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Three Part Question

[In adults presenting with neck pain following RTAs] [what early identifiable factors] determine prognosis in terms of [pain and return to normal activities]

Clinical Scenario

A 24 year old male presents to the emergency department with neck pain following a rear impact RTA. There was minor damage to the vehicle bumper and lights assembly. He was the restrained driver of a mid size 4-door saloon car. He scores 5/10 on a subjective pain score. There is minor limitation of movement some mid-line tenderness of the cervical spine. Neurological examination is normal. He meets the criteria for cervical spine imaging and a 3-series plain X-ray series is reported as normal. You advise conservative treatment with NSAIDs and mobilization techniques. He seems happy with this and declares that he is keen to return to work as he is self employed but asks how long it will take to get better as he has a friend who is still "on the sick" a year after a "whiplash" injury.

Search Strategy

Medline on OVID interface on the world wide web 1966-10/04
CINAHL on OVID interface on the world wide web 1982 to December Week 1 2004
EMBASE on OVID interface on the world wide web 2002-week 50 2004
AMED on OVID interface on the world wide web 1985 to December 2004
Cochrane Library via NELH Issue 4, 2004
MEDLINE
[cervical.mp. or exp CERVICAL VERTEBRAE/ or exp NECK PAIN/ or exp NECK INJURIES/ or exp NECK/ or exp NECK MUSCLES/ or neck.mp. or WAD.mp. or exp WHIPLASH INJURIES/ or whiplash.mp.] limit to "prognosis (sensitivity search from OVID-MEDLINE)
EMBASE, CINAHL
[cervical.mp. or exp CERVICAL VERTEBRAE/ or exp NECK PAIN/ or exp NECK INJURIES/ or exp NECK/ or exp NECK MUSCLES/ or neck.mp. or WAD.mp. or exp WHIPLASH INJURIES/ or whiplash.mp.] AND [exp TRAFFIC ACCIDENT/ or exp ACCIDENT/] AND [prognosis.mp]
AMED
[cervical.mp. or exp CERVICAL VERTEBRAE/ or exp NECK PAIN/ or exp NECK INJURIES/ or exp NECK/ or exp NECK MUSCLES/ or neck.mp. or WAD.mp. or exp WHIPLASH INJURIES/ or whiplash.mp.] AND [prognosis.mp]
Cochrane
[Whiplash] and [prognosis]

Search Outcome

MEDLINE – 378 papers were found. 2 well conducted systematic reviews published in 2001 and 2003 were found. These together with any subsequent papers are shown below.
CINAHL – 4 papers were found. No additional relevant references were identified.
EMBASE – 23 papers identified. No additional references identified.
AMED - 77 papers identified. No additional references identified
Cochrane – 9 hits. No additional references.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Scholten-Peeters GGM 2003 Holland	Papers related to prognosis in whiplash injuries (neck pain associated with motor vehicle accidents). Only prospective cohorts included. No restriction for language. Papers sought from a wide variety of sources from 1966 onwards.	Systematic review	No. of papers found	356 papers identified. 29 included in review after quality and relevance assessment	Some well known studies excluded because they were non-prospective.Few of the studies fully described what treatments had been given to the patients. This may be an important confounding factor.
			Quantitive revioew	Not possible owing to varying designs and outcomes
			Qualitive review	High initial pain score positively associated with poor prognosis
			Other comments made	The following did not appear to influence outcome: Older age, female gender, high acute psychological response, angular deformity, rear end collision and compensation.
Cote P 2001 Canada	Update on the 1995 Quebec task forces finding that there were no reliable prognostic factors for whiplash. Only data from after 1995 included in this review. Only motor vehicle related problems included.	Systematic review.	No of papers included.	3475 papers identified. 22 independantly reviewed, 13 accepted into review after quality assessment.	Limited time period assessed. Prospective and retrospective cohorts included (retrospective open to bias).Limited to English papers only.
			Effect of sociodemographic factors	Many conflicting results. Older age, female gender associated with delayed recovery.
			Effect of general health before injury	No consistent factors identified
			Crash-related factors	No consistent factors identified
			Initial health care	1 study only. Consultation with clinician associated with delayed recovery
			Post collision signs and symptoms	2 studies. Delayed recovery associated with: Neck pain intensity, headache intensity, radicular signs and symptoms.
			Legal and compensation factors	1 study only. Legal proceedings associated with delayed recovery
Suissa 2003 Canada	4766 patients who submitted a compensation claim associated with a whiplash injury in 1987. Quebec in Canada. 2627 had isolated whiplash injury. Different numbers appear in different parts of the analyses dependant upon the availability of data (e.g. not all patients had police crash reports). Univariate and multivariate analysis to determine prognostic risk factors.	Prospective Cohort paper	Clinical findings associated with poor recovery	Multivariate analysis showed the following to be associated with adverse prognosis: Neck pain on palpation (OR 0.85), Muscle pain (OR 0.85), radiating numbness or pain to arms/hands (OR 0.64) or shoulders (OR 0.79), or headache (OR 0.82)	No validation set to test scores or results of analysis. Only compensation patients. Recovery defined as the last date of compensation payments.
			Quebec classification as a risk factor	QTF grade 1 as reference risk, QTF grade 2 (OR 0.64), QTF grade 3 (OR 0.61) for recovery rates
			sociodemographic factors associated with adverse prognosis	older age, female sex, having dependants and not being employed full time associated with adverse outcome (size of effect not stated)
			Crash factors associated wit hadverse prognosis	Being in a truck or bus, being a passenger in a vehicle, colliding with a moving vehicle, side or frontal collision.
			risk score to predict outcome	An 11 point score is presented based on the data recorded which is claimed to predict recovery rates
Pettersson K 2004 Sweden	40 patients with grade 2 and 3 whiplash injuries admitted to Hospital. All patients had temperament/character scores at admission, 2 months and 2 years	Case Control study	Does temperament or character predict outcome?	No differences between full recovery (26 pts), mild symptoms (8 pts) and severe symptoms (5 pts).	Very small numbers. Only admitted patients. Limited patient spectrum.

Comment(s)

The Quebec task force study on whiplash published in 1995 reviewed thousands of papers on the disorder. They concluded that the scientific evidence was of insufficient quality to define specific prognostic factors. However, they did conclude the following general findings in terms of prognosis:- 50% return to usual activity by 31 days only 26% are off work between 2 and 6 months only 12.5% remain off work 6 months after injury only 1.9% remain off work over 1 year 15.3% with multiple injuries are off work after 6 months. The subsequent systematic reviews and papers identified in the table above come to similar conclusions. There appear to be few consistent factors which reliably indicate which patients are likely to have a delayed recovery. It is particularly interesting to note that the 2 systematic reviews come to different conclusions regarding age and gender. This fact is discussed in the latter review and is possibly attributed to a stricter quality filter and a broader language search. For such a common problem facing clinicians in many specialties it is disappointing that that there is no robust research that we can use to advise our patients.

Clinical Bottom Line

There are no robust scoring systems to identify patients at risk of delayed recovery from whiplash injury.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. Scholten-Peeters GG, Verhagen AP, Bekkering GE, van der Windt DA, Barnsley L, Oostendorp RA et al. Prognostic factors of whiplash-associated disorders: a systematic review of prospective cohort studies Pain 104(1-2):303-22, 2003.
2. Cote P, Cassidy JD, Carroll L, Frank JW, Bombardier C A systematic review of the prognosis of acute whiplash and a new conceptual framework to synthesize the literature Spine 26(19):E445-58, 2001.
3. Suissa S Risk factors of poor prognosis after whiplash injury Pain Research & Management 8(2):69-75, 2003.
4. Pettersson K, Brandstrom S, Toolanen G, Hildingsson C, Nylander PO. Temperament and character: prognostic factors in whiplash patients? European Spine Journal 13(5):408-14, 2004.