From: Arch Phys Med Rehabil. 2010 Sep;91(9):1313-1318

To determine whether neck manipulation is more effective for neck pain than mobilization, a randomized controlled trial with blind assessment of outcome was undertaken by the authors. The setting was Primary care physiotherapy, chiropractic, and osteopathy clinics in Sydney, Australia.

Patients (N=182) with nonspecific neck pain less than 3 months in duration and deemed suitable for treatment with manipulation by the treating practitioner were randomly assigned to receive treatment with neck manipulation (n=91) or mobilization (n=91). Patients in both groups received 4 treatments over 2 weeks, from which the number of days taken to recover from the episode of neck pain.

The median number of days to recovery of pain was 47 in the manipulation group and 43 in the mobilization group. Participants treated with neck manipulation did not experience more rapid recovery than those treated with neck mobilization. The authors concluded that neck manipulation is not appreciably more effective than mobilization. The authors further noted that the use of neck manipulation therefore cannot be justified on the basis of superior effectiveness.

It would be interesting to note a similar number of patients without any neck manipulation or mobilization and the number of median days to recover from nonspecific neck pain of less than 3 months duration. Additionally, the conclusion that “the use of neck manipulation therefore cannot be justified on the basis of superior effectiveness” should include – for nonspecific neck pain less than 3 months in duration with 4 treatments over a 2 week period. Without the entire article, one can only speculate why 4 treatments over 2 weeks would be deemed reasonable treatment for a nonspecific entity with either modality.

I presume the full article would delineate the criteria for being deemed suitable for treatment with manipulation or mobilization by the treating practitioner and if the evaluation methods were uniform between practitioners. Furthermore, the article should indicate specific analysis to reach a broad conclusion that manipulation cannot be justified on the basis of superior effectiveness – in fact, the abstract should have indicated that mobilization was more effective than manipulation for nonspecific neck pain of less than 3 months duration in a heterogeneous group of treating practitioners performing 4 treatments over a 2 week period.

From: Man Ther. 2010 Aug 11. [Epub ahead of print]

In the management of neck pain disorders, McKenzie recommends performing neck extension exercises from a fully neck retracted position in order to achieve a maximum range of lower cervical extension. However, no study has investigated the impact of pre-positioning the neck prior to the extension exercise. This study compared end-range sagittal cervical segmental rotation and translation from three starting positions: the neck in neutral, retraction and protraction.

Twenty asymptomatic healthy volunteers were recruited. Lateral radiographs were taken in neutral and at each of the three end-range extension positions and differences in sagittal rotation angles and translation from the neck neutral posture were calculated at each segment.

The results indicated that there was a significant difference in the pattern of the sagittal segmental rotation but no difference in summed rotations (total extension) between the three conditions. Protraction generated significantly greater extension range at C1-2 and retraction produced significantly greater extension range at C6-7 than alternate conditions. In contrast, there was no significant difference in segmental translation values between the three conditions. These results indicate initial neck positions can influence cervical segmental extension range at C1-2 and C6-7.

Pain Med. 2010 Aug;11(8):1169-78

The objective of the study was to investigate clinical effects of low-level laser therapy in patients with acute neck pain with radiculopathy. This was a double-blind, randomized, placebo-controlled study. The study was carried out between January 2005 and September 2007 at the Clinic for Rehabilitation at the Medical School, University of Belgrade, Serbia.

Sixty subjects received a course of 15 treatments over 3 weeks with active or an inactivated laser as a placebo procedure. Low-level laser therapy was applied to the skin projection at the anatomical site of the spinal segment involved with the following parameters: wavelength 905 nm, frequency 5,000 Hz, power density of 12 mW/cm(2), and dose of 2 J/cm(2), treatment time 120 seconds, at whole doses 12 J/cm(2).

The primary outcome measure was pain intensity as measured by a visual analog scale. Secondary outcome measures were neck movement, neck disability index, and quality of life. Measurements were taken before treatment and at the end of the 3-week treatment period.

Statistically significant differences between groups were found for intensity of arm pain and for neck extension. Low-level laser therapy gave more effective short-term relief of arm pain and increased range of neck extension in patients with acute neck pain with radiculopathy in comparison to the placebo procedure.

From: Man Ther. 2010 Aug 4. [Epub ahead of print]

This study investigated effectiveness of manual therapy with transcutaneous electrical nerve stimulation (TENS) to reduce pain intensity in patients with mechanical neck disorder. A randomized multi-centered controlled clinical trial was performed in 12 Primary Care Physiotherapy Units in Madrid Region. Ninety patients were included with diagnoses of subacute or chronic mechanical neck disorder without neurological damage, 47 patients received manual therapy and 43 TENS. The primary outcome was pain intensity measured in millimeters using the Visual Analogue Scale (VAS). Also disability, quality of life, adverse effects and sociodemographic and prognosis variables were measured. Three evaluations were performed (before, when the procedure finished and six months after). Seventy-one patients (79%) completed the follow-up measurement at six months. In more than half of the treated patients the procedure had a clinically relevant “short term” result after having ended the intervention, when either manual therapy or TENS was used. The success rate decreased to one-third of the patients 6 months after the intervention. No differences can be found in the reduction of pain, in the decrease of disability nor in the quality of life between both therapies. Both analyzed physiotherapy techniques produce a short-term pain reduction that is clinically relevant.

From: BMC Musculoskelet Disord. 2010 Jul 30;11(1):171.

Metabolic syndrome has become increasingly common worldwide. Metabolic syndrome is a cluster of risk factors defined by high fasting glucose and triglycerides, low HDL cholesterol, high blood pressure, and abdominal obesity that increases the risk for cardiovascular diseases, type 2 diabetes mellitus, and all-cause mortality. The prevalence of metabolic syndrome in the US population is approximately 35%. In Eastern Finland the corresponding prevalence has been found to be 37%. Neck pain is also a common symptom among the middle-aged population. In a large Finnish population-based study, 24% of men and 37% of women aged at least 30 years had suffered from neck pain during the preceding month.

There are few studies in which the prevalence of pain has been assessed in subjects with metabolic syndrome. In one study females with chronic pain from fibromyalgia were at an increased risk of metabolic syndrome. Another study found that subjects with metabolic syndrome were more likely to have problems with pain symptoms. It has been suggested that stress is related to both metabolic syndrome and neck pain. Low physical activity has been found to be associated with metabolic syndrome and musculoskeletal pain. Some studies have found an association between obesity and neck pain. Because visceral obesity is one of the main features of metabolic syndrome, it could be proposed that metabolic syndrome is also related to neck pain. It has been speculated that both metabolic syndrome and persistent chronic pain syndromes are related to hypothalamus-pituitary-adrenal stress axis dysfunction. Therefore, it could be expected that the prevalence of neck pain is elevated in subjects with metabolic syndrome. Thus, if there were common features in the background of these disorders, the authors hypothesized that neck pain is more prevalent among subjects with metabolic syndrome than among those without metabolic syndrome. In this study the authors aimed to analyse the prevalence of neck pain in subjects with metabolic syndrome.

Neck pain was assessed by asking about neck pain during the preceding month. The presence of neck pain was dichotomized: (0) no neck pain or neck pain only occasionally and (1) daily or almost daily neck pain. Hence, in this study we regarded neck pain as daily or almost daily occurring neck pain.

This study showed that males and females with metabolic syndrome have an increased prevalence of neck pain. This association was stronger in males, but the prevalence of neck pain was higher in females. In accordance with previous studies, psychological distress was associated with neck pain especially in females. Although psychological distress was taken into account, metabolic syndrome was statistically associated with neck pain.

BMI was higher and waist circumference larger in males with neck pain. Previous studies have suggested that obesity is a risk factor of neck pain. Subjects with metabolic syndrome are often obese and waist size is among the criteria of metabolic syndrome. However, BMI and waist size were similar in females regardless of neck pain. Therefore, it is not plausible that the association between metabolic syndrome and neck pain is related solely to obesity. Compared with females, males with neck pain had higher cholesterol and triglyceride levels and a higher BMI. Psychological distress was associated with neck pain in both genders. However, a lower lever of distress was associated with neck pain in females, but in males only severe distress had that association. In general, the level of psychological distress was higher among females than among males. According to a large population-based study, concurrent psychological distress is more prevalent among females.

One background hypothesis for the connection between neck pain and metabolic syndrome found in this study is that there is a common factor resulting in the development of both neck pain and metabolic syndrome. Two such factors could be stress and physical inactivity. Stress has been suggested to be a risk factor of metabolic syndrome. A recent study has suggested that workers with neck, shoulder, or back pain have elevated levels of stress-related biomarkers. Further, it can be speculated that neck pain is an indicator of stress. A recent study has shown that in a specified population, physical inactivity is a risk of metabolic syndrome, whereas perceived stress was not associated with metabolic syndrome. The association between development of metabolic syndrome and low physical inactivity has also been shown in a previous study. A large epidemiological follow-up study indicated that physical inactivity is related to chronic musculoskeletal complaints. It has been suggested that chronic musculoskeletal pain is associated with cardiovascular-related mortality. Hence, physical inactivity may be an intervening factor between metabolic syndrome and neck pain. Further studies with a longitudinal setting could explore the potential causal association between neck pain and metabolic syndrome as well as the potential common background factors of neck pain and metabolic syndrome.

Metabolic syndrome was associated with neck pain. This association was stronger in males but the prevalence of neck pain was higher in females. Prospective studies focusing on the causal relationship between neck pain and metabolic syndrome are needed.

Source: Prevalence of neck pain in subjects with metabolic syndrome – a cross-sectional population-based study

From: Man Ther. 2010 Jul 19. [Epub ahead of print]

Extensive computer use amongst office workers has lead to an increase in work related neck pain. Aberrant activity within the three portions of the trapezius muscle and associated changes in scapular posture have been identified as potential contributing factors. This study compared the activity (surface electromyography) of the three portions of the trapezius in healthy controls (n=20) to a neck pain group with poor scapular posture (n=18) during the performance of a functional typing task.

A scapular postural correction strategy was used to correct scapular orientation in the neck pain group and electromyographic recordings were repeated. During the typing task, the neck pain group generated greater activity in the middle trapezius and less activity in the lower trapezius than the control group. Following correction of the scapula, activity recorded by the neck pain group was similar to the control group for the middle and lower portions.

These findings indicate that a scapular postural correction exercise may be effective in altering the distribution of activity in the trapezius to better reflect that displayed by healthy individuals.

From: Pain. 2010 Jul 22. [Epub ahead of print]

To determine the impact of occupational psychological/social and mechanical factors on neck pain, a prospective cohort study with a follow-up period of 2years was conducted with a sample of Norwegian employees. The following designs were tested: (i) cross-sectional analyses at baseline (n=4569) and follow-up (n=4122), (ii) prospective analyses with baseline predictors, (iii) prospective analyses with average exposure over time [(T1+T2)/2] as predictor, and (iv) prospective analyses with measures of change in exposure from T1 to T2 as predictors. A total of 2419 employees responded to both the baseline and follow-up questionnaire. Data were analyzed using ordinal logistic regression. After adjustment for age, sex, neck pain at T1, and other exposure factors that had been estimated to be confounders, the most consistent risk factors were role conflict and working with arms raised to or above shoulder level. The most consistent protective factors were empowering leadership and decision control. Hence, psychological and social factors are important precursors of neck pain, along with mechanical factors. Although traditional factors such as quantitative demands and decision control play a part in the etiology of neck pain at work, in this study several new factors emerged as more important.

From: BMC Musculoskeletal Disorders 2010, 11:79

This review examines the evidence for an association between computer work and neck and upper extremity disorders (except carpal tunnel syndrome). A systematic critical review of studies of computer work and musculoskeletal disorders verified by a physical examination was performed. A total of 22 studies (26 articles) fulfilled the inclusion criteria. Results show limited evidence for a causal relationship between computer work per se, computer mouse and keyboard time related to a diagnosis of wrist tendonitis, and for an association between computer mouse time and forearm disorders. Limited evidence was also found for a causal relationship between computer work per se and computer mouse time related to tension neck syndrome, but the evidence for keyboard time was insufficient. Insufficient evidence was found for an association between other musculoskeletal diagnoses of the neck and upper extremities, including shoulder tendonitis and epicondylitis, and any aspect of computer work.

There is limited epidemiological evidence for an association between aspects of computer work and some of the clinical diagnoses studied. None of the evidence was considered as moderate or strong and there is a need for more and better documentation.

As related to tension neck syndrome, we will cover this specific entity from the study:

Tension neck syndrome, a condition characterized by pain complaints and neck muscle tenderness elicited by palpation and/or movement of the neck, is in this review by far the most common diagnosis in the neck region and is included in the examination protocol of a majority of the included studies. In three studies the diagnosis somatic pain syndrome, with a similar definition, is used. In a prospective study of newly hired computer workers hours of keying per week was not associated with incident tension neck syndrome. The baseline cross-sectional analysis in the NUDATA-study showed an increased risk for tension neck syndrome, including an exposure-effect relationship, for work with a computer mouse for more than 15-20 h/w. A similar relationship was not observed for keyboard use. The one-year incidence of tension neck syndrome was too low for reliable analyses even if the NUDATA-study included several thousand subjects. Another much smaller and older study found no association between amount of computer work in itself and tension neck syndrome. A community-based case-control study found for women a significant association for shoulder-neck diagnosis (58% of affected subjects had tension neck syndrome) with computer work ≥ 4 hours/day. Several studies of low to moderate quality have found an association between computer work and clinical findings. These studies examine mainly keyboard work. This is supported by a study finding more trigger points and pain provoked by neck sideways flexion in subjects performing data entry work compared with subjects doing data dialogue work. A prospective study of air-traffic controllers changing from varied computer work to a strict mouse-based system, only found significant increase of musculoskeletal disorders in the neck and shoulders among the younger half of the study group. At baseline a majority of the affected controllers had tension neck syndrome, however there is no information on specific diagnoses at follow-up.

The work-related load of the neck in computer work is influenced by the computer workstation lay-out (including use of specific devices) and individual working technique, and several of the studies in this review have tried to take accord of some of these factors. The NUDATA-study with more than six thousand subjects found no significant associations between tension neck syndrome and several recorded ergonomic factors. Among newly hired computer workers a “protective” effect of inner elbow angle above 121° during keyboard use was observed, but this effect was attenuated with increasing hours of keying per week. This study also showed a tendency for increased risk with shoulder flexion above 35° during mouse use, and for a protective effect of the use of chair armrests. In a randomized controlled intervention study a forearm support board was associated with a reduced incidence of neck/shoulder disorders among female call centre operators (tension neck syndrome was found in 59% of the subjects with one or more neck/shoulder diagnoses). However, this relation was not found in a similar randomized intervention study on engineers (male majority), and the NUDATA study gave no support for a protective effect of forearm support on the occurrence of tension neck syndrome. In a study with no observed association to computer work in general, an association to tension neck syndrome was found in subjects with limited rest break opportunities, in subjects who had their keyboard too highly placed relative to elbow level, and in subjects who used bifocal glasses. The association of tension neck syndrome to use of bifocals was also shown in another study. Neck flexion more than 20° was identified as a risk factor, however the outcome measure was not precisely described.

In a comparison of daily workload by comparing part-time and full-time air-traffic controllers, there was no difference in neck-shoulder or arm-hand disorders. However, a significant effect was observed on subjective complaints from the same body regions, illustrating that an effect seen in complaint scores may not be reflected in the number of diagnoses from a physical examination.

Previous critical reviews that include evidence based on subjective reports of pain and symptoms conclude mostly with a causal relationship between computer work per se (or computer work in general) and neck pain. In the NUDATA-study the results on tension neck syndrome were supported by baseline data for neck and shoulder pain symptoms; neck symptoms showed a weaker but still significant exposure-effect relationship to mouse use but not to keyboard use. Some indications were presented that the incident of new neck pain symptoms was associated to mouse use more than 30 h/w and almost significant to keyboard use for more than 15 h/w. Several cross-sectional studies recording subjective pain symptoms only have shown an association between neck and shoulder pain and computer work. However, a number of high quality prospective studies do not confirm these findings. Aspects of work station design, data equipment and work technique have been shown to influence subjective reporting, such as forearm support for neck symptoms, and mouse position, mouse design and neck flexion angle for neck/shoulder symptoms.

Jensen et al. found a lower number of EMG-gaps and a more repetitive activity on the mouse side compared to opposite side, indicating a more harmful muscle activity pattern on the mouse side. However, increased activity in the trapezius muscle has also been reported after exposure to psychological stress and high precision demands. The population at risk is perhaps more prone to a high level of perceived muscular tension, which has been found even when adjusting for high physical exposure, high job strain and age. Several studies document an interaction between mechanical work load in computer work and psychosocial risk factors.

Evidence of a causal relationship for tension neck syndrome?

Of the studies included in this review one cross-sectional study of moderate quality suggests an association between computer work per se and tension neck syndrome. One case-control study of high quality had similar findings, especially for women. One prospective study of high quality found no association. With respect to specific aspects of computer work, one very high quality prospective study documents a clear association between mouse use and tension neck syndrome. In a prospective study following a work-task redesign with intensified mouse use, a similar effect was seen in the younger half of the involved workers. In two very high quality intervention trials the introduction of forearm support protected against shoulder-neck diagnoses among female call centre operators but not in among male engineers. Several high quality prospective studies of symptoms do not support an association. Possible pathomechanisms have been documented.

The authors conclude that there is limited evidence for a causal relationship for computer work per se and for mouse time, but not for keyboard time. Several pathophysiological and experimental studies give biological plausibility to this conclusion. However, indications are found of the importance of individual working technique and work station lay-out in causality of tension neck syndrome. These include lack of forearm support, non-neutral position of forearm and neck flexion. This conclusion is in part also a consequence of the limited number of studies.

Resource: Neck and shoulder symptoms and disorders among Danish computer workers

From: BMC Musculoskelet Disord. 2010 Jul 13;11(1):158.

Whiplash was defined in 1995 by the Quebec Task Force as a neck injury mechanism and may result in injuries within the musculoskeletal and /or neurological system. The Quebec Task Force developed a system for grading Whiplash Associated Disorders : whiplash associated disorders I-II (symptoms without known pathology), III (symptoms and neurological signs), and IV (symptoms and cervical fracture and/or dislocation).

Grade I and II patients represent up to 90 % of “whiplash injury claims”. The proportion of patients who reports pain and disability six months after the accident (i.e. chronic whiplash associated disorders) varies substantially between studies and countries. However, a recent review suggests that approximately 50% of the patients with whiplash associated disorders will report neck pain symptoms one year after their injuries. Patients with chronic whiplash associated disorders report high levels of neck pain, headache, and shoulder pain often accompanied by neck stiffness, dizziness, fatigue, sleeping problems, concentration problems, allergy, breathing disorders, hypertension, cardiovascular disorders, digestive disorders, depression, anxiety, and impairment in cognitive performance. A recent study of a large population-based cohort of victims of car accidents, found that isolated neck pain was rare and that pain from multiple body areas was most commonly reported.

Expectations and coping styles might influence the outcome and prognosis after whiplash injuries. The Cognitive Activation Theory of Stress describes stress response as a general normal, healthy, and necessary alarm. There may be a risk of illness and disease only if the arousal is sustained. The level and duration of the alarm depends on the expectancy of the outcome of stimuli, as well as the results from specific responses available for handling the situation. Therefore, the cognitive activation theory of stress model emphasizes the importance of coping as positive response outcome expectancies. This means that if the individual expects to be able to handle a situation with a positive result (coping), the activation will be short and do no harm. Kivioja et al. found no evidence that early coping strategies influenced the prognosis after whiplash injuries. Others, however, found that high levels of passive coping strategies are associated with a slower recovery after whiplash injury, and that certain coping strategies for pain, such as catastrophizing, is associated with increased risk of disability, and that the importance of coping strategies seem to increase over time. In general, there is considerable controversy as to the importance of psychological factors for developing chronic whiplash associated disorders.

The importance of insight into coping strategies has been emphasized for chronic pain patients such as fibromyalgia, tension-type headache, chronic back pain, and chronic temporomandibular disorder. However, there is little qualitative insight into the ways persons with chronic whiplash associated disorders cope on a day to day basis. Such insight may provide the clinician with a better understanding of lay health recourses, and, possibly, provide a better starting point for suggesting strategies or discussing potentially maladaptive strategies to patients suffering pain following whiplash. Furthermore, Russell & Nicol suggested that whiplash associated disorders patient recovery may be increased if the clinicians better understand patient experiences. In the present study the authors identify what is described as dominant whiplash symptoms, and the behavioral strategies used to cope with whiplash associated disorders.

The aim of the present study was to identify dominant whiplash symptoms, and the behavioral strategies used to cope with these. Participants stated dominating symptoms to be neck and head pain, sensory hypersensitivity, and cognitive dysfunction. In describing their dominating symptoms participants gave emphasis to a fluctuating level of pain – dividing their life into what they described as a repeating cycle of good and bad periods. To cope with these symptoms, maintaining the good periods and avoiding or shorten the bad periods, they used rest, exercise, and social withdrawal. Participants expressed a constant notion of alternating or balancing between these coping strategies following the intensity of symptoms, or the expectancy of participating in situations or events that might trigger pain.

Participants reported severe neck and head pain, sensory hypersensitivity, and cognitive dysfunction as their main complaints. These symptoms are reported in several other studies. The pain was not described as being on a permanent level, but, rather, as fluctuating from a severe and intolerable level of pain to a more manageable pain. This fluctuating pattern was by the participants described as having bad and good periods. The symptoms were closely connected together as one could cause the onset of the other. Such a pattern of fluctuating pain and incapacity which is difficult to predict and manage, has also been reported in other studies on chronic pain, and it affects not only own health, but also family life and social activities.

A main finding in this study was how participants divided everyday life into good and bad periods, and how they adjusted their coping strategies according to this. Participants expressed a constant notion of alternating between or balancing their three main coping strategies; rest, exercise, and social withdrawal. If the balance – viz choosing and implementing the best strategy – was not maintained pain could be triggered or bad periods prolonged. The strategies were, primarily, chosen based on the intensity of symptoms, but it was also reported in the focus groups that the same strategies, mostly rest and social withdrawal, were used as means to prepare for, or unwind from, possible pain triggering situations or events.

Lazarus & Folkman’s cognitive-phenomenological model of stress and coping discriminates between active and passive coping strategies. Active or problem-focused strategies are used to target the source of stress and reduce it, whereas passive or emotional-focused strategies are mostly concerned towards adapting to the stress or problem. Most of the participants in this study used exercise, i.e. active coping strategies in good periods as they experienced that it reduced pain. Passive coping strategies, such as rest and social withdrawal, were mostly used to endure pain and to maintain the important balance as the participants were afraid of provoking bad periods. Social withdrawal may be interpreted as a direct consequence of their lifestyle changes, but participants also perceived it as a coping strategy per se – primarily used to avoid triggering the pain brought on by being exposed to noise, concentrating, or focusing too much.

Contrary to the Lazarus use of coping strategies, the Cognitive Activation Theory of Stress suggests that it is not the strategy or way of coping that is the most important issue, but the expectancy of the result. In the good periods our participants engaged in behaviors they expected to improve their circumstances – regular exercise being the most important one. The use of rest and social withdrawal were also used in good periods as a way of ‘charging the batteries’ for special events. The participants expected and experienced positive results of these behaviors, i.e. coping in the terminology of the cognitive activation theory of stress model.

However, what participants referred to as bad periods was characterized by unremitting pain often leading to frustration, depression, and social isolation. The participants had to socially withdraw and rest during these periods. In bad periods they felt that the symptoms took control of them, and that there was nothing they could do but rest and wait for a good period. Several participants experienced depression due to their situation. Within the cognitive activation theory of stress model helplessness or hopelessness develops when there is either no relationship or a negative relationship between what the individual attempts to do and the outcome. This may lead to sustained arousal, which, in turn, could lead to illness and disease such as depression and chronic fatigue syndrome.

The participants expressed that, to some degree, they could control or predict bad periods; consequently they tried to balance their life to avoid these periods. The constant notion of trying to balance; the restrictions and sacrifices behind their coping strategies took its toll on everyday life. The pattern of coping strategies described in this study was in accordance with other studies on patients with chronic pain, and was perceived as effective for these participants. However, it could be discussed whether or not the behavioral strategies, even though they might lead to positive response outcome expectancies, are adaptive or not. Most participants expressed a wish to be able to participate in working life. Nevertheless, only three in 14 participants had been able to maintain a work situation. So, although the strategies used were considered the most beneficial – or the only way to adjust their life, it is questionable whether or not they led to progress or just maintained the pattern of alternating good and bad periods. Knowledge of patients’ self-initiated coping strategies may give the clinician a better understanding of the patients’ frame of reference; how they organize everyday life to cope with their problems, and, accordingly, establish a better starting point for discussing potentially maladaptive strategies.

Participants reported severe neck and head pain, sensory hypersensitivity, and cognitive dysfunction as their main complaints. To cope with these complaints, and their fluctuating nature, three main strategies were used; rest, exercise, and social withdrawal. The participants portrayed that maintaining a balance between these coping strategies helped control the pain.

From: BMC Res Notes. 2010 Jul 13;3(1):190.

The incidence rate of whiplash injuries in Sweden is estimated to be 1.0-3.2/1000 /year. The injuries constitute a major health problem in Western society due to the large number of people with Whiplash associated disorder and the high economical costs associated with whiplash associated disorder. People with acute whiplash associated disorder, mainly complain of neck pain, stiffness, headache and dizziness. Other symptoms that may occur after the injury are fatigue, concentration and memory problems. Most subjects with acute whiplash associated disorder are reported to recover within three months of the trauma however, a significant number of persons experience symptoms several years after the accident. Persistent neck pain has been reported in 84-90% one to two year and in 55% 17 years after the injury.

It is still unclear why pain and related symptoms do not resolve after the expected time of healing and which factors are involved in the persistence of symptoms and impairments after the trauma. A bio-psycho-social model is often used to describe the complex interaction of physical and psychological factors in the development of chronic whiplash associated disorder. The long lasting problems after the injury may also interfere with occupational activities, the number of persons on sick-leave or unable to perform their ordinary duties six months after whiplash associated disorder have been reported to vary between 13 and 50%. In addition, chronic whiplash associated disorder may also affect leisure and daily life with social contacts and the total experience of life satisfaction.

Many studies of long-term problems after whiplash associated disorder have primarily focused on symptoms, especially neck pain in people seeking health care but fewer studies have investigated the long-term effects on activity/disability and life satisfaction. In addition, less is known about the differences between subjects who consider themselves as recovered and those who suffer from persistent disability. Sterling et al investigated post-traumatic stress in relation to disability on the Neck Disability Index during the first six months after whiplash injury. They found that persons who reported themselves to be recovered or to have mild disability six months post trauma reported decreased post-traumatic stress scores in comparison with early after the injury, whereas persons with moderate/severe disability reported persistent post-traumatic stress scores into the chronic stage.

In a scientific as well as in a clinical context, the need of studying subgroups of subjects has been proposed. Information about the characteristics of these groups may provide help to develop adequate treatments. Since the levels of disability seems to be of importance in whiplash associated disorder, this study aimed to assess the difference in symptoms, psychological factors and life satisfaction between subjects who were classified as recovered and those who suffered from mild/severe disability based on the Neck Disability Index. In addition, this study examines whether the Neck Disability Index is a clinically useful tool to classify whiplash disability.

Although previous studies have investigated disability in whiplash patients, to the authors knowledge this study is the first to investigate differences in pain intensity, symptoms, posttraumatic stress, depression, and life satisfaction between subjects with persistent disability and subjects classified as recovered in a “non-help-seeking” population long time after whiplash injury.

In the present study the Neck Disability Index was used to assess and to classify disability in according to a previous study. In their study of whiplash patients six months post trauma, the Neck Disability Index scores were slightly lower in comparison with the three subgroups in the present study. Regardless of the time difference between the two studies, it seems possible to assume that the character of disability in persons with whiplash associated disorder around half a year after the injury may persist for longer time. The results on the Neck Disability Index in our study also agree with the scores reported three years and 17 years after the injury.

In accordance with previous studies of whiplash associated disorder, neck pain was the most commonly reported symptom in the moderate/severe and the mild groups. These frequencies were close to results (55 %) reported 17 years after the injury. However, pain was also reported in the recovered group, but the frequencies of pain locations (neck, upper and lower back pain) were more equal. Among the whiplash related symptoms, cognitive deficits with poor concentration and poor memory were unexpectedly high both in the recovered group (25%) and in the moderate/severe and mild groups (60-93%). Since chronic pain, depression and post-traumatic stress may affect cognitive symptoms, these factors might have contributed to the cognitive disturbances in all groups in the present study.

The highest post-traumatic stress scores were reported in the moderate/severe group and the frequency of distinct post-traumatic stress reaction (36.3%) was clearly higher than reported in whiplash patients early after injury (13%). Some evidence for an association between greater post-traumatic stress and late whiplash syndrome has been shown. However, since the levels of post-traumatic stress were high especially in the moderate/severe group, these findings may support the recommendation of early diagnoses and treatment of acute stress to minimize the risk for long-lasting symptoms.

Chronic whiplash associated disorder may have a negative impact on quality of life. When comparing life satisfaction on the LiSat-11 between the three disability groups in our study with a large population-based Swedish reference group (2533 subjects), the mild and moderate/severe groups showed lower levels of life satisfaction. However, significant differences were found between the moderate/severe group and the recovered group in eight of eleven domains. Previous research has shown that depression influences outcome for quality of life in chronic whiplash associated disorder and the significantly higher BDI scores in the moderate/severe group may have contributed to their low life satisfaction. Moreover, the association between depression and non-recovered in the multivariate analysis indicates the importance of assessment and treatment of depression in whiplash associated disorder-patients.

This study has implications for clinicians. Although symptoms often are reported after whiplash injury, the activity levels may differ. Due to the complexity of whiplash associated disorder, the importance of identifying subgroups of whiplash associated disorder has been proposed in order to better tailor their treatment. In a previous study, Neck Disability Index was found to be the most sensitive instrument among several questionnaires to predict poor outcome. Our study adds to previous research: the Neck Disability Index seems to be a useful instrument for classifying whiplash subjects into subgroups. In general, we found that the group with moderate/severe disability reported high frequency of symptoms, high depression and post-traumatic stress scores and low level of life satisfaction. However, the recovered group also reported symptoms and post-traumatic stress scores, but these levels were not related to disability.