Impact of Motor Vehicle Accidents on Neck Pain
and Disability in General Practice

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:    Frankp@chiro.org

British Journal of General Practice 2008 (Sep);   58 (554):   624–629 ~ FULL TEXT

Cees J Vos, MD, PhD, GP, Arianne P Verhagen, PhD, Jan Passchier, and Bart W Koes, PhD

Department of General Practice, Erasmus MC, University Medical Centre Rotterdam, the Netherlands. c.vos@erasmusmc.nl


BACKGROUND:   High levels of continuous neck pain after a motor vehicle accident (MVA) are reported in cross-sectional studies. Knowledge of this association in general practice is limited.

AIM:   To compare the differences in perceived pain and disability in patients with acute neck pain due to an MVA versus other self-reported causes. The secondary aim was to identify prognostic factors for continuous neck pain.

DESIGN OF STUDY:   Prospective cohort study with 1-year follow-up.

SETTING:   General practices in Rotterdam and its suburban region.

METHOD:   Patients with non-specific acute neck pain were invited to participate. Questionnaires were collected at baseline and after 6, 12, 26, and 52 weeks. The numerical pain-rating scale (NRS) and the neck disability index (NDI) were measured. Regression analysis was used to identify prognostic factors for continuous neck pain.

RESULTS:   A total of 187 patients were included. The MVA subgroup (n = 42) was significantly younger (P = 0.007), reported more sick leave (P = 0.037), higher levels of headache (P<0.001) and higher NDI scores at baseline (P = 0.018) but lower scores for previous neck pain (P = 0.015) compared to the remaining cohort. At follow-up the MVA subgroup had higher scores for continuous neck pain (63% versus 40%) and at the NDI (11.0 versus 7.1). After multivariate analysis 'pain in the upper part of the neck' (odds ratio [OR] = 1.6), 'duration of complaints at baseline longer than 2 weeks' (OR = 5.3), and an 'MVA' (OR = 5.3) were significantly correlated with outcome.

CONCLUSION:   Individuals exposed to MVAs constitute a relevant subgroup of patients with neck pain. An MVA and a longer duration of complaints are prognostic factors for continuous neck pain.


From the FULL TEXT Article:

Discussion

Summary of main findings

Patients experienced higher levels of continuous neck pain and disability after an MVA compared with patients who had not reported such an accident. An MVA seems also to be an important independent prognostic factor for continuous neck pain.

Strengths and limitations of the study

This study has some limitations. For instance, the sample size is small and, therefore, external validity may be limited. Studies with larger numbers of patients are necessary to gain a more precise insight into the differences between the two sub-groups. A logical third sub-group for comparison purposes would have included patients with acute neck pain following a non-MVA-related injury but insufficient numbers of these patients were gathered to create an acceptable sub-group. The results presented may, in some respect, be flawed by non-response. Nonresponders were mainly younger males. This finding has been reported before. [20]

Due to this selective non-response and somewhat incomplete follow-up, the generalisability of the results is limited. However, the number of dropouts was limited and almost equally divided over both subgroups and the input of data did not reveal significant differences.

The study queried whether the percentage of patients who had been involved in an MVA in the cohort of participants with acute neck pain (23%) was representative of GPs' daily practice. An MVA is not the same as a whiplash-type injury but neck pain as a result of an MVA is a well-known disorder in the general population and most patients would be well aware of the condition. In addition, it could be that the emotionally charged concept of whiplash stimulates patients to visit their GP, resulting in selection bias and over-representation in this cohort. However, a patient population with a wide range of self-reported causes has the potential to be very heterogeneous. This study consisted of patients with a variety of self-reported causes, thereby representing the wide spectrum of patients' characteristics for general practice.

Comparison with existing literature

This study showed that the percentage of patients who had been involved in an MVA and reported continuous neck pain was significantly higher than for those patients with other self-reported causes of neck pain. Reported prevalences of continuous neck pain in patients who had experienced MVAs vary widely in the literature and seem to consist of two different groups of figures — lower prevalence figures of chronic neck pain range between 8% and 24%, [21] while higher reported figures range from 43% up to 66%. [22,23] Marshall reported that even 80% of patients experienced neck discomfort after an MVA. [12]

It is difficult to give a direct explanation for this apparent dualism in presented figures. The heterogeneity in study design, duration of follow-up, setting, and chosen outcome makes it difficult to compare these results with each other. One reason for the variation could be the definition of chronicity that is used. The outcome measures of ‘chronic pain’ and ‘recovery’ are not interchangeable and are each related to different perspectives of the same situation. In general, chronicity is defined as the persistence of symptoms for more than 3 months. Subsequent episodes of neck pain can be new or recurrent and the link with chronicity is not simple. A pattern of recurrence and intermittent pain may be a more realistic description of a patient's experience after an MVA than the presence of continuous symptoms. [20]

It is important to remember that it is not exclusively MVAs that seem to be associated with chronic neck pain, but all types of neck trauma. [3] The reason why a higher percentage of patients experience chronic neck pain after an MVA is still being debated.

Self-reported pain in the upper part of the neck was also a significant item in the final model. This finding may represent a link with the often-reported headache in patients who have whiplash. Zygapophyseal joint pain has been suggested as the single most-common basis for chronic neck pain and it might be responsible for many of the headaches. [24] The Cervicogenic Headache International Study Group concluded that headache arising from the upper part of the neck is one of the three major criteria for the diagnosis, [25] a finding that could have consequences for treatment modalities in general practice and can be implemented in routine examination after an MVA.

The duration of complaints being longer than 2 weeks is also of prognostic value. This item remained by logistic regression analysis in the final model. In the study by Jónsson et al all patients who were symptomatic after 6 weeks still had complaints at the 1-year and 5-year follow-ups. [23]

This study shows that an MVA forms a major factor in predicting a higher chance of developing chronic neck pain. Although there is still a difference of opinion on this aspect, more authors — in the last few years in particular — have reported on this association. [3, 6] Contrary to prior belief, most individuals with neck pain do not experience complete resolution of their symptoms and disability. According to the 2007 guidelines of the New South Wales Motor Accidents Authority in Australia, most patients can expect a favourable outcome but recurrences are common and 10% can have persistent problems. [26] This still represents a view that is too optimistic.

The usefulness of the NDI for the assessment of disability has been advocated before. [27] In a 3-year prospective study on the prediction of long-term health problems after an MVA from three simple questionnaires, only the NDI was significantly related to outcome. [27] The authors concluded that the analysis of the decrease of the level of activities obtained by NDI provides a tool to identify individuals at risk. Using the NDI as the measure of disability enabled demonstration of significant differences between the sub-group of patients who had had an MVA and the remaining cohort at baseline and after 1-year follow-up.

Implications for future research and practice

MVAs are an important factor for acute neck pain in general practice. The findings of this study stress the fact that patients who have experienced MVAs constitute a separate sub-group and may be subject to long-lasting neck pain and disability. The dualism in presented causes (traumatic and non-traumatic) and their consequences for the clinical course of neck pain is important and must be borne in mind. In daily practice, a more active approach to assessment of this particular sub-group could help to prevent chronicity. An active approach entails encouraging the patient to stay active, to avoid sick leave and bed rest, and to develop an active coping strategy according to the principles of graded activity.

Evidence for the efficacy of measures taken by a GP is still absent and, as such, future research is required to find proof for strategies that are effective in reducing the chances of acute neck pain becoming chronic. Evaluating an active approach by GPs with an emphasis on patient education for sub-groups of patients at risk of developing chronic neck pain would be of interest.

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