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health.bcu.ac.uk/craigjackson
 Psychosocial
Aspects
of
Whiplash
Injury

Craig Jackson
Prof. of Occupational Psychology

Head of Division of Psychology

BCU
Whiplash

Harold Crowe in 1928, first used term to describe movement of

neck in accident

Acceleration then Deceleration

Now describes “injuries” induced by this motion

Arthur E Davis in Erie, Penn. first used term in 1945

“Most patients recovered well”

Used in 1953 in relation to auto-accidents (Gay & Abbott)

Used the term “psychoneurotic reaction” to explain delayed
recovery
RTA Figures
RTA Figures

Kills: 1,200,000 per year

Injured: 10,000,000 per year

RTA most common cause of Head Injury

Most Head Injuries are mild

Many left with long-lasting problems

Young males at biggest risk – alcohol often implied

Data suggests female drinking habits catching up with males

Implications for Female RTAs?
RTA Figures

80% of serious RTA injury is to head

1 concussion every 15 seconds in USA
Head Injury major cause of death and injury in RTAs
15,000,000 Brain Injuries per year in USA
RTAs
Playgrounds
Sports

1990 - 5,563,000 intra-cranial injuries worldwide from RTA

Murray et.al 1996
Psychological de-briefing after RTAs may help
Hobbs et.al 1996
RTA Figures
Mechanics of Occupant RTAs

Hazards: Steering wheel / column

Instrument panel

Seatbelt

Windscreens
RTA Brain injuries

Contre-Coup

Concussion

Intracranial Haematoma – Epidural, Intracerebral, Subdural

Diffuse axonal injury

How are Brain Injuries Assessed?

PAA
Post Accident Amnesia – memory problems when regaining
consciousness

• Minor Brain Injury

Unconscious for < 15 mins

• Moderate Brain Injury

Unconscious > 15 mins but < 6 hrs + PTA < 24 hrs

• Severe Brain Injury

Unconscious > 6 hrs OR PTA > 24 hrs

• Very Severe Brain Injury

Unconscious > 48 hrs OR PTA > 7 days
Mechanics of Whiplash

Hyperextension HyperFlexion

Majority of cases, no injury can be identified

Symptoms attributed to musculo-ligamental sprain

Mechanics of Whiplash

Accelerating Duration Acceleration Head-Neck Movement

Phase

Phase 1 0-60 msec. 0g Rest State

Phase 2 60-120 msec. 0.3 g Head rise, neck flexion and

backbone extension

Phase 3 120-200 msec. 4.3 g Neck extension

Phase 4 200-300 msec. 2.8 g Head and neck

hyperextension

Phase 5 300-400 msec. 1.0 g Head forwards with neck

flexion (whiplash)

Phase 6 + de 400 msec. 0.8 g Little flexion, back to

starting position
Whiplash Associated Disorder

Transfer of energy into the neck

May result from rear-end or side

impact collision

Can occur with other accidents

Impact of injury can occur on soft tissue and bone in the neck

Can lead to a variety of clinical

presentations known as WAD

Whiplash injury feasible at 5 MPH

85% of UK RTA injury insurance claims

Whiplash Statistics

USA 1995:
5.5 million people involved in traffic accidents
53% of them suffered whiplash injury

Germany 1992:
395,462 traffic accidents
197,731 (49%) suffered whiplash injury
Whiplash as a “Pseudo Psychiatric” Condition?

American Psychological Association recognises 3 types

“dissimulating” disorders

1. Malingering
2. Somatoform disorders
3. Factitious disorders

Doctors, alternative practitioners, scientists,

lawyers, and patients have colluded in promoting
a disorder that now afflicts millions and costs
billions

While patients who sustain serious neck injuries

have a good prognosis minor collisions producing
no demonstrable tissue damage now result in
lifelong disability in around 10% of cases
Whiplash as a “Pseudo Psychiatric” Condition?

One of a family of fashionable conditions, including:

Fibromyalgia
Repetitive strain injury
Chronic fatigue syndrome
Occupational back pain
Chronic pain syndrome

Are these diagnoses are offered to patients who are either

consciously or unconsciously seeking an escape from the
pressures of modern life into the roles of sickness and victim-
hood?

Do these conditions risk degrading medicine and bankrupting

health services? Worst of all, they condemn patients to
disorders from which there is little hope of recovery
Malleson 2002
Prevention is OK -

Lots of research in area of whiplash injury prevention

Cars better at preventing injury than ever before

Not much known about prevention of chronic pain after incident

Some treatment may foster chronic pain

Quebec Task Force on Whiplash

Extensive literature review of work from 1980 – 1993

10,382 papers examined

Only 62 (0.6%) were relevant and scientifically good

Papers before 1980 generally of little clinical / scientific value

Pathophysiology – a Sprain

Majority of whiplash injuries arise in soft tissue injury to neck

involving ligaments, joints, joint capsules, muscles and
tendons

Type 1: Injury at microscopic level without altering

structure

Type 2: Partial tear at macroscopic level no separation

Type 3: Severe stretching and tearing with separation of

tissues
Whiplash Associated Disorders (WAD)

Classed by severity of signs and symptoms

WAD 0 No complaints or physical signs

WAD 1 Neck complaints but no physical signs
WAD 2 Neck complaints and musculoskeletal signs
WAD 3 Neck complaints and neurological signs
WAD 4 Neck complaints and fracture / dislocation

Most whiplash injury results from low impact collisions

Prolonged and Escalated Symptoms

Excess stress 10% have WAD symptoms for > 2

Psychosocial difficulties years after accident:
Anxiety (approx 40%)
Caused by. . .
Depression (approx 40%)
PTSD
Poor sleep Poor sleep
Ear pain
Depression, Anxiety, Stress
Poor posture
Dizziness Psychosocial difficulties
Memory problems Pre-existing conditions
Concentration problems
Inappropriate therapeutics
Headaches
Movement difficulty Prolongation of litigation
Post Traumatic Fibromyalgia?

Saskins & Moldofsky 1986

11 cases of PTFS
Generalised pain on 11 of 18 designated
tender points

A happy marriage of Whiplash and Fibromyalgia?

Post Traumatic Fibromyalgia abandoned in 1994

Wolfe 1996
Chronic Whiplash

Complex interaction between many factors:

Biological

Psychosocial Legal

Economics Beliefs / Attitudes

Psychological factors are also hypothesized to influence

the existence of whiplash-related cognitive impairments.
Other Countries 1

Mills & Horne 1986 – New Zealand

Very low incidence
Significantly lower than Australia
Difference in process of dealing with: insurance companies
lawyers
therapists

Awerbuch 1992 - Australia

WAD claims dropped from 6000 to 2000 / year in 1987
Legislative changes limited compensation and claim sizes
Claimants had to: bear initial cost of claim
report to police
have minimum 30% disability
Other Countries 2

Cassidy et.al 1995 – Canada

27% reduction in claims under a “no fault system” in courts
Statute of limitations to 200 days after accident
“No Crash No Cash”

Obelieniene 1999 – Lithuania

No notion of chronic pain resulting from rear end collision
No fear of long term disability
No involvement of lawyers

Partheni et.al 1997 – Greece

91% of WAD victims recover in 4 weeks
Treatments – Quebec Task Force (1995)

Most studies show little or no efficacy of treatments

Collar and NSAIDs on short term basis

Avoid long term physiotherapy

Mobilization by trained person & active exercise for grade 2 & 3

Drugs for insomnia or anxiety

Early return to activities and promote mobility

Myths about Whiplash

1. “Whiplash Personality”

2. Malingering (for monetary gain) is common

3. Illness & Disability are biological phenomena

4. Men are more vulnerable than women

5. Direct impact upon neck is necessary for WAD

6. X-ray shows nothing so no WAD

7. Complaints are psychosomatic

8. Rest, time, muscle relaxants and tranquillisers cure the

distress

9. Seatbelts would prevent injury

Case Summary of a Whiplash Patient

Male, Age 34.

Head Injury, Whiplash, Headaches, Sleep Disorder, Fatigue.

Suffered a head injury during an auto accident in which he was
rear-ended at 50mph. He described severe pain in his neck and
back and headaches that originated at the base of his skull and
spread to his left eye. His pain was so severe that it prevented
him from sleeping, so he suffered from severe fatigue. To
maintain some level of function during the day, he relied on
multiple caffeinated beverages such as jolt or bull colas and/or
coffee. At the time of his initial upper cervical chiropractic
evaluation (14 months after the accident), he had been suffering
with all of the above symptoms for over a year. He had sought
help from numerous practitioners including physicians,
neurologists, and therapists, to no avail. He reported receiving
some temporary relief from Pilates.
Case Summary of a Whiplash Patient

Female, Age 56.

Neck Pain, Headaches, Chronic Fatigue.

Suffered from chronic neck pain, headaches, and fatigue for
years. She thought the problems may have started sometime
after an auto accident she experienced 14 years before. During
the accident, she was hit head-on and totalled her car. The pain
bothered her on and off for years-- sometimes on a daily basis
and other times a month would go by without pain. She tried
many practitioners such as massage therapists and
chiropractors and received some relief but still the problem
continued year after year. Finally, after struggling over a
decade, she sought help from upper cervical chiropractic care.
Case Summary of a Whiplash Patient

Female. Age 52.

Migraine Headaches, Neck Pain, Whiplash, Head Injury.

Involved in two auto accidents three years apart. The first
accident (she was rear-ended) caused migraines, neck pain,
and head injury symptoms, including insomnia, depression,
memory loss, and inability to multi-task. These symptoms were
worsened after her second auto accident in which she was also
rear-ended. She tried multiple therapies including physical
therapy, chiropractic care, cranial sacral therapy, as well as
medications from her neurologist but she could hardly function
due to severity of her cognitive symptoms and pain.
Case Summary of a Whiplash Patient

Female, Age 49.

Headaches, Neck Pain, Loss of Sense of Taste
Involved in 6 different auto accidents during a 5-year period.
After each accident, she suffered increased pain in her neck
and head. Her third accident was most severe in that she
suffered a head injury. After that accident, in addition to
experiencing an increase in pain, she lost her sense of taste.
Her neurologist told her the damage to the nerves controlling
taste was most likely permanent and due to the head injury. She
tried many forms of treatment over the years including pain
pills, chiropractic care, and physical therapy. Sometimes she
received benefit, sometimes not, but the results were never
consistent or long lasting. After struggling for 8 years with
headaches and neck pain and 6 years with loss of her sense of
taste, she sought help from upper cervical chiropractic care.
Chronic Patient’s Attributions of Ill-Health

Work Environment Chemicals

Stress Toxins Virus

Allergies Anatomy / Ergonomic Traumatic injury

Non-Traumatic injury

Living in a litigious society

“Victim” culture
Living in a “risk-controlled” world
Someone must therefore always be to blame
Urgency of Treatment?

Poor knowledge of management of acute whiplash symptoms

Best early treatment involves:

1) Frequently repeated active sub-maximal movements
2) Mechanical diagnosis
3) Therapy

More effective in reducing pain than standard program of:

a) Initial rest
b) Use of a soft collar
c) Gradual self-mobilization

This therapy could be performed as home exercises initiated

and supported by a physiotherapist
Rosenfeld et.al 2000
Treatment For Patients – Cochrane Review 2004

15 studies met the inclusion criteria – only 3 were good quality

Overall a poor methodological quality

Passive & Active interventions more effective than no treatment

Found conflicting evidence about the effectiveness of active

interventions compared to passive ones

Data of the high quality studies were conflicting

‘Rest makes rusty', can no longer be justified

There is a suggestion that active interventions are more

effective than passive ones, but no clear conclusion about
chronic WAD can be drawn.
Predictors of Disability in Patients

Reported frequencies of disability ranging from 0% to 50% in

follow-up studies

After 1 year, (7.8%) persons with whiplash injury had not

returned to usual level of activity or work

Initiation of lawsuit within first month after injury did not

influence recovery

The cervical range-of-motion test has a high sensitivity in

prediction of handicap after acute whiplash injury
Kasch et.al 2001

WAD patients' self-efficacy at an early stage after injury

significantly predicts the development of pain intensity and
disability. Patients' confidence in performing daily activities
should be reinforced in order to optimize treatment after injury
Kyhlback et.al 2002
Cognitive Dysfunction in Patients

Bosma & Kessells 2002

WAD Patients often experience cognitive impairments

Neuro(psycho)logical test results do not always support this

WAD Patients performed similarly to neurology patients on the

cognitive tasks and performed worse on memory and attention
tasks compared with the control group

WAD Patients had high scores on subscales measuring

somatization and displayed a palliative coping style

Somatization, in combination with inadequate coping, might

play a role in the development, persistence, or aggravation of
whiplash-related symptoms, such as pain or cognitive
dysfunction.
 Prognostic Factors in Patients

Malt & Sundet 2002

15% of WAD patients suffer long lasting health problems
5% do not return to work

Psychosocial impairment following injury is influenced by:

Vulnerability Symptom Formation

Biomechanical
Low mental ability Musculature
Past mental illness Neural structures Acute stress response
Older age Joints Head position @ impact
Female Musculature
Narrow spinal canal

Manual work, expectation of disability and an ongoing

compensation claim case seem to be important moderator
variables affecting symptom formation
Prognostic Factors in Patients

Psychological factors more important than crash parameters

(e.g. velocity) in predicting course of WAD at 6 months

Greater initial pain or symptoms persisting for 28 days were

associated with reduced QoL and PTSD symptoms
Richter et.al 2004

Stress at time of accident predicted > symptoms at follow-up

Long-lasting distress and poor outcome were more related to

the occurrence of stressful life events than to clinical and para-
clinical findings
Karlsborg et.al 1997
Prognostic Factors in Patients

WAD patients 2 times sensitive to cold in neck

Overall elevated level of distress > in the WAD gp than controls
Neither vibration or heat caused different responses

Pain in response to non-noxious stimulation over presumably

healthy tissues suggests that central mechanisms are
responsible for ongoing pain in at least some whiplash patients

Moog et.al 2002

WAD patients have lower pain thresholds for electrical stimulus

Hypersensitivity to peripheral stimulation in WAD patients

Curatolo et.al 2001

Hassles and Daily Problems in Patients

“Everyday Problem Checklist” (EPCL) scores were higher in

WAD patients than healthy controls

Chronic WAD patients report a high stress load

WAD patients (especially those with a low educational level)

appear to be more vulnerable and react with more distress than
healthy people to all kinds of stressors

Stress responses probably play an important role in the

maintenance or deterioration of whiplash-associated complaints

Blokhorst et.al 2002

Anxiety and Depression in Patients

Depression & Anxiety 2 years before accident, significantly

overlaps with WAD patients
Wenzel et.al 2002

Depression & Anxiety greater in WAD patients than controls

Those with longest history of pain gave highest ratings of pain

Those with longest history of pain were most depressed

Most of these patients were involved in litigation.

Whiplash injury sufferers are anxious and depressed

Their psychological distress could be aggravated by litigation

Lee et.al 1993
Pre-injury Psychiatry in Patients

Outcome measured for 33 WAD patients and correlated with a

range of pre-accident variables

No association between pre-accident psychiatric factors and

overall outcome

Older age and pre-accident history of MSD complaints

correlated with physical and psychiatric outcomes

Pre-accident psychiatric factors may have little bearing on long-

term prognosis

Outcome of late whiplash syndrome is probably worse in older

individuals and in patients with a pre-accident history of MSD
complaints
Turner et.al 2003
Expectation of Problems in Patients

Compared self-reported outcomes of physicians and non-

physicians

Physicians Non-Physicians

Recall being in RTA? 71% 60%

Recall acute symptoms? 31% 46%

Symptoms lasting > 1 year? 9% 32%

Physicians symptoms were shorter than non-physicians

Physicians appear, however, to be more resistant than non-

physicians to the progression from acute pain to chronic pain
and disability.
Virani et.al 2001
Cognitive Model of Physical Symptoms in WAD
Preventing Chronicity of Pain

Teach professionals

Educate patients

Avoid anxiety provoking terms e.g. “PTFS” or “disc bulge”

Avoid excessive investigation & test – Iatrogenesis

Be rational

Avoid prolonged litigation involvement

Make patient aware of lengthy outcomes of litigation

Patient Education

Explain benign nature of WAD

Avoid confusing and conflicting info
Watch for factors leading to pain chronicity
Home / work programmes as effective as physiotherapy
Teach relaxation and stress management
Educate posture and neck care
Ergonomics at home and work
Home program of heat and cold & exercises
Self Monitor stress, sleep and mood
Headaches
Avoid excessive investigation
Acute Rational Care

Take good history

Physical examination

X-ray of cervical spine

Analgesics and muscle relaxants

Use of local cold and heat

Cervical collar for a few days

NSAIDS for few weeks

Gradual mobilization

Correction of disturbed sleep

Compensation Neurosis

Pending litigation

Treatment results often poor

Some overt malingering

Exaggerated illness due to:

suggestion + somatization
rationalization + distorted sense of justice
victim status + entitlement beliefs

Adverse legal / admin. systems

Harden patient’s convictions

With time, care-eliciting behaviour may remain permanent

Bellamy, 1997
Compensation Neurosis

Improvement in health.....

...may result in loss of status

Patient compelled to guard against getting better

Financial reward for illness is a powerful nocebo

Exacerbates illness

In a litigious society, will compensation neurosis become more

widespread?
Accident Neurosis

Failure to improve with treatment until compensation issue

settled

Accident must occur in circumstances with potential for

compensation payment

Inverse relationship to severity of injury - Accident neurosis rare

in cases of severe injury

Low socio-economic status favors accident neurosis

Complete recovery common following settlement of

compensation issue ? ? ?
Miller 1961
Abnormal Illness Behaviour after Compensable Injury
Accident neurosis Accident victim syndrome
Aftermath neurosis American disease
Attitudinal pathosis Barristogenic illness
Compensatory hysteria Compensationitis
Compensation neurosis Fright neurosis
Functional overlay Greek disease
Greenback neurosis Invalid syndrome
Justice neurosis Perceptual augmenter
Post accident anxiety syndrome Pensionitis
Postaccident fibromyalgia Post-traumatic syndrome
Profit neurosis Psychogenic invalidism
Railway spine Secondary gain neurosis
Traumatic hysteria Symptom magnification syndrome
Traumatic neurasthenia Traumatic neurosis
Triggered neurosis Unconscious malingering
Vertebral neurosis Wharfie’s back
Whiplash neurosis Mendelson, 1984
Secondary Gain Pre-disposition

Potential Claimants

• Military patients nearing severance

• Workers under retirement age

• Workers soon to be made redundant

•Low job satisfaction

Non-economic motivation
• Members of support groups Loneliness
Depression
Anxiety
Difficulty expressing emotional pain
Previous history of attention seeking when ill
Summary of Whiplash

Most common injury following RTA (Spitzer et al. 1995)

Sufferers no more likely to be worriers or have psychiatric

problems than non-suffers who had RTAs

Sufferers more likely to find an accident frightening and be the

innocent party than non-suffers who had RTAs

33% of sufferers have psychiatric complications at 1 year after

accident

No “psychology of whiplash” – many physical and

psychological interactions combine together to produce a
complicated clinical problem
Finally. . .

It’s a sexual thing – theory that anal retentive people (especially

females) find being shunted / rear-ended to be distressing

Is psychoanalytic theory any more unlikely than that of other

whiplash theories ? ? ?