Академический Документы
Профессиональный Документы
Культура Документы
Keywords: Background and purpose: Physical mechanisms are the possible factors involved in the
headache, neck pain, development and maintenance of long-term handicaps after acute whiplash injury.
prognostic factors, This study prospectively examined the role of active neck mobility, cervical and extra-
prospective studies, risk cervical pains, as well as non-painful complaints after a whiplash injury as predictors
factors, whiplash injuries for subsequent handicap. Methods: Consecutive acute whiplash patients (n = 688)
were interviewed and examined by a study nurse after the median of 5 days after
Received 29 January 2008 injury, and divided into a high- or a low-risk group by an algorithm based on pain
Accepted 14 July 2008 intensity, number of non-painful complaints and active neck mobility [active cervical
range of motion (CROM)]. All 458 high-risk patients and 230 low-risk patients
received mailed questionnaires after 3, 6 and 12 months. Two examiners examined all
high-risk patients (n = 458) and 41 consecutive low-risk patients at median 11, 109,
380 days after injury. The main outcome measures were: handicaps, severe headaches,
neck pain and neck disability. Results: The relative risk for a 1-year disability
increased by 3.5 with initial intense neck pain and headaches, by 4.6 times
with reduced CROM and by four times with multiple non-painful complaints.
Conclusion: Reduced active neck mobility, immediate intense neck pain and
headaches and the presence of multiple non-painful complaints are the important
prognostic factors for a 1-year handicap after acute whiplash.
Funen Hospital/University of Southern Denmark) (d) Number of non-painful symptoms (02 = 0 points;
prospective interventional three parallel group trial in 35 = 1 point; 611 = 3 points) where 0 denotes no
which immobilization or active mobilization was com- pain and 10 denotes worst imaginable pain, where
pared with advice to act-as-usual. Emergency units and minimum was having no non-painful complaints and
general practitioners located in four counties, repre- maximum was having 11 of 11 possible non-painful
senting approximately 1.7 million inhabitants, referred complaints.
acute whiplash patients to the study. Enrolment took As shown, VAS scores >4 and total CROM <240
place between May 2001 and June 2003. were considered high-risk on its own.
The inclusion criteria were age 1870 years; exposure
to a rear- or frontal-end car collision; WAD [3] symp-
Data collection
toms within 3 days post-injury (WAD grade IIII [3]);
participants understood written and verbal Danish; and Questionnaires were lled in at baseline and after 3, 6,
inclusion performed within 10 days after injury. and 12 months after the injury by all participants.
The exclusion criteria were injuries with fractures or Frequency and intensity of neck pain, headache and
dislocations (WAD grade IV); trauma other than the non-painful symptoms were recorded at each time-
whiplash including cerebral concussion; pre-existing point, and neck pain and headache were scored on a 11-
signicant somatic or psychiatric disease and signicant Point VAS. A record of the previous symptoms, disease,
headache and neck pain; known alcohol- or drug abuse. medication, and socio-demographic and injury related
Signicant previous pain conditions were in detail: factors were also obtained at baseline. Results from
disability pension because of headache; neck pain; SF-36, Symptom Check List 90 Revised (SCL-90R),
shoulder pain or low back pain; sick leave for more Coping Strategies Questionnaire [18] and Impact of
than 3 months duration during last year because of Event Questionnaire [19] are reported elsewhere.
neck pain, headache, low back pain or shoulder-pain
condition; regularly prescribed analgesic medication or
Clinical assessment
other regular interventional therapy for chronic pain
condition. Average neck-pain and/or headache during At the rst examination, all patients underwent struc-
the last 6 months rated from 3 to 10 on an 11-Point tured neurological examination of cranial nerves and
Visual Analogue Scale (VAS) Box Scale. upper and lower extremities including assessment of
The study was approved by the local ethical com- tendon reexes, sensory function and muscle strength at
mittees and conducted in accordance with the Helsinki baseline and at 3 and 12-month follow-ups.
II Declaration. Each participant, who gave permission Active neck mobility (exion, extension, left and
to be contacted when seen in the emergency unit or by right rotation and lateral-exion) was assessed with a
the general practitioner, received verbal and written CROM Device (Performance Attainment Associates,
information about the study by the study nurse before Roseville, MN, USA) as previously described [20,21].
giving verbal and written consent to participation. During neck movement in all of six directions, the
examiner asked the patient whether pain was elicited by
that particular movement, and if so, whether pain oc-
Determination of risk status
curred in the neck region or in a region remote from the
The criteria for high- and low-risks were determined a neck.
priori and have been previously described [17]. Briey, Methodical palpation was performed at nine sites
these risk factors were combined into a risk score. To be bilaterally: (i) the anterior and (ii) posterior part of the
included in the high-risk group, the risk score had to be temporal muscle, (iii) the masseter muscle, (iv) the
4. The scoring was as follows: lateral pterygoid muscle, (v) the sternocleid at inser-
(a) Active neck mobility, total CROM which included tion point and (vi) the sternocleid at its belly, (vii) the
the following six directions of movement; exion; suboccipital muscle, (viii) trapezius at its superior part
extension; right and left latero-exion, and right and and (ix) the rhomboid muscle along the medial border
left rotation [16] (range below 200 = 10 points; 200 of scapula. From 0 to 4 points was given at each site
220 = 8 points; 221240 = 6 points; 241260 = according to the American College of Rheumatology
4 points; 261280 = 2 points; above 280 = 0 points). (ACR) criteria [22]. 0 = (no pain) denial of tenderness,
(b) 11-Box VAS present neck pain/headache (02 = 1 = (mild pain) complaint of pain without grimace,
0 points; 34 = 1 point; 58 = 4 points; 910 = 6 inch or withdrawal, 2 = (moderate pain) plus
points). On this scale 0 denotes no pain and 10 denotes grimace or inch, 3 = (severe pain) plus marked inch
worst imaginable pain. or withdrawal, 4 = (unbearable pain) patient is
(c) Female gender (yes = 1 point, no = 0 points). untouchable, withdraws without palpation.
Patients were blinded with respect to assignment to last 6 months, work inability during the last month, or
the high- or low-risk groups, and patients were not not working anymore because of the accident [16]. The
aware of any division being made. Initial assessment number of days with handicap was computed by means
was performed after the median of 5 days by the study of questionnaire data after 3, 6 and 12 months post-
nurse and included examination and division into high- injury. Days with sick leave were counted as full days
and low-risk groups. At this point, the study nurse and days with reduced working hours were counted as
knew if the patient belonged to the high- or the low-risk half days. If the patient could manage full time, but had
groups. changed functions after injury, it was counted as full-
Based on these ndings, a division into a low- and a working hours. Patients who did not work prior to
high-risk group by means of a block randomization injury (on leave, unemployed, disability pension and
took place using the software program MINIMIZE to retired) were not considered in the calculated risk for
ensure that the two low-risk treatment groups (verbal handicap, but were included in computation of
info or booklet) and the three high-risk treatment secondary outcome measures.
groups (McKenzie physiotherapy [23], verbal info or
sti neck collar [24]) were balanced according to the
Secondary outcome measures
following items [gender (0/1), age categories (1830;
3145, 4655 and 5670), VAS pain (02; 34; 57 and After 12 months, neck pain and headache were rated on
810) and CROM (300+; 250299; 200249 and 0 11-Point Box Scales (0 = no pain, 10 = worst imag-
199). inable pain) pain scores from 0 to 4 were considered as
In the high-risk group, if randomized to immobili- minimal pain and from 5 to 10 were considered con-
zation, a sti neck collar was mounted, and the patient siderable pain [25].
was instructed how to use it for 14 days and was Neck disability after 12 months was assessed by
enabled to receiving active physiotherapy after 2 weeks means of the Copenhagen Neck Disability Scale [26],
being in contact with the study physiotherapists where scores from 0 to 6 were dened as minimal neck
to receive advice and also to assess compliance. If disability and from 7 to 30 were considered consider-
randomized to active mobilization, the patient was able neck disability.
scheduled to meet the study physiotherapist, and, based
on the principles for McKenzie treatment, to receive
Statistical analysis
active mobilization (mechanical diagnosis and therapy
[MDT] including two weekly contacts for a maximum Data analysis was made using SPSS 11.0 (SPSS Inc.,
of 6 weeks). In this group, compliance was also evalu- Chicago, IL, USA), STATA 8.0 (Circle Systems Inc,
ated. There was no dierence regarding compliance in Seattle, WA, USA), and Microsoft Excel 2002 for
the mobilization and immobilization groups. Windows. Data were analysed and investigators re-
When high-risk patients were seen in the following mained blindfolded until the analysis of the treatment
2 weeks, 3 months and 12 months after injury, the eect had been performed.
examiners at the research centres were blindfolded to KaplanMeier (KM) survival analysis was applied to
whether the patient was receiving immobilization, determine recovery rates in the high- and low-risk strata
mobilization or verbal information as treatment. based on the primary end-point handicap and the three
The high-risk patients receiving active treatment were secondary end-points: severe neck pain, severe head-
guided in this respect by the physiotherapists, who also aches and persistent neck disability. For computational
made a standardized evaluation of the patient regarding reasons, it was assumed that each participant was
compliance to active treatment. handicapped and had considerable neck pain and
At the Back Research Centre, further 41 consecutive headache and considerable disability at time of injury,
low-risk patients were examined by the same means as which was deemed day 0 (for KM plots and Cox
high-risk patients. regression analysis). For the preparation of the Cox
There was no dierence regarding answering ques- regression, time-to-event was chosen as time-parameter.
tionnaires or drop-outs between the three high-risk Following pairs of events (i) and time-to event (ii) were
groups and the two low-risk groups or between high- chosen:
and low-risk patients. (1) (i) Status change from handicap to recovery and (ii)
days until recovery from handicap.
(2) (i) Status change from severe headache (VAS: 510)
Primary outcome measure
to less severe headache or pain-free at the following
Handicaps after 12 months were assessed based on the time-points and (ii) days until recovery from severe
presence of: more than 3 months sick leave during the headache.
(3) (i) Status change from severe neck pain (VAS 510) Table S1 shows the socio-demographic comparison
to less severe pain or pain-free at consecutive time- of the high- and low-risk groups by means of a Krus-
points, and (ii) days until recovery from severe neck kalWallis test which showed that patients were less
pain. vocationally trained in the high-risk group
The following prognostic factors were evaluated in the (P < 0.002). There was no age dierence or dierence
Cox regression analysis: on actual occupation, marital status, or the number of
Factor 1: Total cervical range of motion, three catego- children at home.
ries: (0240; 241280; 281+) [16]. As would be expected, the initial examination and
Factor 2: Initial Neck pain VAS010, three categories: 0 pain scores found that high-risk patients had higher
2; 35; 610. number of painful neck movements (06 directions)
Factor 3: Initial Headache VAS010, three categories: 0 during active cervical range of motion (P < 0.001), a
2; 35; 610. signicantly higher total tenderness scores by muscle
Factor 4: Initial number of non-painful symptoms palpation (P < 0.001), a higher number of painful
(range 011), three categories: 02; 35; 611. symptoms (P < 0.001), a higher intensity (P < 0.001)
Factor 5: Number of movement directions with local and frequency (P < 0.001) of painful symptoms and a
pain during CROM test (02; 34; 56). higher intensity of non-painful symptoms (P < 0.007).
Factor 6: Total palpation pain score, neck and jaw Major properties of high- and low-risk groups are
muscle-pairs (012; 1324; 2548). shown in detail in Table S2 and details on development
Factor 7: Female gender (Y/N). in painful and non-painful neurological symptoms are
Factor 8: Age, three categories (1830; 3150; 5170). provided in Fig. S1.The intensity of non-painful
Factor 9: Reported Seriousness of Car accident (mild, symptoms as well as the frequency of these symptoms
moderate, severe). diered between recovered and handicapped patients as
Factor 10: Initial VAS score of being back at work after shown in Figs S1b and d. The results also show that not
6 weeks (0 = most likely; 10 = most unlikely, three only intensity and frequency of cognitive symptoms are
categories (02; 35; 610). higher in the non-recovered patients from the rst
examination, especially fatigue, irritability, concentra-
tion problems and memory disturbances, but also sleep
Results
disturbances are present from very early after injury
A total of 1495 [F/M: 898/597] acute patients were (for all disabilities listed, P < 0.001).
contacted from emergency units and general practi- Figures S1a and d show that not only neck pain and
tioners and 680 eligible acute whiplash patients [443/ headache, but also shoulder pain, arm pain, low back
252] gave informed consent to participate. Six-hun- pain, but not jaw pain diered signicantly in patients
dred patients [353/247] were not eligible for partici- with disability as compared with recovered whiplash
pation, but from this group, we followed-up 52 patients after rst examination. The dierence was even
patients with previous moderate neck pain (VAS < 4) more pronounced after 1 year, and after 1-year handi-
according to the principles in the low-risk group (to capped also diered signicantly from recovered
be published elsewhere) and 200 [102/98] declined regarding intensity and frequency of jaw pain.
participation. The majority of this group declined As part of the algorithmic procedure for dividing
because of lack of time, vacation and no interest in patients by means of risk criteria, high-risk patients had
treatment intervention. Patients were divided accord- reduced CROM, high neck pain and headache intensity
ing to a previously described stratication procedure as well as frequency of multiple non-painful symptoms.
[17] into a high-risk group of 458 [328/130] patients, The relative risk for 1-year disability by means of
and a low-risk group consisting of 230 patients [110/ either handicap, continuous signicant neck pain or
120]. See owchart in Fig. 1. The two treatments were neck disability was assessed for various prognostic
not superior to acting as usual in high-risk patients, factors. Gender (rr: 1.6; CI95: 0.99; 2.5) was not a sig-
for details refer to [17] and the acting as usual mes- nicant risk factor for being handicapped after 1 year,
sage given by booklet or verbally did not inuence but women were in the risk group for neck disability (rr:
recovery end-points in low-risk patients, for details 1.3; CI95: 1.0; 1.7) and long-term neck pain (rr: 1.5;
refer to [27]. Twenty-three of 688 whiplash patients CI95: 1.2; 1.9). The relative risk in the high-risk group
fullled the criteria for WAD grade III (F/M:19/7; for a 1-year handicap was more than 10-fold (rr: 10.5;
age 37.2 2.2); none of these had areexia or hyp- CI95: 3.9; 28.2). Initial high neck pain intensity was
oexia, but were mainly characterized by diuse associated with 3.5-fold risk increase (rr: 3.5; CI95: 2.2;
muscle weakness in upper and/or lower extremities at 5.5), as was headache intensity (rr: 3.7; CI95: 2.4; 5.7).
the rst examination. Reduced active cervical range of motion was associated
Ineligible:
n = 540 [311/229]
Declined participation
n = 200 [102/98]
Protocol violation
n = 15 [11/4]
Baseline evaluation
n = 740 [474/266]
with a 4.6-fold risk increase for chronic handicap. A headache (P < 0.01) or neck pain (P < 0.004). The
four-fold increase for handicap was seen with initial presence of initial severe neck pain and headache was risk
high palpation tenderness score (rr: 4.0; CI95: 1.9; 8.5). factors for being handicapped (P < 0.01 and P < 0.02).
Figures 2ad: KM plots showing development in Severe initial neck pain was associated with long-term
recovery after the injury. Fig. 2a shows that 1-year severe neck pain, but not associated with the develop-
handicap was found in 19.3% of high-risk patients ment of a long-term and severe headache, severe initial
(17.1; 21.8) and in 2.4% (1.8; 2.9) of low-risk patients headache was associated with long-term headache, but
after 1 year, and that patients in the high-risk group not associated with a long-term severe neck pain.
had signicantly slower recovery from handicap A large number of non-painful symptoms at rst
(Fig. S1a: Log Rank: 110; P < 0.001), from high examination were a risk factor for a long-term handicap
intensity neck pain (Fig. S1b: Log Rank: 155.96; (P < 0.007), but not associated with a long-term
P < 0.001), and high intensity headache (Fig. S1c: Log headache or neck pain. Initial reduction of active neck
Rank: 40.99; P < 0.001) and from neck disability mobility was a signicant risk factor for a long-term
(Fig. S1d: Log Rank: 95.81; P < 0.001). handicap (P < 0.0001), but not associated with long-
A Cox-regression analysis showed that gender was not term neck pain or headache.
a signicant risk factor for being handicapped, but was a The best prognostic marker for a long-term handicap
risk factor for the development of long-term severe or changed work function after 1 year was active cer-
80 80
Handicapped (%)
40 40
20 20
0 0
0 100 200 300 400 0 100 200 300 400
Figure 2 (a) Time to recovery from Time to recovery (days) Time to recovery (days)
handicap after acute whiplash injury in
high- and low-risk whiplash patients (c) 100 (d) 100
vical range of motion with an accuracy of 74%, whereas by bias than subjective symptoms. It may be argued
high initial neck pain score and headache score revealed that handicap in our study terms can be caused by
an accuracy of 65% and 69% respectively. other factors than the injury itself, for example
Log-minus-log (LML) curves were made for each of psychological [3133], legislative [14,34] and socio-
the six prognostic factors, and the time-dependent demographic factors [11,35]. Nevertheless, the fact
covariance of each factor was examined before running that the same measure and assessment in the present
the Cox regression analysis. There was no signicant study were performed as early as ve 5 days after
time-dependency of factors (SPSS TIME PROGRAM: injury in both the high- and the low-risk groups
a = 0.05; b = 0.10), LML-graphs showed parallel which were similar in terms of socio-demographic
curves for the split factors in all plots. ndings suggests that disabilities are linked to the
whiplash injury per se.
We have previously shown that reduced active neck
Discussion
mobility (active CROM) was related to handicap [16]
This prospective study of acute whiplash injured per- and was a clinical sign in acute whiplash patients, but
sons showed that patients with a reduced active neck reduced CROM was not present in acute ankle injured
mobility, high intensity of neck pain and headache and patients [20]. This study conrms these preliminary
multiple non-painful symptoms carry a 10-times raised results. Reduced active neck mobility is not a biome-
risk for the development of chronic WADs. In the chanical test per se, but is probably to be inuenced by
high-risk group one out of ve as compared to one out both physical and psychological factors. Whether the
of 40 in the low-risk group were handicapped 1 year presence of reduced active CROM is related to tissue
after injury and the recovery rates for the high- and damage or is a pseudo-biomechanical nding inu-
the low-risk groups diered remarkably according to enced by pain-related fear [36,37] is an interesting
the a priori chosen 1-year end-points: handicap, possibility open for discussion and further studies.
severe neck pain and headache and neck disability However, focal neck pain and sensitization [3840] or
(Figs S1ad). pre-existing pain [41] may also play a role for initial
Previous studies have observed similar ndings neck disability. In this study, neck pain, pain elicited
[28,29]; however, this study is the rst to test the sig- by CROM testing, reduced pain threshold and muscle
nicance of a priori identied prognostic factors. tenderness, high intensity and frequency of painful and
There are neither clinical nor paraclinical measures non-painful symptoms are all factors that contribute
of the chronic WAD syndrome [30], but we used to long-term handicap. Reported severity of injury was
return-to-work and daily activity as our primary end- not related to recovery rate in this study and previous
point because they are rather robust and less aected studies [28,42]. However, the fact that patients with
initial reduced cervical range of motion had a work capability is an assessor of independent parameter
4.6 times higher risk for disabilities after 1 year, pa- and is not sensitive to investigator bias; (iii) the CROM
tients with high initial neck pain and headache inten- test has previously been found to be a reproducible test
sity were associated with a 3.5 times higher risk for with a low variation coecient [20].
long-term handicap and those with a high number of
non-painful symptoms were associated with about
Conclusion
4.0 times raised risk for a long-term handicap may
indicate that nociceptive sensitization could therefore This study substantiates previous suggestions that ini-
be one of the several features involved in the devel- tially reduced active neck mobility, high neck pain and
opment of chronic WAD [2,3840,43,44]. In this headache intensity, as well as multiple non-painful
study, however, in parallel to the development of symptoms are associated with a high-risk for a long-
painful symptoms and a spread of pain, we also found term handicap after acute whiplash injury. These data,
non-painful symptoms to predict long-term handicap, because of the prospective character of the study and a
which may further involve somatization or other priori dened risk factors, indicate that symptoms and
psychological phenomena [33,45]. Non-painful symp- signs associated with acute whiplash injury are impor-
toms may also reect alterations in pain processing by tant determinants for the development of a long-term
means of primary or secondary sensitization of the handicap.
nociceptive system [46], referred sensory disturbances
are seen in deep muscle pain [40,44].
Acknowledgements
It may be speculated that the interventions applied in
the high-risk group could bias the results of this study Participants were recruited with the help of sta at the
towards a more severe outcome in patients receiving emergency units in hospitals in the four former counties
active mobilization or immobilization compared with a of Viborg, Aarhus, Vejle and Funen during enrolment
verbal stay active message. Patients exposed to an period. Statistical consulting was provided from the
active treatment either it be immobilization or active Department of Statistics, University of Southern Den-
mobilization after an injury could be more prone to mark on designing the study. Financial support was
catastrophizing [13,45], or just more worried about provided by an unrestricted grant from Insurance and
being injured. However, we nd this unlikely in this Pensions in Denmark.
study, as the interventions did not signicantly aect
the outcome parameters as they have been reported
Supporting Information
previously [17]. Neither was a verbal stay-active mes-
sage given by the study nurse in the low-risk group Additional Supporting Information may be found in
superior to a booklet [27]. the online version of this article.
In addition, the patients were blind-folded regarding
high- or low-risk category of the patient. This large Figure S1 (a) Pain presentation 5 days after acute
clinical study is consistent with formerly proposed risk whiplash injury. (b) Non-pain symptom presentation
factors [16]. Previous studies have also found pain 5 days after acute whiplash injury. (c) Pain presentation
intensity and non-pain symptoms to be of importance 1 year after acute whiplash injury. (d) Non-pain
for non-recovery [4749]. On the basis of previous symptom presentation 1 year after acute whiplash in-
studies [4,49,50], we included female gender as a risk jury. Frequencies of symptoms are shown in percent-
factor in this study when dividing them into high- or ages SD (from 0% to 100%). Intensities of
low-risk groups and also in our work, female gender symptoms both painful and non-painful symptoms
was found to be a relative risk factor for long-term neck represent a four-point ordinal scale from 0 = none,
disability and severe neck pain, but not for long-term 1 = mild, 2 = moderate and 3 = severe, grading the
handicap, the former being in concordance with general severity of that symptom in relation to the injury.
population studies [5153]. Table S1 Socio-demographic factors in acute high- and
There are no objective parameters to document low-risk whiplash patients.
handicap in whiplash, so the present results are poten- Table S2 Initial properties and assessment in acute
tially open to bias. We consider this less probably for the high- and low-risk whiplash patients.
following reasons: (i) return to daily activity was based Please note: Wiley-Blackwell are not responsible for
on a standardized semi-structured interview/question- the content or functionality of any supporting materials
naire applied 6 and 12 months after the injury. All pain supplied by the authors. Any queries (other than
and muscle tenderness assessments and the CROM test missing material) should be directed to the corre-
were carried out prior to the time of assessment; (ii) sponding author for the article.
whiplash-associated disorders. Spine 2006; 31: E759 44. Graven-Nielsen T, Curatolo M, Mense S. Central sensi-
E765; discussion E766. tization, referred pain, and deep tissue hyperalgesia in
35. Ferrari R, Kwan O, Russel AS, Pearce JM, Schrader H. musculoskeletal pain. In: Flor H, Kalso E, Dostrovsky
The best approach to the problem of whiplash? One ticket JO, eds. Proceedings of the 11th World Congress on Pain.
to Lithuania, please. Clinical and Experimental Rheuma- Seattle: IASP Press, 2006: 217230.
tology 1999; 17: 321326. 45. Nederhand MJ, Hermens HJ, Ijzerman MJ, Groothuis
36. Vlayen JWS, Jong JD, Geilen M, Heuts PHTG, Breuke- KG, Turk DC. The effect of fear of movement on muscle
len GV. Fear of Movement/(re) Injury: Graded Exposure activation in posttraumatic neck pain disability. Clinical
In Vivo as an Effective Treatment: Pain in Europe V. Journal of Pain 2006; 22: 519525.
Istanbul, Turkey: EFIC, European Federation of IASP 46. Sterling M, Jull G, Vicenzino B, Kenardy J, Darnell R.
Chapters, 2006. Physical and psychological factors predict outcome
37. Vangronsveld K, Peters M, Goossens M, Linton S, Vla- following whiplash injury. Pain 2005; 114: 141148.
eyen J. Applying the fear-avoidance model to the chronic 47. Radanov BP, Sturzenegger M, Di Stefano G. Long-term
whiplash syndrome. Pain 2007; 131: 258261. outcome after whiplash injury a 2-year follow-up con-
38. Sterling M, Jull G, Vicenzino B, Kenardy J. Sensory sidering features of injury mechanism and somatic,
hypersensitivity occurs after whiplash injury and radiologic, and psychosocial ndings. Medicine 1995; 74:
is associated with poor recovery. Pain 2003; 104: 509 281297.
517. 48. Radanov BP, Sturzenegger M, Di Stefano G, Schnidrig A,
39. Kasch H, Qerama E, Kongsted A, Bendix T, Jensen TS. Aljinovic M. Factors inuencing recovery from headache
Deep muscle pain, tender-points and recovery in acute after common whiplash. BMJ 1993; 307: 652655.
whiplash patients. A 1-year follow-up study. Pain 2008; 49. Hartling L, Brison RJ, Ardern C, Pickett W. Prognostic
(in press). value of the Quebec classication of whiplash-associated
40. Kasch H, Qerama E, Bach FW, Jensen TS. Reduced cold disorders. Spine 2001; 26: 3641.
pressor pain tolerance in non-recovered whiplash patients. 50. Borchgrevink GE, Stiles TC, Borchgrevink PC, Lereim I.
A 1-year prospective study. European Journal of Pain Personality prole among symptomatic and recovered
2005; 9: 561569. patients with neck sprain injury, measured by MCMI-I
41. Sjaastad O, Fredriksen TA, Batnes J, Petersen HC, acutely and 6 months after car accident. Journal of Psy-
Bakketeig LS. Whiplash in individuals with known pre- chosomatic Research 1997; 42: 357367.
accident, clinical neck status. The Journal of Headache and 51. Bovim G, Schrader H, Sand T. Neck pain in the general
Pain 2006; 7: 920. population. Spine 1994; 19: 13071309.
42. Ferrari R, Russell AS, Carroll LJ, Cassidy JD. A 52. Cote P, Cassidy JD, Carrol LJ. The factors associated
re-examination of the whiplash associated disorders with neck pain and its related disability in the Saskatch-
(WAD) as a systemic illness. Annals of the Rheumatic ewan population. Spine 2000; 25: 11091117.
Diseases 2005; 64: 13371342. 53. Cote P, Cassidy JD, Carrol LJ. Is a lifetime of neck injury
43. Curatolo M, Petersen-Felix S, Arendt-Nielsen L, Giani C, in a trafc collision associated with prevalent neck pain,
Zbinden A, Radanov B. Central hypersensitivity in headache and depressive symptomatology? Accident
chronic pain after whiplash injury. Clinical Journal of Pain Analysis and Prevention 2000; 32: 151159.
2001; 17: 306315.