There were one or two really stand out ‘practice changing’ moments for me when I first started exploring the literature on whiplash injury: one is the research on oculomotor control in neck pain (see here) and the other – which we’ll be discussing here – is the role of the post traumatic stress reaction following trauma.
I really can’t emphasise enough what a difference this has made to my practice and I don’t think this should only be the concern of those clinicians working with motor vehicle collisions / whiplash injury.
At any one time many of us will meet individuals who have experienced physical trauma in the home, recreational or sports setting and the ability to screen for potential stress reactions is just as important there.
The bottom line here is that if your patient has a post traumatic stress reaction and this has not been recognised, they are at high risk of poor physical recovery. So it naturally follows that it is critical that clinicians are confident screening for this condition.
In this blog post I will review the role of psychological risk factors following whiplash injury and highlight formal, questionnaire based screening methods to detect them.
Note that this is the second blog post in a series of three on predicting and managing risk of poor recovery following whiplash injury. In the previous blog post here I discussed those factors that can be gleaned from the history and clinical examination that appear to impact on prognosis.
We saw that physical / mechanical aspects of the trauma do not appear to be related to recovery whereas high initial pain intensity, disability and widespread mechanical and local cold hyperalgesia do appear to be related.
In the third and final blog post in this series here I examine current thinking around managing individuals at risk of poor recovery. I will also suggest ways that we can screen for these problems in a busy clinic. If you are wondering about pathology and how it impacts prognosis then look here.
Let’s slip inside the eye of the mind…
Presenting signs and symptoms – psychological impairment
Carroll et al (2008) found that psychological factors are prognostic of recovery in whiplash injury with passive coping, helplessness, fear of movement, catastrophising and anxiety all predicting slower recovery.
Catastrophising appears to have a significant effect on recovery (Walton et al. 2009) with negative expectancies, increased attention to pain sensations (‘rumination’), less effective coping strategies (eg activity reduction) and endogenous opioid dysregulation all possible pathways to poor outcome (Sullivan et al 2011).
Fear of movement also appears to contribute to the relationship between pain and disability post whiplash injury (Kamper et al. 2012). Depressive symptoms appear to play no role in outcome (Walton et al. 2009).
Williamson et al’s systematic review of psychological risk factors (2008) concluded that decreased self-efficacy (‘confidence to perform activities despite pain’) and a post-traumatic stress reaction are predictive of poor recovery but identified no other prognostic psychological factors. Sterling and Kenardy (2008) have suggested a score of > 25 on the Impact of Event Scale questionnaire (IES), a measure of post-traumatic reaction, indicates risk of poor recovery.
In one study utilising a group based trajectory model at three months post whiplash, 22% of participants met the criteria for a probable PTSD diagnosis with this percentage decreasing to 17% at 12 months (Sterling et al 2010). Sterling has noted that these data are surprisingly similar to that documented for people with more severe traumatic injury that requires hospitalisation or admission to intensive care (Sterling and Kenardy 2011).
In a prospective cohort followed up for three years, age, NDI score, cold hyperalgesia and post-traumatic stress symptoms measured at 4 weeks had a classification rate of 60% for this group of non-recovered ‘high pain and disability’ subjects at 3 years (Sterling, Jull, and Kenardy 2006).
In the latter study ‘at risk’ subjects presented with high levels of pain, high levels of disability, an unresolved post-traumatic stress response and increased sensitivity to both mechanical pressure at areas removed from the site of injury (reduced pressure pain threshold) and cold stimuli (cold hyperalgesia). This group has been described as having, ‘complex whiplash’ (Sterling and Kenardy 2008).
As discussed previously here, a recent study has derived a clinical prediction rule for identifying recovery and non-recovery that includes age, the NDI Score and the hyper-arousal sub-scale of the Post-traumatic Diagnostic Scale (PDS): an individual who meets the following three criteria is likely to develop moderate/severe disability: NDI > 40%, age > 35 years and > 6 on the hyper-arousal sub-scale of the PDS (Ritchie et al. 2013, Foa et al. 1997). Hyper-arousal symptoms include feelings of irritability, being easily startled and increased sweating. Conversely, an individual who meets the following two criteria is likely to fully recover: NDI < 32% and age < 35 years.
Screening for risk of poor recovery in the clinic
Table 1 (below) lists those factors that appear to be strongly predictive of poor recovery following whiplash injury. The list includes those factors derived from the history and clinical examination (see the first blog post in this series here).
|Less than post-secondary education
Failure to wear a seatbelt
Post injury pain > 5.5/10
Number and severity of injury related symptoms
Presence of radicular signs and symptoms
Post injury headache
Post injury low back pain
Neck Disability Index score > 40%
Post traumatic stress symptoms
Reduced pressure pain threshold at shin
Cervical spine cold hyperalgesia
Table 1: Risk factors for poor recovery following whiplash injury.
The subjective self-report aspects (eg pain levels, sites of injury etc.) are easily assessed in the clinic. Assessing disability levels, screening for neuropathic pain, post-traumatic stress reactions and catastrophisation requires the use of standardised, validated questionnaires (Table 2).
An interactive Neck Disability Index that sums the total automatically is available on-line here. To download and print see here. The Pain Catastrophising Scale is now (sadly) only available through a licensing arrangement here.
A logical evidence based pathway for screening for poor recovery would be: if NDI > 40% then screen for a) posttraumatic stress response and b) widespread hyperalgesia (PPT’s at shin – algometer) and c) cold hyperalgesia at the neck (thermoroller / ice pack).
|Neck Disability Index||Disability measure||> 40% suggests increased risk of poor recovery|
|S-LANSS||Neuropathic Pain measure||> 12 suggests increased risk of poor recovery|
|Impact of Event Scale||Post Traumatic Stress Reaction Screen||> 26 more than 6 weeks post injury suggests increased risk of poor recovery|
|Pain Catastrophising Scale||Catastrophising||> 30 ‘clinically relevant levels’|
Table 2. Identifying poor outcome following whiplash injury.
Take Home Massages
So, how to negotiate this mass of questionnaires and physical tests?
Let’s remind ourselves what our goal is: to identify those at risk of poor recovery as early as possible to prevent persistent problems in the future.
The bottom line appears to be that it is psychological factors that have the greatest impact on recovery.
With this in mind I would suggest as a first step using the Neck Disability Index score as a general measure of improvement and if this remains elevated (> 40%) six weeks post trauma, then consider if this particular individual has any symptoms of a post traumatic stress reaction (e.g. easily startled, irritability, nightmares about trauma, excessive sweating). Such questions can be asked in an informal manner during the subjective examination or during treatment and perhaps followed up more formally with the Impact of Event Scale questionnaire if deemed appropriate.
The same then follows for fear of movement and catastrophisation, but in my view it is definitely worthwhile screening for post traumatic stress reactions as a priority.
I would also suggest assessing physical sensitivity both in the painful area and at an uninjured site (e.g. front of shins).
As discussed in the preamble to this post, I have found it invaluable to integrate screening for post traumatic stress reactions into my clinical work, but there is one important point to note: don’t screen prior to six weeks post-trauma. Before this time stress-levels can be raised and may be settling naturally with time.
In the third and final blog post in this series here I discuss current thinking around managing those at risk of poor recovery.
Carroll, Linda J., Lena W. Holm, Sheilah Hogg-Johnson, Pierre Cote, J. David Cassidy, Scott Haldeman, Margareta Nordin, Eric L. Hurwitz, Eugene J. Carragee, Gabrielle van der Velde, Paul M. Peloso, and Jaime Guzman. 2008. “Course and prognostic factors for neck pain in whiplash-associated disorders (WAD) – Results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders.” Spine 33 (4):S83-S92.
Dunne RL, Kenardy J, Sterling M. A Randomized Controlled Trial of Cognitive-behavioral Therapy for the Treatment of PTSD in the Context of Chronic Whiplash. Clinical Journal of Pain 2012;28(9):755-65. 52
Field, S, J Treleaven, and G Jull. 2008. “Standing balance: a comparison between idiopathic and whiplash-induced neck pain.” Manual Therapy 13 (3):183-191.
Foa, E. B., L. Cashman, L. Jaycox, and K. Perry. 1997. “The validation of a self-report measure of posttraumatic stress disorder: The Posttraumatic Diagnostic Scale.” Psychological Assessment 9 (4):445-451. doi: 10.1037//1040-35220.127.116.115.
Jull G, Kenardy J, Hendrikz J, Cohen M, Sterling M. Management of acute whiplash: a randomized controlled trial of multidisciplinary stratified treatments. Pain 2013;154(9):1798-806.
Kamper, Steven J., Christopher G. Maher, Luciola da C. Menezes Costa, James H. McAuley, Julia M. Hush, and Michele Sterling. 2012. “Does fear of movement mediate the relationship between pain intensity and disability in patients following whiplash injury? A prospective longitudinal study.” Pain 153 (1). doi: 10.1016/j.pain.2011.09.023.
Kongsted, Alice, Lars Vincents Jorgensen, Charlotte Leboeuf-Yde, Erisela Qerama, Lars Korsholm, and Tom Bendix. 2008. “Are altered smooth pursuit eye movements related to chronic pain and disability following whiplash injuries? A prospective trial with one-year follow-up.” Clinical Rehabilitation 22 (5):469-479. doi: 10.1177/0269215507082141.
Kongsted, Alice, Joan S. Sorensen, Hans Andersen, Bjarne Keseler, Troels S. Jensen, and Tom Bendix. 2008. “Are early MRI findings correlated with long-lasting symptoms following whiplash injury? A prospective trial with 1-year follow-up.” European Spine Journal 17 (8):996-1005. doi: 10.1007/s00586-008-0687-9.
Maxwell, Samuel, and Michele Sterling. 2013. “An investigation of the use of a numeric pain rating scale with ice application to the neck to determine cold hyperalgesia.” Manual Therapy 18 (2):172-174. doi: 10.1016/j.math.2012.07.004.
Ritchie, Carrie, Joan Hendrikz, Justin Kenardy, and Michele Sterling. 2013. “Derivation of a clinical prediction rule to identify both chronic moderate/severe disability and full recovery following whiplash injury.” Pain 154 (10):2198-206. doi: 10.1016/j.pain.2013.07.001.
Siegmund, Gunter P., Martin B. Davis, Kyle P. Quinn, Elizabeth Hines, Barry S. Myers, Susumu Ejima, Kishiri Ono, Koichi Kamiji, Tsuyoshi Yasuki, and Beth A. Winkelstein. 2008. “Head-turned postures increase the risk of cervical facet capsule injury during whiplash.” Spine 33 (15).
Spearing, Natalie M., Luke B. Connelly, Susan Gargett, and Michele Sterling. 2012. “Does injury compensation lead to worse health after whiplash? A systematic review.” Pain 153 (6). doi: 10.1016/j.pain.2012.03.007.
Spearing, NM, and LB Connelly. 2010. “Is compensation” bad for health”? A systematic meta-review.” Injury.
Sterling, M, G Jull, and J Kenardy. 2006. “Physical and psychological factors maintain long-term predictive capacity post-whiplash injury.” Pain 122 (1-2):102-108.
Sterling, M, and J Kenardy. 2008. “Physical and psychological aspects of whiplash: Important considerations for primary care assessment.” Manual Therapy 13 (2):93-102.
Sterling, M, and A Pedler. 2009. “A neuropathic pain component is common in acute whiplash and associated with a more complex clinical presentation.” Manual Therapy 14 (2):173-179.
Sterling, Michele, Joan Hendrikz, and Justin Kenardy. 2010. “Compensation claim lodgement and health outcome developmental trajectories following whiplash injury: A prospective study.” Pain 150 (1):22-28.
Sterling, Michele, and Justin Kenardy. 2011. Whiplash: Evidence base for clinical practice: Elsevier Australia.
Sterling M. Physiotherapy management of whiplash-associated disorders (WAD). J Physiother 2014;60(1):5-12.
Sullivan, M. J., Marc-Olivier Adams H Fau – Martel, Whitney Martel Mo Fau – Scott, Timothy Scott W Fau – Wideman, and T. Wideman. 2011 “Catastrophizing and perceived injustice: risk factors for the transition to chronicity after whiplash injury.” Spine 2011 Dec 1;36 (25 Suppl) (S244-9)
Treleaven, J, G Jull, and M Sterling. 2003. “Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error.” Journal of Rehabilitation Medicine 35 (1):36-43.
Treleaven, Julia, Gwendolen Jull, and Nancy LowChoy. 2005. “Smooth pursuit neck torsion test in whiplash-associated disorders: relationship to self-reports of neck pain and disability, dizziness and anxiety.” Journal of Rehabilitation Medicine 37 (4):219-23.
Treleaven, Julia, Gwendolen Jull, and Nancy LowChoy. 2006. “The relationship of cervical joint position error to balance and eye movement disturbances in persistent whiplash.” Manual Therapy 11 (2):99-106.
Treleaven, Julia, Nancy LowChoy, Ross Darnell, Ben Panizza, David Brown-Rothwell, and Gwendolen Jull. 2008. “Comparison of sensorimotor disturbance between subjects with persistent whiplash-associated disorder and subjects with vestibular pathology associated with acoustic neuroma.” Archives of Physical Medicine & Rehabilitation 89 (3):522-30.
Vernon, H, and S Mior. 1991. “The Neck Disability Index: a study of reliability and validity.” Journal of Manipulative and Physiological Therapeutics 14 (7):409.
Walton, David M, Jason Pretty, Joy C MacDermid, and Robert W Teasell. 2009. “Risk factors for persistent problems following whiplash injury: results of a systematic review and meta-analysis.” J Orthop Sports Phys Ther 39 (5):334-350.
Walton, David M., Joy C. MacDermid, Anthony A. Giorgianni, Joanna C. Mascarenhas, Stephen C. West, and Caroline A. Zammit. 2013. “Risk Factors for Persistent Problems Following Acute Whiplash Injury: Update of a Systematic Review and Meta-analysis.” Journal of Orthopaedic & Sports Physical Therapy 43 (2):31-43. doi: 10.2519/jospt.2013.4507.
Walton, David, Joy MacDermid, Warren Nielson, Robert Teasell, Tamara Nailer, and Phillippe Maheu. 2011. “A Descriptive Study of Pressure Pain Threshold at 2 Standardized Sites in People With Acute or Subacute Neck Pain.” Journal of Orthopaedic & Sports Physical Therapy 41 (9):651-657. doi: 10.2519/jospt.2011.3667.
Walton, David, Joy MacDermid, Warren Nielson, Robert Teasell, Hilary Reese, and Lenerdene Levesque. 2011. “Pressure Pain Threshold Testing Demonstrates Predictive Ability in People With Acute Whiplash.” Journal of Orthopaedic & Sports Physical Therapy 41 (9):658-665. doi: 10.2519/jospt.2011.3668.
Williams, M, E Williamson, S Gates, S Lamb, and M Cooke. 2007. “A systematic literature review of physical prognostic factors for the development of late whiplash syndrome.” Spine 32 (25):E764.
Williamson, E, M Williams, S Gates, and SE Lamb. 2008. “A systematic literature review of psychological factors and the development of late whiplash syndrome.” Pain 135 (1-2):20-30.
Winkelstein, B. A., R. W. Nightingale, W. J. Richardson, and B. S. Myers. 2000. “The cervical facet capsule and its role in whiplash injury – A biomechanical investigation.” Spine 25 (10). doi: 10.1097/00007632-200005150-00007.