Psychological and behavioural
factors and risk for development of chronic pain syndrome in relation to
Tatjana Sivik, Olle Bunketorp, Natasha Delimar, Rebecca Schoenfeld
Chronic pain syndrome after necks injuries in traffic
accident causes the society considerable costs in addition to the suffering
of the victims. This study is an integrated part of a large study, evaluating
the injury mechanisms, the diagnostic procedures, the treatment, and the
prognosis of all types of neck-injuries in traffic accidents.
The purpose of the study was to investigate if there
are any relationships between work related psychosocial factors and psychological
(emotional) factors on the one hand and the risk for development of chronic
pain syndrome following cervical spine distortions in traffic accidents
on the other.
Method: In area of West
Sweden all consecutive patients who reported traffic accident related to
neck trauma were investigated within 2 weeks after the accident. One year
following the investigation, a follow-up questionnaire was mailed to all
participants. Those that returned a completed questionnaire were included
in this study.
Results: Follow-up interview
data were obtained from 282 patients (83% compliance) . Discriminant analysis
revealed that those patients still on sick-leave at the one-year follow-up
had significantly less favorable Work-APGAR scores and emotional state at
the time of the initial investigation. Based on the data, a predictive discriminant
model was identified.
Conclusions: The results
of this study imply that work related psychosocial as well as general behavioral/emotional
factors are related to the risk for development of chronic pain syndrome
and that an integrative bio-psycho-social approach would be of advantage
for the diagnosis and treatment of injured and traumatized patients at an
Key words: Neck injury,
psychosocial work factors, persistent pain, emotional vulnerability, predictive,
discriminant, STAI, BDI, PTSD.
ADDRESSES: The Traffic Injury
Register, Department of Orthopaedics (Bunketorp O, MEng MD PhD Project
leader), Östra Hospital, University of Göteborg, S-416 85 Gothenburg,
Sweden and the Institute of Psychosomatic Medicine, Kvibergsvägen
5, S-415 05 Gothenburg, Sweden (Sivik T, MD PhD MA, Delimar N, PhD,
Schoenfeld, R). Correspondence to Dr Olle Bunketorp or Dr Tatjana Sivik.
The frequency of neck injuries reported as a result of
road traffic accidents has increased during the last years. In the Scandinavian
countries, the increase has taken an epidemic course and according to insurance
companies (Länsförsäkringar AB, Sweden and Uni Storebrand, Norway) these
injuries account for about 80% of the total costs for all traffic injuries.
This might in part be due to increased traffic intensity, mainly in urban
districts. In Gothenburg, the frequency of rear end collisions has increased
almost threefold during the last ten years according to the local traffic
authorities. Another explanation could be the more general use of seat belts,
which is related to better survival but also to a greater risk for minor
The major part of these injuries are classified as cervical
spine distortions, so-called acceleration-deceleration injuries, most of
which are caused by rear-end collisions, resulting in a whiplash trauma.
According to a previous study in Gothenburg2,
50 percent of the injured recovered from symptoms during the first three
months but 40 percent had symptoms after three years. About 15 percent
had significant problems and were on sick leave over a year. Nygren3
has shown that ten percent of the injured in rear end collisions develop
significant permanent impairment.
Several authors have demonstrated that some persons are
more inclined than others to develop a chronic pain syndrome, irrespective
of a connection with a known injury or an accident4-11.
Psychiatric symptoms and post-traumatic disorders are common after road
and it seems therefore likely that vulnerable persons would be at a greater
risk of developing disabling symptoms and disorders in connection to an
Other factors may also be involved in the process. Recently, Awerbuch evaluated
studies, published in English and derived from MEDLINE, that covered epidemiological,
pathogenic and psychological aspects of whiplash trauma13.
This review concludes that, at least in Australia, "Comparative studies
suggest that "whiplash" is an illness reinforced by legal and social sanctions."
Many authors also doubt that there are only organic reasons for persistent
symptoms and suspect emotional factors or compensation neurosis as additional
It would be of great value to identify those individuals
with risk factors for persisting problems at an early stage. There are several
such factors as Evans15
have noted in excellent overview articles. Older age of patients, previous
neck-shoulder problems, degenerative spine disorders, cervical stenosis,
the presence of inter scapular or upper back pain, occipital headache, objective
neurological signs, neck stiffness and muscle spasm, insurance claim, and
litigation are some. However, the risk factors are not unanimously agreed
upon in the literature as was pointed out by Amundson16,
stressed the need for further evaluation with prospective randomized studies.
Disabling psychiatric sequelae are important markers
among those patients who develop a chronic pain syndrome in relation to
the accident, while there is no evidence that the severity of the injury
would be a sole reason of chronification. One important question is if there
are any psychological and psychosocial factors associated with the prognosis.
Radanov et al.17
investigated the personality structure of 78 neck-injured patients about
a week after the accidents, and they found no significant psychological
differences between patients with and those without remaining problems six
months later. However, they found injury related cognitive impairment as
predictive of persistent symptoms. A study presented by Salminen et al.18
showed that tenderness and pain in the neck and shoulder region was correlated
with "Type A behavior". This might indicate that, indeed, there are psychological
factors associated with persistent problems after neck injuries as many
of these patients develop pain and tenderness in the neck-shoulder region.
The purpose of this study was to investigate if there
are any relationships between work related psycho-social and general emotional
psychological factors on the one hand and the risk for development of chronic
pain symptoms following cervical spine distortions in traffic accidents
on the other.
Patients and methods
This study is an integrated part of a large study, evaluating
the injury mechanisms, the diagnostic procedures, the treatment, and the
prognosis of all types of neck-injuries in traffic accidents. The study
is conducted by The Traffic Injury Register, an organization affiliated
to the Department of Orthopaedics, Östra Hospital, which has been established
to investigate the causes and consequences of traffic accidents in general.
All patients who registered at the emergency departments
of the two main hospitals in Gothenburg and who were complaining of neck
pain following a traffic accident were offered a routine check-up by a special
neck injury team organized by the Traffic Injury Register. The study was
prospective with a one-year follow-up.
The following inclusion criteria were
used for those who entered the study:
• Age between 20 and 60 years.
• Not pregnant.
• Neck injury-AIS19
• No significant injuries in other body regions.
• Ability to understand and speak the Swedish language.
• No previous neck and back problem causing more than
two weeks on sick leave during the year before the accident.
• Living in the Gothenburg area.
Medical examination and treatment
A neck injury team examined all patients. Forty percent
were investigated within 2 weeks, 80% within one month and the remainder
within 3 months. The circumstances of the accident, previous medical history
and work history were thoroughly investigated by a nurse with good experience
of neck injured patients. At the same time, the nurse also checked all the
answers of the psychological tests described below. A specialized physiotherapist
made a thorough clinical examination and evaluated the mobility of the neck
and shoulders. In cases with more pronounced symptoms, a medical examination
was made by an orthopedic surgeon and a neurologist. Standardized radiological
examinations of the cervical spine were made in all cases, including flexion-extension
radiographs six weeks after the accidents or as fast as possible in those
cases who were examined later. All interviews and examinations were made
with standardized protocols. All patients were given a written neck/shoulder
training-program at their first visit to the emergency department. Further
training instructions were given by the physiotherapist. A soft collar was
recommended during the first weeks and the patients were sent for regular
treatment to one of 20 specially educated physiotherapists in the Gothenburg
region in cases with more pronounced symptoms. The patients were recommended
a medical check-up by their own doctor within a couple of weeks if the symptoms
did not improve. Follow-up data was collected after one-year by means of
a mailed 34-item questionnaire regarding quality of life. Informed consent
was obtained in all cases.
The psychometric investigation
at the first examination by the neck injury team included the following
• State Trait Anxiety Inventory (STAI) 20
• Beck Depression Inventor (BDI) 21
• CIDI-PTSD interview22
• Work-APGAR, a one-factor solution of items included
in the 6 factors in the Theorell Work Situation test23,
measuring the individual's experience of control, demands, stress, influence,
and social support at his/her work.
In order to study the relationship between the length
of sick-leave and the psychological/work-related variables a correlation
analysis was performed. Discriminant function analysis of the variables
tested was made between two groups: those who were and those who were not
on sick-leave at the time of completing the follow-up questionnaire. Regression
analyses was performed in order to determine the relationship between sick-leave
and the psychological and work related psychosocial variables.
The follow-up questionnaire was completed and returned
by 282 (116 men and 166 women), which were 85% of the subjects. The mean
age of these was 35,6 yr. (SD=11,1), with no significant age difference
between the sexes.
In this context, we were particularly interested in analyzing
the relationship between perceived work-situation and emotional states during
the initial investigation and sick leave as reported in the one-year follow-up.
There were significant differences noted between the two groups, those that
were and those that were not on sick-leave one year following the accident.
There was a clear relationship between length of sick
leave and the parameters measured. Length of sick leave was positively correlated
to STAI, BDI, PTSD and perceived stress at work and demands, and negatively
correlated to perceived control, stimulation, influence and social support
The discriminant function analysis revealed that Work-APGAR,
STAI, BDI and PTSD show good discriminant capacity between those who are
and those who are not on sick-leave one year after the accident. Work-APGAR
and BDI have the strongest impact (table 2).
Regression analysis of the relationship between sick-leave
and the variables measured reveal that sick-leave is dependent upon all
the measured variables. Thus the results show that low scores on BDI, STAI
and PTSD are strongly related to low scores on sick-leave (fig 1, 2, 3).
High scores on Work-APGAR are strongly related to low scores on sick-leave
In this study, we observed a significant relationship
between work related psychosocial variable, emotional state on the one hand
and sick-leave on the other.
The only way to identify with full certainty what factors
are involved in the development of the whiplash syndrome would be a strict
prospective study of all persons involved in these types of accidents, which
for obvious reason is almost impossible to conduct. This study does not
fulfil these criteria as it includes only those patients who accepted a
follow-up by the neck injury team. However, even though the investigated
group in this study is selected, and the injured were examined at various
times after the accident, the results are interesting. The study presented
here is the closest we can come to the ideal study for the time being. It
involves a thorough psychological, social, and somatic investigation of
a consecutive group of injured patients in relation to detailed accident
data and clinical and radiographic findings, which are to be reported separately.
The standardized examinations were made within a month after the accident
in 80 percent of the cases and a follow up was made after one year. A possible
explanation to the high frequency of persons with remaining symptoms in
this study may be that the symptom-free persons (of that reason) were less
interested in answering the questionnaire. Eighteen percent did not send
back the questionnaire despite repeated contacts.
Considering the total costs for the society due to neck
injuries sustained in traffic accidents, and the sufferings of the victims,
it seems to be of utmost importance to prevent the accidents in the first
place - and to reduce the risk of injury by appropriate means in the vehicles.
Improved head restraints are one important way. But this would certainly
not be enough - accidents and injuries would still occur and cervical injuries
are caused by a variety of trauma mechanisms and in accidents where an ideal
neck restraint will have no effect. Further, many people would still remain
anxious and tense and because of this and other reasons be at risk for the
development of post-traumatic symptoms. They may also - and perhaps because
of the anxiety - become involved in new accidents as has been noted in some
cases in our study. Some of these victims are, according to this and other
recent studies in psychosomatic research, prone to get stuck in a state
of chronic pain because of a certain constellation of personality attributes
and psychosocial conditions. It appears, of course, rational if these could
be identified at an early stage and treated adequately with an integrative
bio-psycho-social treatment besides from the somatic routine treatment.
Such an approach should naturally be recommended for all kinds of patients,
diseases and injuries - but particularly, perhaps, in the orthopedic field
where the psychological components of the healing process in the patients
earlier by tradition have been less obvious.
In conclusion, it is clear that early identification
of individuals at risk for developing chronic pain syndromes following traffic
related injury is of high value. Early identification and multidisciplinary
integrative psychosomatic treatment of somatic, behavioral and work related
psychosocial aspects can potentially significantly reduce length of sick-leave.
This would lead to less suffering for the individual as well as significantly
reduced health care costs for society at large.
We thank Marianne Berqvist,
assistant at The Traffic Injury Register, for her devoted work during the
study and for her ability to take good care of all the patients who worry
for their many problems after the accidents. Other persons involved in the
main study are Bengt Lind, Malin Lindh, Lars-Erik Linder and Carsten Byrn.
We are very grateful for their contribution to the planning of the study.
The study was fully supported by the insurance company Länsförsäkringar
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Correlations between length of sick-leave and psychosocial/work related
are significant at p < ,05000
deletion of missing data)
2. Discriminant function analysis of Work-APGAR, STAI, BDI and PTSD.
grouping: Sick-leave (2 groups: YES, NO) Wilks' Lambda: ,86 approx. F(4,120)=5,0923
Figure 1. Regression analysis
between length of sickleave and variable BDI.
Figure 2. Regression analysis
between length of sickleave and variable STAI.
Figure 3. Regression analysis
between length of sickleave and variable PTSD.
Figure 4. Regression analysis
between length of sickleave and variable Work-APGAR.