Lithuanians and Greeks, who have minimal expectation of secondary gain from chronic whiplash, do not seem to suffer from chronic whiplash and are able to recover from acute whiplash injury on their own within a few weeks or months. Current research on symptom expectation, symptom amplification, and symptom attribution may help explain why many other countries, including Canada and the US, seem to experience such a high incidence of chronic whiplash syndrome.
The word whiplash, coined from whip and lash in 1928, pervades modern culture. An Internet search reveals that the term now appears in widely varying contexts and connotations including trade names, novel characters, discussions of heavy metal music, unusual stinging beetles, motor racing, and computer games. That whiplash profoundly impacts and involves many aspects of society is thus not in doubt. Whiplash is a social and medicolegal dilemma and a catchy and versatile word. The more important issue, however, deals with a related question: “Does society profoundly influence the development and propagation of the chronic whiplash syndrome?” If so, how so?
How could whiplash be a social disorder? It brings the people together: accident victims of all walks of life—the guilty, the innocent, the upwardly mobile, the downtrodden, and the woebegone all take the stage. The industry that copes with epidemic proportions of chronic pain following acute whiplash injuries includes physicians of many specialties, nurses, paramedics, physiotherapists, occupational therapists, massage therapists, dentists, oral surgeons, chiropractors, osteopaths, pharmacists, acupuncturists, psychologists, lawyers, judges, historians, philosophers, herbal remedists, and the occasional psychic.
Lithuania is a country in which there is little or no awareness or experience among the general population of the notion that a whiplash injury may cause chronic pain and disability. Collision victims view it as a benign injury not requiring medical attention. Possibilities for secondary gains are minimal. In a controlled historical inception cohort study published in 1996, none of the 202 subjects involved in a rear-end car collision 1 year to 3 years earlier had persistent or disabling complaints that could conceivably be linked to the collision. In this study, of 202 collision victims, 31 recalled having had acute or subacute neck pain. This symptom lasted in most cases less than a week and only two subjects had neck pain for more than 1 month. Due to recall problems, the true incidence of collision victims with acute symptoms such as neck pain and/or headache was unknown. There were no significant differences between the collision victims and controls concerning prevalence of symptoms including neck pain, headache, and subjective cognitive dysfunction. When this paper was published, the critics cried out for auto-da-fé (burning of the heretic). This research could be considered a threat to a whiplash industry.
In the subsequent prospective controlled inception cohort study, 47% of 210 victims of rear-end car collisions consecutively identified from the daily records of the traffic police had initial pain. The symptoms disappeared in most cases after a few days. No subject reported collision-induced pain later than 3 weeks. After 1 year, there were no significant differences between the collision victim group and the control group concerning frequency and intensity of either neck pain or headache.
Combining the two studies, the 95% confidence limits for the true incidence of acute symptoms are 40% and 54%, giving an estimated minimum of a total of about 180 subjects with acute whiplash injury in both studies.[1,2] As none of the collision victims seemed to have developed persistent and disabling symptoms due to the collision, the studies either evaluated alone or together have sufficient power to reject estimates of the incidence of the so-called chronic whiplash syndrome in previous methodologically inferior studies and to seriously question the validity of whiplash as a high-prevalence chronic physical injury. It would appear from this society that while the acute whiplash injury may be common, chronic whiplash is rare, and perhaps culturally dependent. Does this mean that chronic whiplash is culturally suppressed in Lithuania, or culturally enhanced elsewhere? If it is culturally suppressed, then over time the incidence of chronic whiplash should show a downward trend.
Chronic whiplash syndrome also appears to be rare in Greece. Of 130 consecutive collision victims suffering acute whiplash injury, 91% recovered in 4 weeks and the remainder recovered within 3 months, with substantial improvement to the point where their frequency of neck pain was similar to the general population. Extending this study data to 180 patients, the authors confirmed their earlier results, not only for recovery from acute neck pain, but from the other symptoms commonly reported as part of the acute injury syndrome. Are Greeks socially detuned from whiplash, or do they represent the true natural course of the disorder?
The last two decades of this past millennium brought an epidemic of whiplash to Germany, one that so rattled the insurance industry and medical community that avid research interest in whiplash grew in that country. What is unusual in Germany, however, is that the epidemic they faced was not chronic whiplash, but hordes of acute whiplash claims, where anyone within an eyelash of a rear-end collision claimed 3 to 4 weeks of pain. Thus, Germany witnessed an epidemic of whiplash without chronicity. Germany has a litigation system that allowed them to experience the social phenomenon of dispersion of an illness mechanism throughout the popular notion within mere years, while physicians marvelled at how accident victims changed from previously experiencing neck sprains and getting on with life rather well, to being acute invalids. The claims of acute whiplash generated a near-collapse in the long-stable insurance fiscal structure.
The prognosis of acute whiplash injury is remarkably good in Germany, a country where there is widespread awareness of the possibilities of acute symptoms after whiplash in the general population, but little expectation of chronic disability. In a study of physiotherapy treatment, by 6 weeks the active treatment group and control (healthy) groups were equal in their symptom reporting. Even the group given only a collar for 3 weeks and no other therapy recovered by 12 weeks, despite the fact that collar use probably aggravated neck symptoms. That is, the acute whiplash injury does not appear to confer a greater risk of reporting chronic symptoms than found in the general, uninjured population, or at least in a population that is not conditioned to expect chronic whiplash.
A prospective outcome study of 103 subjects in another locale in Germany found the same good prognosis, recovery often within 3 weeks, and virtually all within 6 weeks, as did a more recent outcome study in still another region of Germany.
Despite having differing insurance systems, different cultures, different cars, and different compensation systems, Lithuanians, Greeks, and Germans behave remarkably the same; and yet very differently from people in Canada, the United States, and the United Kingdom. What social order can explain this phenomenon? Current research is delving into the following three facets of the social order that brings about chronic whiplash: symptom expectation, symptom amplification, and symptom attribution.
In Canada and the US, as in many other western countries, there is widespread public information regarding the potential for chronic pain following whiplash injury, as well as knowledge of the expected symptoms—even among individuals with no experience of having a collision.[8,9] This expectation can lead to an individual becoming hypervigilant for symptoms, registering normal bodily sensations as abnormal, and reacting to bodily sensations with affect and cognitions that intensify them and make them more alarming, ominous, and disturbing—which is known as symptom amplification. In Lithuania, Germany, and Greece, recent studies (using the methodology of Aubrey8 and Mittenberg9) find a lack of expectation of chronic symptoms, and the whiplash injury is viewed as benign.[10,11]
It would appear that the circumstances of the collision create an immediate impression that whatever happened was not benign. The patient’s fear may then cause a paramedic to initiate serious injury procedures such as extricating him or her out of the car in a special stretcher, applying a hard collar, and warning him or her not to move. Symptoms tend to be intensified when attributed to a serious disease rather than to other causes such as lack of sleep, lack of exercise, or overwork, anxiety, or a simple benign strain.
Another aspect of symptom amplification occurs with medicalization, when others encourage the collision victim to repeatedly draw attention to the symptoms (i.e., every time the patient sees a therapist, or is asked to keep a diary of symptoms). Attention to a symptom amplifies it, whereas distractions diminish it. Thus the more frequently patients are asked to rate their pain, the more intensely they rate it.
Symptom expectation and amplification may cooperate to alter a collision victim’s behavior in a detrimental way. Feeling pain and fearing future disability, a victim can develop the cognitions and behaviors that lead to withdrawing from activities and becoming inactive generally in a manner that leads to maladaptive postures, a key source of postural stress in the neck. It is known that postural abnormalities, if induced even in healthy subjects, causes pain. The whiplash patient, in response to his or her heightened pain and anxiety, has just created a new source of pain—and a physical source at that. This source forms a further part of the substrate upon which symptom amplification can act; patients do not realize they have a new source of pain, but instead feel they have a chronic injury—matching their expectations. Thus, a psychosocial factor ultimately generates a physical source for pain.
Another example of abnormal behavior leading to anomalous complaints is the over-use of medication. A patient, experiencing amplified and fearful symptoms, seeks relief through drugs. Yet the many medications commonly used for pain have their own adverse effects such as dizziness and cognitive disturbances, which can then become a new physiological source for symptoms that the patient may perceive is part of the original injury. This new source of symptoms is amplified and attributed to a chronic injury, and has arisen because of the initial behavior of the collision victim and those in his or her environment.
Zygapophysial joint pain has been claimed as the most common basis for chronic neck pain as a result of whiplash injury. This is important, because this attribution is a key to the whiplash phenomenon. In one study, 39 people with chronic neck pain were investigated. Five of the 39 had not been in a motor vehicle accident, but had apparently had a neck injury in some other type of accident. Two of 39 claimed their chronic pain began 3 months after the accident. Some of the accidents took place 44, 27, and 21 years prior to entering the study. Those in motor vehicle accidents were reported to have experienced high-speed collisions, far higher than most current whiplash victims. Using sophisticated techniques, the authors found that the current neck pain in these subjects could be traced to the facet joint or nearby structures. These subjects were a highly select, heterogeneous, non-representative group of what they arbitrarily called chronic whiplash patients. Despite the attribution to whiplash, this study did confirm that neck pain in some cases may have a current physical cause. The results do not confirm the current cause is also a past cause of the neck pain, or has been for, say, the last 44 years. The results tell us nothing about the injury (if there was one) in these subjects and nothing about whether or how a purported acute injury developed into a chronic physical source of pain.
It is possible that a small proportion of subjects could have chronic structural damage to their facet joints from whiplash, even in countries like Lithuania. However, compared to other studies that show a background prevalence of chronic neck pain in the general or control population of about 10%, it would be important to distinguish the possible 2% to 3% effects of acute-to-chronic injury from the background effect. Yet, this additional 2% to 3% of patients are not the group of patients of greatest concern. It is the high percentage of patients with chronic accident-attributed pain (50% in Saskatchewan and 58% in Norway) that provide the greatest health care and economic burden, and facet joint studies are irrelevant to this larger group.
The facet joint studies, by establishing that a physical source of pain can exist, offer a mark of approval to doctors, patients, and researchers to place the label of whiplash patient on anyone who wants to attribute chronic neck pain to an accident. The problem therefore becomes rephrased into trying to prove that chronic physical injury does not exist—a difficult null hypothesis. What cultural factors promoted this non-scientific decision to make such an attribution? Why can one assume that a current cause of neck pain has any relationship to an accident of many years ago? That such assumptions were made is the greatest revelation of the facet joint research. Physical sources of pain can and do exist, but it is how people interpret the significance of that pain in relation to other events that creates the problem. If these subjects attribute their neck pain to an accident, then they are called whiplash patients. If they choose to dismiss the attribution, then they are not whiplash patients—the label has a limited and flimsy basis that can be dismissed on a whim or clung to passionately.
The final facet of this social symptom triad is symptom attribution. As a collision victim becomes hypervigilant for symptoms, and as one comes to expect chronic symptoms, the problem of symptom attribution is a natural result. In the setting of amplification, previously unintrusive symptoms, largely ignored in daily life, become far more intrusive after the collision. The patient regards them as new (they are now being registered), and attributes them to the collision. The symptom pool for new symptoms is drawn upon while the acute injury resolves. The pool arises from life’s aches and pains, disuse, stress, occupational sources, symptoms from medication use, and potentially from maladaptive postures and changes in physical fitness that arise as patients withdraw from normal activities. One would not expect these various benign, physical sources to be capable of causing severe or significant pain (and they likely did not in the past), but that is the effect of symptom amplification—to alter the naturally benign appearance of the symptoms. A biopsychosocial model is therefore not a psychogenic model. It merely suggests that what patients expect, how they perceive symptoms, and how they focus and attribute symptoms will alter the character of those symptoms and the patients’ behavior. Following this, entirely new physical problems may arise to contribute to the symptom pool. Add whatever further contribution is made by anxiety, depression, and compensation systems, and the chronic whiplash syndrome evolves.
Chronic whiplash in its most popular form is a social disorder. In the new millennium, as the world becomes smaller and we learn to take lessons from other societies and find solutions through a more open-minded free trade of ideas in the international spheres, the social disorder we call whiplash will, one hopes, come to rest, and be no more. Yet, a healthy skepticism suggests that perhaps whiplash will always be with us. The task for the new century will be to differentiate chronic social whiplash from those few victims of chronic physical injury—for they also need our attention, and are lost in the quagmire of a larger social disorder.
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Robert Ferrari, MD, FRCPC
Dr Ferrari is a clinical professor in the Department of Medicine, University of Alberta in Edmonton, and a researcher/independent examiner of matters concerning whiplash and chronic pain syndromes.