Analysis and management of whiplash associated disorders. Studies on prevalence, disability, pain perception, pain-related cognitions and supervised physical training that is tailored to the individual needs of patients

Abstract

The overall aim of the present thesis was to describe and analyse whiplash-associated disorders (WAD) in terms of long-term consequences and pain-related cognitions following motor vehicle accidents (MVAs) and to evaluate a physical training model that was supervised and tailored to the individual needs of patients with WAD. Studies I and II were based on a postal questionnaire survey and investigated symptoms of long-term WAD, work disability, involvement in settlement of claims, medical disability, and neck-related disability in 121 patients who had been exposed to MVAs 17 years previously. A control group comprising 1491 subjects who were representative of the general population was included in the analyses. Study III used a non-parametric statistical approach to evaluate the reliability of two multi-item scales: the Swedish version of the Tampa Scale for Kinesiophobia (TSK) and the Self-Efficacy Scale (SES). Study IV was a descriptive and prognostic study that assessed the perception of pain and factors that may predict disability. The data in study III and IV were obtained from study V a randomised, controlled study that evaluated the effectiveness of a physical training programme which was supervised and tailored to individual needs of patients. In studies I and II, 108 exposed patients (89%) and 1039 control subjects (64%) participated. Seventeen years following the MVAs, 55% of the exposed patients had residual disorders and one third of these suffered from work disability. All patients who had reached a final claim settlement had a poor outcome and 15 of the claimants had been assigned a medical disability between 5% and 30%. The patients' degree of medical disability and the neck disability scores were non-significantly correlated. There was a significant difference between the exposed group and the control group regarding neck pain (p<0.001) and neck-related disability (p<0.001). Studies III V involved 47 patients enrolled in an interdisciplinary rehabilitation centre in Göteborg, Sweden, that specialised in patients with WAD. Forty patients (85%) completed study V. Study III demonstrated that the SES and the TSK are reliable for patients with WAD. The correlation between the sensory and affective dimensions of pain was found to be non-significant in study IV, which indicates that they are two independent components, and self-efficacy was the most powerful predictor of persistent disability. Study V showed that, in the short term, supervised training improved self-efficacy (p=0.03) and reduced fear of movement/(re)injury (p=0.03), pain disability (p=0.03) and consumption of analgesics (p=0.03) significantly more than did home training. These improvements were partly maintained at 9 months, even though there was no amelioration in pain and physical disorders. In conclusion, a history of an MVA with sequelae of neck pain is a predictor of long-lasting neck pain. This pain will continue to contribute to the overall disability of the patient long after the accident. The management approach to patients with subacute WAD should be multidimensional incorporating both the sensory and affective components of pain and special effort should be made to enhance the patient s self-efficacy beliefs. Physical training that is supervised and adjusted to meet each patient s needs is significantly more favourable than home training in terms of improvement in self-efficacy, fear of movement/(re)injury, pain disability, and analgesic consumption in the short term.