognised that patients with chronic pain, in particular, chronic whiplash-associated neck pain, exhibit psychological distress. However, debate continues as to whether the psychological distress precedes and causes the chronic pain or, conversely, the psychological distress is a consequence of chronic pain. Using cervical zygapophysial joint pain as a model for chronic pain, the effect of a definitive neurosurgical treatment on the associated psychological distress was studied. Seventeen patients with a single painful cervical zygapophysial joint participated in a randomised, double-blind, placebo-controlled trial of percutaneous radiofrequency neurotomy. Their pain and psychological status were evaluated pre-operatively and 3 months post-operatively by medical interview and examination, a visual analogue pain scale, the McGill Pain Questionnaire, and the SCL-90-R psychological questionnaire. All patients who obtained complete pain relief exhibited resolution of their pre-operative psychological distress. In contrast, all but one of the patients whose pain remained unrelieved continued to suffer psychological distress. Because psychological distress resolved following a neurosurgical treatment which completely relieved pain, without psychological co-therapy, it is concluded that the psychological distress exhibited by these patients was a consequence of the chronic somatic pain.
Up to one in eight of the working age population receives permanent disability benefits. As little is known about the consequences of this major event, analysis aimed to compare health status before and after disability pension award.
Data from the population based Hordaland Health Study (HUSK) in Norway 1997-99 (n = 18 581) were linked to official disability benefits registries. The study identified 1087 participants who were awarded a disability pension before, during and after the health survey. These were grouped into different strata defined by temporal proximity between disability pension award and health survey participation. The study then compared health status across these strata covering the 7 years before to the 7 years after the award.
The study found an inverse U-shaped trend with an increase in reported symptoms (anxiety, depression, pain distribution, sleep problems and somatic symptoms) approaching the award, and a reversing of this trajectory afterwards (p<0.05 for the non-linear trend for all symptoms). We found no similar trend for the more objective health measures blood pressure, physical diagnoses and prescribed medication. For most measures, similar levels of health problems were found 3-7 years before compared to 3-7 years after the award.
When comparing the strata defined by time to the event of disability pension award, there was an increase in symptoms around the time of the disability pension award, with a subsequent return towards pre-award levels. The design precludes any firm conclusions as to what causes the observed results, but possible explanations include temporary adverse health effects from the process itself, the beneficial effects of being removed from harmful work conditions, and recovery after increasing health problems leading up to disability pension award.
The long-term effect of anxiety and depression on blood pressure is unclear.
To examine the prospective association of anxiety and depression with change in blood pressure in a general population.
Data on 36 530 men and women aged 20-78 years participating in the Nord-Trøndelag Health Study (HUNT) in Norway in 1984-86 were re-examined 11 years later.
A high symptom level of anxiety and depression at baseline predicted low systolic blood pressure (< 10th percentile) at follow-up (OR=1.30, 95% CI 1.08-1.57) when those with low systolic blood pressure at baseline were excluded. Change in symptom level of anxiety and depression between baseline and follow-up was inversely associated with change in systolic blood pressure. For diastolic blood pressure, the findings were weaker or non-significant.
Symptoms of anxiety and depression predicted lower blood pressure 11 years later.
Misconceptions about whiplash injury and its common course are discussed. Different patient populations appear to suffer to varying degrees and social copying is evident in certain groups--features shared with the Australian 1983 to 1985 'epidemic' of 'repetitive strain syndrome'. Psychosocial factors and overtreatment delay recovery. Family physicians have the opportunity to properly assess and manage most patients. Wasteful therapy must be discouraged, and self care and patient responsibility encouraged.
With the increased incidence of whiplash injury following the introduction of compulsory car seat belts, a large number of reports have dealt with the aftermath of this condition. Previous studies, however, focused on somatic symptoms on the one hand or considered only psychological or neuropsychological variables on the other hand, often in loosely defined or selected groups of patients. No study so far has analyzed the long-term outcome in a nonselected group of patients using a clear injury definition considering patient history; somatic, radiologic, and neuropsychological findings; and features of the injury mechanisms assessed soon after trauma and during follow-up. the present investigation was designed to assess these combined factors. According to a strict definition of whiplash injury, we assessed a consecutive nonselected sample of 117 patients with recent injury who had similar sociocultural and educational backgrounds. The patients had been in automobile crashes and were all equally covered by accident insurance according to the country-wide scheme. Initial examination was performed 7.2 +/- 4.2 days after trauma, and follow-up examinations 3, 6, 12, and 24 months later. At baseline, features of injury mechanism, subjective complaints, and different aspects of patient history were documented and cervical spine X rays performed. At all examinations patients underwent neurologic examination and cognitive and psychosocial factor assessment. At 2 years, patients were divided into symptomatic and asymptomatic groups and then compared with regard to the initial findings. In addition, symptomatic patients who were disabled at the 2-year follow-up examination and symptomatic patients not disabled (that is, they were able to work at the pretraumatic level) were compared regarding initial and 2-year findings. At 2 years, 18% of patients still had injury-related symptoms. With regard to baseline findings the following significant differences were found: Symptomatic patients were older, had higher incidence of rotated or inclined head position at the time of impact, had higher prevalence of pretraumatic headache, showed higher intensity of initial neck pain and headache, complained of a greater number of symptoms, had a higher incidence of symptoms of radicular deficit and higher average scores on a multiple symptom analysis, and displayed more degenerative signs (osteoarthrosis) on X ray. In addition, symptomatic patients scored higher with regard to impaired well-being and performed worse on tasks of attentional functioning and showed more concern with regard to long-term suffering and disability.(ABSTRACT TRUNCATED AT 400 WORDS)
In Lithuania, few car drivers and passengers are covered by insurance and there is little awareness among the general public about the potentially disabling consequences of a whiplash injury. We took this opportunity to study the natural course of head and neck symptoms after rear-end car collisions.
In a retrospective questionnaire-based cohort study, 202 individuals (157 men; 45 women) were identified from the records of the traffic police department in Kaunas, Lithuania. These individuals were interviewed 1-3 years after experiencing a rear-end car collision. Neck pain, headache, subjective cognitive dysfunction, psychological disorders, and low back pain in this group were compared with the same complaints in a sex-matched and age-matched control group of uninjured individuals selected randomly from the population register of the same geographic area.
Neck pain was reported by 71 (35% [95% CI 29-42]) accident victims and 67 (33% [27-40]) controls. Headache was reported by 107 (53% [46-60]) accident victims and 100 (50% [42-57]) controls. Chronic neck pain and chronic headache (more than 7 days per month) were also reported in similar proportions (17 [8.4%; 5-13] vs 14 [6.9%; 4-12] and 19 [9.4%; 6-15] vs 12 [5.9%; 3-10]) by the two groups. Of those who reported chronic neck pain or daily headache after the accident, substantial proportions had had similar symptoms before the accident (7/17 for chronic neck pain; 10/12 for daily headache). There was no significant difference found. No one in the study group had disabling or persistent symptoms as a result of the car accident. There was no relation between the impact severity and degree of pain. A family history of neck pain was the most important risk factor for current neck symptoms in logistic regression analyses.
Our results suggest that chronic symptoms were not usually caused by the car accident. Expectation of disability, a family history, and attribution of pre-existing symptoms to the trauma may be more important determinants for the evolution of the late whiplash syndrome.
Empirical results from epidemiological studies on pain-depression comorbidity in primary care and population samples have shown that: (a) pain is as strongly associated with anxiety as with depressive disorders; (b) characteristics that most strongly predict depression are diffuseness of pain and the extent to which pain interferes with activities; (c) certain psychological symptoms (low energy, disturbed sleep, worry) are prominent among pain patients, while others (guilt, loneliness) are not; (d) depression and pain dysfunction are evident early in the natural history of pain, but dysfunction and distress are often transient; and (e) among initially dysfunctional pain patients whose dysfunction is chronic, depression levels do not improve but neither do they increase over time with chronicity alone. These results seem consistent with these mechanisms of pain-depression comorbidity; (1) a trait of susceptibility to both dysphoric physical symptoms (including pain) and psychological symptoms (including depression), and a state of somatosensory amplification in which psychological distress amplifies dysphoric physical sensations (including pain); (2) psychological illness and behavioural dysfunction being interrelated features of a maladaptive response to pain evident early in the natural history of the condition, and often resolving during an early recovery phase; (3) pain constituting a significant physical and psychological stressor that may induce or exacerbate psychological distress. Thus, pain and psychological illness should be viewed as having reciprocal psychological and behavioural effects involving both processes of illness expression and adaption, as well as pain having specific effects on emotional state and behavioural function.
Psychological factors have been alleged to be important in the course and outcome of 'whiplash' neck injury but there is little quantitative evidence. This study uses quantitative methods involving a prospective interview assessment to describe psychological and quality of life predictors, and 3 and 12 month outcome. Consecutive attenders to the Accident and Emergency department of a teaching district hospital with a clinical diagnosis of 'whiplash' neck injury were included and there were follow-up interviews at home. Neck symptoms were recorded, and there was a standard mental-state interview with added questions about post-traumatic symptoms and a semi-structured interview for disability and consequences for quality of life. There was a wide individual variation in course and outcome; the majority of subjects complained of persistent neck symptoms and a sizeable minority reported specific post-traumatic psychological symptoms (intrusive memory, phobic travel anxiety), similar to those described by patients suffering multiple injuries. Social impairment, including effects on travel, were considerable in one-quarter. Reports of persistent neck symptoms were not associated with any baseline psychological variables or with compensation proceedings; psychological factors appeared to be more important in determining the extent of social impairment. We conclude that travel, social and psychological morbidity is substantially greater than previously recognized.
To study driver suicides, all motor vehicle driver fatalities in Finland from 1987 to 1991 were analysed.
Cases were collected from all driver fatalities (n = 1419), as those that accident investigation teams considered possible suicides (n = 99). Drivers committing suicide classified according to ICD-9 by two forensic pathologists were selected as cases (n = 84). Drivers of unintentional motor vehicle fatalities served as the control group.
While 5.9% of all driver fatalities were classified as suicides, the figure given in the official statistics was 2.6%. Driver suicides accounted for 1.2% of all suicides. Fifty per cent of driver suicides were committed by men aged between 15 and 34 years. The victims had often suffered from life-event stress, mental disorders and had alcohol misuse problems. The cases were usually head-on collisions between two vehicles with a large weight disparity.
Misclassification of driver suicides does not significantly influence the total suicide rate. However, people who commit suicide by this method could often be recognised, and prevention of these events would improve traffic safety.
In countries with a very low or non-existent prevalence of late whiplash syndrome, accident victims do not routinely hear reports of acute whiplash injury leading to chronic symptoms or disability. They do not witness such behaviour in others, and do not thereby have any expectation of such possibilities. They do not engage in a process that encourages hypervigilance for and attention to symptoms,thus eliminating many factors that promote symptom amplification. They also do not engage in a process that engenders anxiety, frustration, and resentment (that is, battling with insurance companies and proving that your pain is real). They do not change their activity in response to what they, after all, view as a minor injury. They will not amplify pre-accident symptoms, or symptoms or amplify daily life's aches and pains. They will not attribute all these different sources of symptoms to chronic damage they believe the accident caused. There is no cultural information to encourage this chronic pain behaviour being seen in other cultures.
A study was set up to determine the trends in medical impairment and work disability ratings for persons affected by whiplash associated disorders (WAD) and other injuries secondary to road traffic collisions, and into the influence of age, gender, professional status, and final medical impairment rating on final work disability. A cross-sectional study was carried out of insurance files of 2,523 subjects in 1989 and 3,223 subjects in 1994 judged to have a permanent medical impairment of 10% or more and work disability due to road traffic injury. Files were obtained from the Swedish Road Traffic Injury Commission. The main outcome measures were the crude frequency and age-specific, standardized percentage of traffic injuries with a medical impairment of 10% or more for the years 1989 and 1994. Final work disability status was analysed with respect to age, gender, type of injury, degree of medical impairment, and professional status. The proportion of medical impairment due to WAD was found to have increased from 16% in 1989 to 28% in 1994, but the proportion of work disability was found to have remained the same. Age over 40 years, low professional status, and having a medical impairment judgement of 15% or more were independently associated with reduced or full work disability.
IT IS A CONTRADICTION that neck strain caused by a rear-end car collision may leave the victim with chronic symptoms and disability, whereas the comparable jolting and neck strain of the offending driver or in the context of a sport1 will cause no lasting symptoms. Is this the reaction of a susceptible patient to a painful injury for which someone is responsible and who, entangled in the adversary system, is examined repeatedly, overtreated, and subjected to the negative effects and disincentives of secondary gain and the illness role? Or is it simply the result of injury to the neck, inner ear, brain, or other structures that newer and more sensitive investigations eventually will demonstrate?
OF CONCERN to a neurologist, when faced with a patient with whiplash injury, is whether the patient has a neurological injury and, if not, whether the patient's complaint is genuine.1 +Barnsley
LLord
SBogduk
N The pathophysiology of whiplash. Malanga
GAedsCervical Flexion-Extension/Whiplash Injuries. Spine State of the Art Reviews. Vol 12 Philadelphia, Pa Hanley & Belfus1998;209- 2422 +Radanov
BPSturzenegger
MDi Stefano
G Long-term outcome after whiplash injury: a 2-year follow-up considering features of injury mechanism and somatic, radiologic, and psychosocial findings. Medicine. 1995;74281- 297Link to Article[[XSLOpenURL/10.1097/00005792-199509000-00005]]3 +Hoffman
JRSchriger
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JSZucker
M Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study. Ann Emerg Med. 1992;211454- 1460Link to Article[[XSLOpenURL/10.1016/S0196-0644(05)80059-9]]4 +Kaneoka
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K Motion analysis of cervical vertebrae during whiplash loading. Spine. 1999;2433Link to Article[[XSLOpenURL/10.1097/00007632-199904150-00006]]5 +Jonsson
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W Findings and outcomes in whiplash-type neck distortions. Spine. 1994;192733- 2743Link to Article[[XSLOpenURL/10.1097/00007632-199412150-00001]]6 +Taylor
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LT Acute injuries to cervical joints: an autopsy study of neck sprain. Spine. 1993;181115- 1122Link to Article[[XSLOpenURL/10.1097/00007632-199307000-00001]]7 +Barnsley
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N The prevalence of chronic cervical zygapophysial joint pain after whiplash. Spine. 1995;2020- 26Link to Article[[XSLOpenURL/10.1097/00007632-199501000-00004]]8 +Lord
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BJBogduk
N Chronic cervical zygapophysial joint pain after whiplash: a placebo-controlled prevalence study. Spine. 1996;211737- 1745Link to Article[[XSLOpenURL/10.1097/00007632-199608010-00005]]9 +Gibson
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N Cervical zygapophyseal joint pain in whiplash injuries. Malanga
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CL Acute whiplash injury: is there a role for MR imaging? a prospective study of 100 patients. Radiology. 1996;20193- 96Link to Article[[XSLOpenURL/10.1148/radiology.201.1.8816527]]16 +Seitz
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N Percutaneous radiofrequency neurotomy of the cervical medial branches: a validated treatment for cervical zygapophysial joint pain. Neurosurg Q. 1998;8288- 308Link to Article[[XSLOpenURL/10.1097/00013414-199812000-00004]]20 +McDonald
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KF Course of psychological variables in whiplash injury—a 2-year follow-up with age, gender and education pair-matched patients. Pain. 1996;64429- 434Link to Article[[XSLOpenURL/10.1016/0304-3959(95)00148-4]]24 +Radanov
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The incidence and prognosis of whiplash injury from motor vehicle collisions may be related to eligibility for compensation for pain and suffering. On January 1, 1995, the tort-compensation system for traffic injuries, which included payments for pain and suffering, in Saskatchewan, Canada, was changed to a no-fault system, which did not include such payments. To determine whether this change was associated with a decrease in claims and improved recovery after whiplash injury, we studied a population-based cohort of persons who filed insurance claims for traffic injuries between July 1, 1994, and December 31, 1995.
Of 9006 potentially eligible claimants, 7462 (83 percent) met our criteria for whiplash injury. The six-month cumulative incidence of claims was 417 per 100,000 persons in the last six months of the tort system, as compared with 302 and 296 per 100,000, respectively, in the first and second six-month periods of the no-fault system. The incidence of claims was higher for women than for men in each period; the incidence decreased by 43 percent for men and by 15 percent for women between the tort period and the two no-fault periods combined. The median time from the date of injury to the closure of a claim decreased from 433 days (95 percent confidence interval, 409 to 457) to 194 days (95 percent confidence interval, 182 to 206) and 203 days (95 percent confidence interval, 193 to 213), respectively. The intensity of neck pain, the level of physical functioning, and the presence or absence of depressive symptoms were strongly associated with the time to claim closure in both systems.
The elimination of compensation for pain and suffering is associated with a decreased incidence and improved prognosis of whiplash injury.
Time-to-claim-closure is a common outcome in cohort studies of whiplash injuries. However, its relationship to health recovery is unknown. We investigated the association between neck pain, physical functioning, depressive symptomatology and time-to-claim-closure in a Saskatchewan cohort of 5398 whiplash claimants in 1994-1995. Participants were surveyed five times over 1 year. In 1995, the insurance system changed from tort to no-fault, eliminating compensation for pain and suffering. Under tort, a 10-point increase in pain reduced the claim-closure rate by 13-24% while a 10-point increase in physical functioning increased it by 17%. Depressive symptomatology reduced the claim-closure rate by 37%. Under no-fault, a 10-point increase in pain reduced the claim-closure rate by 18% while a 10-point increase in physical functioning increased it by 10-35%. The presence of depressive symptomatology reduced the claim-closure rate by 36%. The results suggests lower pain, better function and the absence of depressive symptoms are strongly associated with faster time-to-claim-closure and recovery after whiplash, independent of the insurance system.
Physicians and other therapists continue to grapple in daily practice with the controversies of the late whiplash syndrome. For decades much of the debate and the approach to this controversial syndrome has centred on the natural history of and progression to chronic pain after acute whiplash injury. Recognising that there is recent epidemiological data that defines the natural history of the acute whiplash injury outside of many of the confounding factors occurring in many western countries, and the lack of evidence for a "chronic whiplash injury", this article will thus introduce the biopsychosocial model, its elements, its advantages over the traditional model, and the practical application of this model. The biopsychosocial model recognises physical and psychological sources of somatic symptoms, but fundamentally recognises that the late whiplash syndrome is not the result of a "chronic injury".
This study reports results of a large-scale epidemiological investigation of the prevalence of mental disorder in Oslo.
A random sample of Oslo residents age 18-65 years was drawn from the Norwegian National Population Register. A total of 2,066 subjects, 57.5% of the original sample, were interviewed with the Composite International Diagnostic Interview in 1994-1997. The mean age of the interviewed subjects was 39.3 years.
The 12-month prevalence of all mental disorders was 32.8%, and the lifetime prevalence was 52.4%. Alcohol abuse/dependence and major depression had the highest lifetime prevalence and 12-month prevalences. All mental disorders were more prevalent in women than in men, with the exception of alcohol and drug abuse/dependence. Severe psychopathology (e.g., three or more diagnoses) was found in 14%-15% of the respondents. The lifetime and 12-month prevalences for all diagnostic categories except drug abuse/dependence were similar to those found in the United States Comorbidity Survey.
Epidemiological data for Oslo show that the lifetime and 12-month prevalences of mental disorder are quite high, with alcohol abuse/dependence and major depression particularly frequent. The rates for women are higher than those for men for all diagnostic categories, except for alcohol and drug abuse/dependence.
The Hospital Anxiety and Depression (HAD) rating scale is a commonly used questionnaire. Former studies have given inconsistent results as to the psychometric properties of the HAD scale.
To examine the psychometric properties of the HAD scale in a large population.
All inhabitants aged 20-89 years (n=92 100) were invited to take part in The Nord-Trøndelag Health Study, Norway. A total of 65 648 subjects participated, and only completed HAD scale forms (n=51 930) formed the basis for the psychometric examinations.
Principal component analysis extracted two factors in the HAD scale that accounted for 57% of the variance. The anxiety and depression sub-scales shared 30% of the variance. Both subscales were found to be internally consistent, with values of Cronbach's coefficient (alpha) being 0.80 and 0.76, respectively.
Based on data from a large population, the basic psychometric properties of the HAD scale as a self-rating instrument should be considered as quite good in terms of factor structure, intercorrelation, homogeneity and internal consistency.
To review the literature of the validity of the Hospital Anxiety and Depression Scale (HADS).
A review of the 747 identified papers that used HADS was performed to address the following questions: (I) How are the factor structure, discriminant validity and the internal consistency of HADS? (II) How does HADS perform as a case finder for anxiety disorders and depression? (III) How does HADS agree with other self-rating instruments used to rate anxiety and depression?
Most factor analyses demonstrated a two-factor solution in good accordance with the HADS subscales for Anxiety (HADS-A) and Depression (HADS-D), respectively. The correlations between the two subscales varied from.40 to.74 (mean.56). Cronbach's alpha for HADS-A varied from.68 to.93 (mean.83) and for HADS-D from.67 to.90 (mean.82). In most studies an optimal balance between sensitivity and specificity was achieved when caseness was defined by a score of 8 or above on both HADS-A and HADS-D. The sensitivity and specificity for both HADS-A and HADS-D of approximately 0.80 were very similar to the sensitivity and specificity achieved by the General Health Questionnaire (GHQ). Correlations between HADS and other commonly used questionnaires were in the range.49 to.83.
HADS was found to perform well in assessing the symptom severity and caseness of anxiety disorders and depression in both somatic, psychiatric and primary care patients and in the general population.
The purpose of this study was to explore whether self-reported whiplash traumas were associated with increased prevalence of anxiety disorder and depression. A cross-sectional design (N = 61,110) based on data from the health study (HUNT-II) was used. Anxiety and depression were measured with the Hospital Anxiety and Depression Scale (HADS). A positive association was found between whiplash traumas and anxiety disorder and depression in traumas that happened more than 2 years ago, but not in more recent whiplash traumas. Some of the association between whiplash traumas and anxiety and depression is due to neck pain and headache. Two different explanations, the "memory bias" and the "attribution" hypothesis, are discussed as explanations of these results.
Neck pain is second only to low back pain as the most common musculoskeletal disorder in population surveys and primary care, and, like low back pain, it poses a significant health and economic burden, being a frequent source of disability. While most individuals with acute neck pain do not seek health care, those that do account for a disproportionate amount of health care costs. Furthermore, in the setting of the whiplash syndrome, neck pain accounts for significant costs to society in terms of insurance and litigation, and days lost from work. Much neck pain is not attributable to a specific disease or disorder and is labelled as 'soft-tissue' rheumatism or muscular/mechanical/postural neck pain. Most chronic neck pain is attributed to whiplash injury, another enigmatic diagnosis. Despite decades of research and posturing to explain chronic neck pain on the basis of a specific disease or injury, and despite increasingly sophisticated radiological assessment, little advance has been made in either achieving a specific structural diagnosis or, more importantly, in reducing the health and economic burden of chronic neck pain. There is some evidence, however, that measures which address the psychosocial factors that promote pain chronicity, and shift the patient's view away from injury and disease to more benign perspectives on their condition, may be helpful. This chapter considers briefly the magnitude of the neck pain problem, our limitations in understanding it from a traditional medical perspective, and suggestions for therapeutic and societal approaches that appear more likely to be helpful.
Alcohol impairment of drivers is considered the most important contributing cause of car crash injuries. The burden of injury attributable to drinking drivers has been estimated only indirectly.
We conducted a population-based case-control study in Auckland, New Zealand between April 1998 and July 1999. Cases were 571 car drivers involved in crashes in which at least 1 occupant was admitted to the hospital or killed. Control subjects were 588 car drivers recruited on public roads, representative of driving in the region during the study period. Participants completed a structured interview and had blood or breath alcohol measurements.
Drinking alcohol before driving was strongly associated with injury crashes after controlling for known confounders. This was true for several measures of alcohol consumption: for self-report of 2 or more 12-g alcoholic drinks in the preceding 6 hours compared with none, the odds ratio (OR) was 7.9 (95% confidence interval = 3.4-18); for blood alcohol concentration 3 to 50 mg/100 mL compared with <3 mg/100 mL, the OR was 3.2 (1.1-10); and for blood alcohol concentration greater than 50 mg/100 mL compared with <3 mg/100 mL, the OR was 23 (9-56). Approximately 30% of car crash injuries in this population were attributable to alcohol, with two-thirds involving drivers with blood alcohol concentration in excess of 150 mg/100 mL. Equal proportions of alcohol-related injury crashes were attributable to drivers with blood alcohol concentrations of 3 to 50 mg/100 mL as those with levels of 51 to 150 mg/100 mL.
Evidence about the proportion of crashes attributable to drivers at different blood alcohol concentrations can inform the prioritization of interventions that target different groups of drivers. These data indicate where there is the most potential for reduction of the injury burden.
Somatic symptoms are prevalent in the community, but at least one third of the symptoms lack organic explanation. Patients with such symptoms have a tendency to overuse the health care system with frequent consultations and have a high degree of disability and sickness compensation. Studies from clinical samples have shown that anxiety and depression are prevalent in such functional conditions. The aim of this study is to examine the connection between anxiety, depression, and functional somatic symptoms in a large community sample.
The HUNT-II study invited all inhabitants aged 20 years and above in Nord-Trondelag County of Norway to have their health examined and sent a questionnaire asking about physical symptoms, demographic factors, lifestyle, and somatic diseases. Anxiety and depression were recorded by the Hospital Anxiety and Depression Scale. Of those invited, 62,651 participants (71.3%) filled in the questionnaire. A total of 10,492 people were excluded due to organic diseases, and 50,377 were taken into the analyses.
Women reported more somatic symptoms than men (mean number of symptoms women/men: 3.8/2.9). There was a strong association between anxiety, depression, and functional somatic symptoms. The association was equally strong for anxiety and depression, and a somewhat stronger association was observed for comorbid anxiety and depression. The association of anxiety, depression, and functional somatic symptoms was equally strong in men and women (mean number of somatic symptoms men/women in anxiety: 4.5/5.9, in depression: 4.6/5.9, in comorbid anxiety and depression: 6.1/7.6, and in no anxiety or depression: 2.6/3.6) and in all age groups. The association between number of somatic symptoms and the total score on Hospital Anxiety and Depression Scale was linear.
There was a statistically significant relationship between anxiety, depression, and functional somatic symptoms, independent of age and gender.
A prospective study of 135 patients with whiplash injury.
To identify factors predictive of prolonged disability following whiplash injury.
Although patients with whiplash associated disorders lack demonstrable physical injury, many exhibit prolonged disability. Disability appears unrelated to the severity of the collision.
A total of 147 patients with recent whiplash injury were interviewed for putative risk factors for disability, and 135 were reinterviewed 12 months later to assess degree and duration of disability. Bivariate and multivariate analyses were undertaken to measure the association between putative risk factors and measures of outcome (change in Neck Pain Outcome Score [NPOS] and visual analogue pain score [VAPS], return to work, still requiring treatment, settlement of claim).
The bodily pain score and role emotional scores of the Short Form-36 health questionnaire showed a consistent significant positive association with better outcomes. After adjustment for bodily pain score and role emotional scores, consulting a lawyer was associated with less improvement in NPOS (P < 0.05), but there was no association with change in VAPS. Consulting a lawyer was associated with a lesser chance of claim settlement (P < 0.01) and a greater chance of still having treatment (P < 0.01) after 1 year, but there was no significant association with a return to work. The degree of damage to the vehicle was not a predictor of outcome.
Short Form-36 scores for bodily pain and role emotional are useful means of identifying patients at risk of prolonged disability. The findings support the implementation of an insurance system designed to minimize litigation.
The aim of this study was to examine the impact of the first myocardial infarction (MI) and the relative influence of preexisting confounding factors on anxiety and depression in the following 5 years.
A total of 23,693 participants, 35-79 years of age at baseline, attended two population-based prospective studies in 1984-1986 and in 1995-1997. They underwent physical examination and self-reported demographic, lifestyle, psychosocial, and medical health characteristics in both surveys. Outcome measure was the Hospital Anxiety and Depression rating Scale (HADS).
Five hundred twelve participants suffered their first MI in the last 5 years before follow-up. Women showed an increased risk for both anxiety and depression in the first 2 years post-MI, followed by a significant symptom reduction. In contrast, the risk for depression in men increased after 2 years post-MI. Anxiety and depression, low educational level, obesity, daily smoking, and physical inactivity pre-MI significantly predicted a poor psychiatric outcome at follow-up.
Five-year follow-up after MI revealed gender-specific outcomes of anxiety and depression not previously described.
Chronic insomnia is common in the general population. Its effect on functioning and disability is usually attributed to an
underlying condition, so the diagnosis of insomnia does not qualify for award of a disability pension in the United States
or Europe. The aim of this study was to investigate whether insomnia, defined according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, contributed to long-term work disability. Using a historical cohort design, the authors gathered baseline
data from a population-based Norwegian health study of 37,308 working-age people not claiming a disability pension through
1995–1997. The outcome was subsequent award of a disability pension (18–48 months after the health screening) as registered
by the National Insurance Administration. Insomnia was a strong predictor of subsequent permanent work disability (adjusted
odds ratio = 3.90, 95% confidence interval: 3.20, 4.76). Sociodemographic and shift-work characteristics had little confounding
effect (adjusted odds ratio = 3.69, 95% confidence interval: 3.00, 4.53), and this association remained significant after
adjustment for psychiatric and physical morbidity and for health-related behaviors (adjusted odds ratio = 1.75, 95% confidence
interval: 1.40, 2.20). This study suggests that insomnia should receive increased attention as a robust predictor of subsequent
work disability.
Population-based incidence cohort.
To report the incidence, timing, and course of depressive symptoms after whiplash.
Evidence is conflicting about the frequency, time of onset, and course of depressive symptoms after whiplash.
Adults making an insurance claim or seeking health care for traffic-related whiplash were followed by telephone interview at 6 weeks, and 3, 6, 9, and 12 months post-injury. Depressive symptoms were assessed at baseline and at each follow-up.
Of the 5,211 subjects reporting no pre-injury mental health problems, 42.3% (95% confidence interval, 40.9-43.6) developed depressive symptoms within 6 weeks of the injury, with subsequent onset in 17.8% (95% confidence interval, 16.5-19.2). Depressive symptoms were recurrent or persistent in 37.6% of those with early post-injury onset. Pre-injury mental health problems increased the risk of later onset depressive symptoms and of a recurrent or persistent course of early onset depressive symptoms.
Depressive symptomatology after whiplash is common, occurs early after the injury, and is often persistent or recurrent. This suggests that, like neck pain and headache, depressed symptomatology is part of the cluster of acute whiplash symptoms. Clinicians should be aware of both physical and psychologic injuries after traffic collisions.