The Effect of Hidden Beliefs on PostWhiplash Syndrome
What is it about some people who have a whiplash injury from a car accident that causes them to develop chronic neck pain referred to as postwhiplash syndrome? Is it the severity of the injury or the way they view the experience? In this study, researchers from the Netherlands look at the role of catastrophizing and causal beliefs as possible predictive factors in postwhiplash syndrome.
Pain catastrophizing refers to a negative focus on pain, whether that pain is real or anticipated. A person's pain is increased or amplified and prolonged because of the way they view every physical action as a possible source of pain. This type of thinking becomes a habit and leads to chronic pain and disability.
Causal illness beliefs describe the patient's ideas about what originally caused the problem in the first place. In the case of a whiplash injury, the patient may have been given the wrong impression about their prognosis.
Information provided at the emergency department or in the doctor's office may have led him or her to believe there was severe, irreparable damage done to the neck. This impression added to the social or cultural belief that whiplash injuries are permanent could lead to a negative spiral in thoughts and actions.
The patient starts requesting more medical help. He or she constantly scans the body for any new symptoms or to check the severity of the old symptoms. Expecting pain and looking for symptoms can lead to more severe and longer lasting complaints. Intense anxiety and fear of pain are linked with a poor outcome or prognosis.
Social research has also shown that pain catastrophizing actually leads to more dysfunctional causal beliefs. In time, a vicious cycle is set up that creates a pathway from acute to chronic neck pain. In order to test the theory that pain catastrophizing and causal beliefs lead to more severe pain and delay recovery, traffic accident victims were studied.
Everyone in the study had filed a compensation claim for personal injury with an insurance company. Questionnaires were sent to each claimant between the ages of 18 and 65. The Neck Disability Index (NDI), Pain Catastrophizing Scale (PCS), and Causal Beliefs Questionnaire Whiplash (CBQ-W) were filled out and returned by 747 people with postwhiplash syndrome. Postwhiplash syndrome was defined as patients suffering from chronic neck pain after a motor vehicle accident. No one had lost consciousness for more than one minute and no one had a previous history of neck problems.
The Causal Beliefs Questionnaire was developed by the authors for use in this study. As part of the study, they were evaluating its use for validity and reliability in measuring four causal factors. These four factors relate to the patient's expectation of where the symptoms are coming from (psychological, severity of injury, vertebral bone, muscular).
The results showed that the more severe the pain at first, the more likely whiplash symptoms would persist beyond six and 12 months. Pain severity was linked with pain catastrophizing. And pain catastrophizing was linked with disability. Patients who thought all their neck pain was caused by the whiplash injury were also more likely to still have pain and disability 12 months later.
The authors couldn't tell if more pain catastrophizing leads to more disability. The research was not designed to answer that question. They could see that believing a car accident will cause a whiplash injury and that a whiplash injury creates pain was a good predictor of a poor outcome (more than even the intensity or severity of symptoms when the accident first happened).
This is the first published study to prove that attributing complaints to whiplash (i.e., believing that whiplash causes neck problems) is a negative prognostic factor in chronic whiplash or postwhiplash syndrome. This information suggests that patient education is a critical feature in the management of the acute injury.
Overcoming culturally embedded beliefs and modifying patient expectations about their recovery process could possibly help prevent postwhiplash syndrome. Given these findings, it may be necessary to rethink our current treatment focusing on the vertebrae and muscles in the early stages of recovery. It may be better to identify people who have high anxiety related to the accident and injury and offer them helpful information to reduce wrong or dysfunctional thinking.
The authors point out that this study only includes one group of people (from the Netherlands) and may not apply to other populations. The fact that everyone in this group was involved in an insurance claim could be an additional factor to consider. Not everyone with postwhiplash syndrome has a compensation claim -- maybe it makes a difference.
J. Buitenhuis, MD, et al. Catastrophizing and Causal Beliefs in Whiplash. In Spine. October 15, 2008. Vol. 33. No.22. Pp. 2427-2433.
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