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Whiplash—review of a commonly misunderstood injury

2002; Elsevier BV; Volume: 112; Issue: 2 Linguagem: Inglês

10.1016/s0002-9343(01)00953-6

1555-7162

Robert Ferrari,

Myofascial pain diagnosis and treatment

Eck et al. (1Eck J. Hodges S.D. Humphreys S.C. Whiplash—a review of a commonly misunderstood injury.Am J Med. 2001; 110: 651-656Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar) and Rosenfeld (2Rosenfeld M. Whiplash.Am J Med. 2001; 110: 667-668Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar) are correct in their assessment of how clinicians should approach whiplash patients: with respect, sympathy, and a greater awareness of what the current data tell us about the progression from acute pain to chronic pain. And they are right to disagree with passive therapies and purely psychologic explanations. However, they fail to reconcile their understanding of the syndrome with the fact that acute whiplash injury (whatever one believes it is) progresses to chronic pain often in some countries and seldom in others. Given the biologic evidence, a psychologic model cannot adequately describe whiplash, but a "chronic injury" model is not adequate either. There are more recent findings from Lithuania (3Obelieniene D. Schrader H. Bovim G. et al.Pain after whiplash—a prospective controlled inception cohort study.J Neurol Neurosurg Psychiatry. 1999; 66: 279-283Crossref PubMed Scopus (265) Google Scholar, 4Schrader H. Obelieniene D. Bovim G. et al.Natural evolution of late whiplash syndrome outside the medicolegal context.Lancet. 1996; 347: 1207-1211Abstract PubMed Scopus (328) Google Scholar), Germany (5Bonk A. Ferrari R. Giebel G.D. et al.A prospective randomized, controlled outcome study of two trials of therapy for whiplash injury.J Musculoskeletal Pain. 2000; 8: 123-132Crossref Scopus (60) Google Scholar, 6Keidel M. Rieschke P. Stude P. et al.Antinociceptive reflex alteration in acute posttraumatic headache following whiplash injury.Pain. 2001; 92: 319-326Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar), and Greece (7Partheni M. Constantoyannis C. Ferrari R. et al.A prospective cohort study of the outcome of acute whiplash injury in Greece.Clin Exp Rheumatol. 2000; 18: 67-70Crossref PubMed Scopus (18) Google Scholar) that Eck et al. and Rosenfeld do not cite. And in their failure to attend to these data, the authors also fail to get to the "meat" of the problem. The question is: can we explain the chronic whiplash syndrome to patients in a way that avoids both the "chronic injury" and the "all-in-your-head" approach? In medicine we rely on probabilities in every diagnosis, and we give patients our best explanation based on current knowledge. Do we have the courage to tell them that the injury heals within weeks in North America just as it does in Lithuania, Germany, and Greece; and that the physical basis for chronic pain lies in maladaptive behaviors in some cultures—these behaviors leading to poor physical fitness, weight gain, and postural abnormalities, all of which contribute to the chronic illness long after the injury has healed? The biopsychosocial model, which has been described in detail elsewhere (8Ferrari R. The Whiplash Encyclopedia. Aspen Publishers, Inc, Gaithersburg, MD1999Google Scholar, 9Ferrari R. Schrader H. The late whiplash syndrome. A biopsychosocial approach.J Neurol Neurosurg Psychiatry. 2001; 71: 722-726Crossref Scopus (101) Google Scholar, 10Ferrari R. The biopsychosocial model—a tool for rheumatologists.Bailliere's Clin Rheumatol. 2000; 14: 787-795Abstract Full Text PDF PubMed Scopus (41) Google Scholar), allows us to tell patients the truth (or at least to tell them all that we now know). We can tell patients that there are places in the world where acute whiplash injury has much better outcomes, that we are beginning to understand why, and that it is not "all in your head." How patients respond to acute injury, whether or not they are told to keep a pain diary, whether they choose to exercise or have massage therapy, how the environment of litigation encourages hypervigilance and pain amplification, as well as misattribution of symptoms in the long term, and how pain medications produce many of the symptoms of the whiplash syndrome are all important concerns that this model has allowed us to address. Eck et al. and Rosenfeld do not have to ignore any of the recent results. All of these data can be included in a biopsychosocial model that avoids the stigmatization of malingering and psychiatric labels that Eck et al. quite rightly reject. The most important conclusion to be drawn from the epidemiology of whiplash in other countries may, in fact, be that it is not important to know what exactly acute whiplash injury is. Eck et al. argue that all we need to do is design automobiles in a way that prevents this injury, although there are many arguments that indicate why such planned designs will not likely make a difference, and that it is unhelpful to hinge all our hopes on that approach (11Ferrari R. Putting head restraints to rest.Acc Anal Prev. 2001; 33: 685-686Crossref PubMed Scopus (4) Google Scholar). In that vein, we also need to be careful before labeling patients with "facet joint injuries." There have been recent studies suggesting that there is a lesion—you just have to look for it (9Ferrari R. Schrader H. The late whiplash syndrome. A biopsychosocial approach.J Neurol Neurosurg Psychiatry. 2001; 71: 722-726Crossref Scopus (101) Google Scholar). Yet, this approach may have very little to do with "whiplash" itself and more to do with uncommon cases of nontraumatic chronic neck pain (9Ferrari R. Schrader H. The late whiplash syndrome. A biopsychosocial approach.J Neurol Neurosurg Psychiatry. 2001; 71: 722-726Crossref Scopus (101) Google Scholar). You can imagine whiplash to be an injury to many structures, but whatever it is, it cannot be avoided in Lithuania, Greece, or Germany any more than it can in North America. However, patients with whiplash in those countries get better faster. It is all right for North American physicians and their patients to accept that fact. Indeed, this knowledge can give hope to whiplash patients in North America: if others can get better, so can they. We should direct less research toward locating this nebulous injury, and more toward identifying the culturally specific behaviors that result in such widely varying outcomes (9Ferrari R. Schrader H. The late whiplash syndrome. A biopsychosocial approach.J Neurol Neurosurg Psychiatry. 2001; 71: 722-726Crossref Scopus (101) Google Scholar).