Editorial: Whiplash-associated disorder—advances in pathophysiology, patient assessment and clinical management
Rutger M. J. de Zoete
Iris Coppieters
Scott F. Farrell- 1School of Allied Health Science and Practice, The University of Adelaide, Adelaide, SA, Australia
- 2Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
- 3Laboratory for Brain-Gut Axis Studies (LaBGAS), Translational Research Centre for Gastrointestinal Disorders TARGID, Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
- 4RECOVER Injury Research Centre, The University of Queensland, Herston, QLD, Australia
- 5NHMRC Centre of Research Excellence: Better Health Outcomes for Compensable Injury, The University of Queensland, Herston, QLD, Australia
- 6Tess Cramond Pain & Research Centre, Royal Brisbane & Women’s Hospital, Herston, QLD, Australia
Editorial on the Research Topic
Whiplash-associated disorder—advances in pathophysiology, patient assessment and clinical management
“Whiplash injury’ refers to an acceleration-deceleration mechanism of injury to the cervical spine. Neck pain arising from such an injury—termed whiplash-associated disorder (WAD)—is the most common injury sustained in a motor vehicle crash (MVC) (1) and a substantial component of MVC compensation claims (2). In the Western world, around 300/100,000 people sustain a whiplash injury each year (3).
After a whiplash injury, approximately 50% of patients develop chronic WAD, with around 16% reporting ongoing severe pain-related disability (4). Despite decades of research, current guideline-based treatments such as education, advice and exercise, typically demonstrate modest effects (5–9). This may reflect our incomplete understanding of WAD's complex and heterogenous mechanisms, which span contributions from musculoskeletal (10, 11), neurological (12–19), inflammatory (20, 21) and psychological (22) factors, often within a “compensable injury” social context (4). In this special Research Topic Whiplash-associated disorder—Advances in pathophysiology, patient assessment and clinical management, we sought to bring together a series of papers that provide new insight into mechanisms underpinning WAD, considerations in clinical assessment, as well as approaches to patient management.
Post-traumatic stress symptoms (PTSS) and sensory hypersensitivity are established predictors of poor outcome after whiplash injury (23, 24) and likely contribute to mechanisms underlying patient symptoms. Andersen et al. build on this prior data with a large cohort study (N = 740) exploring PTSS, pain and quantitative sensory testing (pressure algometry) across a 12-month period following a whiplash injury. Those patients with clinical PTSS had sensory hypersensitivity across all time points as well as greater pain intensity and more widespread pain—demonstrating a clear link between PTSS, sensory hypersensitivity and clinical outcomes. These data elegantly reflect the biopsychosocial dimensions of WAD and clinical importance of PTSS, especially in the context of a recent clinical trial targeting PTSS after whiplash injury, with clinically meaningful effects on neck pain-related disability at 6 weeks, 6 months and 12 months (25).
Kasch et al. revisit results from a previously published cohort study that investigated motor and sensory dysfunction after whiplash injury—employing a unique study design using patients with ankle injuries as a control group. These authors performed a comprehensive assessment of pain, disability, nociceptive sensory processing and motor function across a 12-month period post-injury. Those patients that had reduced work capacity one year after injury had early reports of higher pain and demonstrated early sensory (cold pressor test, pressure pain) and motor (maximal voluntary contraction) dysfunction compared with whiplash patients that recovered and ankle-injured controls. These data suggest an interplay between patient symptoms, nociceptive sensitisation and motor control, that is associated with long term clinical outcome, which reflects the complexity of mechanisms underlying poor outcome after a whiplash injury.
Cervical sensorimotor control, and its association with patient clinical presentation, has been explored in relation to various types of neck pain. Sensorimotor deficits are arguably most relevant for WAD, considering its associated symptoms such as dizziness and unsteadiness. One of the most commonly used cervical sensorimotor control tests is the cervical movement sense test, in which a participant or patient with a laser pointer attached to the head, follows a target line as accurately as possible with controlled head movements. The study by Röijezon et al. investigates the discriminative validity and reliability of the cervical movement sense test, assessing the level of proprioceptive disturbance in people with WAD, idiopathic neck pain (INP), and healthy controls. Movement acuity was found to be a valuable outcome measure to assess disturbed cervical movement sense in both WAD and INP, with few differences in outcomes between the two neck pain groups. Yet, it was concluded that altered movement control strategies may exist between types of neck pain. Future investigation of such differential strategies can be used to inform management approaches tailored to WAD.
Alongside investigations of pain mechanisms, assessments, and the effectiveness of various treatments, there has been an increased emphasis on the clinical translation and implementation of evidence-based and high-value care approaches. As the clinical management of WAD remains to be challenging and development of physiotherapeutic care continues, a focus on quality improvement is warranted. Quality indicators can be used to standardise the assessment of such improvements, however, evidence lacks concerning their assessment, management, and patient-related outcome measures. Oostendorp et al. provide a synthesis of recent literature on quantitative measures of quality improvement in physiotherapy care. Included were more than 800 patients with WAD and a set of quality indicators used over a 16-year period. The authors conclude that physiotherapeutic care of WAD has substantially improved, and provide detailed suggestions for continued quality assurance.
The combined articles in this Research Topic illustrate the variety of work being undertaken to improve the understanding and clinical management of WAD. Building on the themes presented across these articles, further investigation is required to better understand the association between biopsychosocial mechanisms and the clinical presentation of patients with WAD and the symptoms they experience. Recent investigations into the (causal) relationship between genetic factors, biological mechanisms, and chronic pain presentations (26, 27) are a promising avenue to further explore the importance of these factors for the clinical management of WAD. Management approaches with demonstrable effects should be explored in large scale clinical trials. Preventing the transition from acute pain to a chronic condition, or the management of chronic pain itself, requires interventions with proven, clinically meaningful effects. Current evidence suggests that physical exercise, education, and psychological approaches should be considered as mainstay management for chronic WAD (9), however a more personalized approach for the prescription of these treatments may be needed. The implementation of evidence-based practice and utilization of clinical guidelines (28) can, and arguably should, be supported by reliable measures of quality improvement. A potential mechanism as posed by Oostendorp and colleagues is pursuing international consensus on quality monitoring and improvement, an initiative to be considered for improving targeted care for WAD.
Author contributions
All authors contributed to manuscript preparation and decision to submit for publication. All authors approved the submitted version.
Acknowledgments
We wish to thank the article authors and the manuscript peer reviewers for their contributions to the Research Topic.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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References
1. Hincapié CA, Cassidy JD, Côté P, Carroll LJ, Guzmán J. Whiplash injury is more than neck pain: a population-based study of pain localization after traffic injury. J Occup Environ Med. (2010) 52(4):434–40. doi: 10.1097/JOM.0b013e3181bb806d
2. Motor Accident Insurance Commission. Annual CTP scheme insights: 2020–21. (2021). Available from: https://maic.qld.gov.au/publications/annual-ctp-scheme-insights-2020-21/
3. Holm LW, Carroll LJ, Cassidy JD, Hogg-Johnson S, Côté P, Guzman J, et al. The burden and determinants of neck pain in whiplash-associated disorders after traffic collisions: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and its Associated Disorders. Spine. (2008) 33(4S):S52–9. doi: 10.1097/BRS.0b013e3181643ece
4. Sterling M, Hendrikz J, Kenardy J. Compensation claim lodgement and health outcome developmental trajectories following whiplash injury: a prospective study. PAIN. (2010) 150:22–8. doi: 10.1016/j.pain.2010.02.013
5. Griffin A, Leaver A, Moloney N. General exercise does not improve long-term pain and disability in individuals with whiplash-associated disorders: a systematic review. J Orthop Sports Phys Ther. (2017) 47(7):472–80. doi: 10.2519/jospt.2017.7081
6. Gross A, Forget M, St George K, Fraser MM, Graham N, Perry L, et al. Patient education for neck pain. Cochrane Database Syst Rev. (2012) 3:CD005106. doi: 10.1002/14651858.CD005106.pub4
7. Southerst D, Nordin MC, Côté P, Shearer HM, Varatharajan S, Yu H, et al. Is exercise effective for the management of neck pain and associated disorders or whiplash-associated disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Spine J. (2016) 16(12):1503–23. doi: 10.1016/j.spinee.2014.02.014
8. Teasell RW, McClure JA, Walton D, Pretty J, Salter K, Meyer M, et al. A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): part 2—interventions for acute WAD. Pain Res Manag. (2010) 15(5):295–304. doi: 10.1155/2010/640164
9. Sterling M, de Zoete RMJ, Coppieters I, Farrell SF. Best evidence rehabilitation for chronic pain part 4: neck pain. J Clin Med. (2019) 8(8):1219. doi: 10.3390/jcm8081219
10. Farrell SF, Smith AD, Hancock MJ, Webb AL, Sterling M. Cervical spine findings on MRI in people with neck pain compared with pain free controls: a systematic review and meta-analysis. JMRI. (2019) 49(6):1638–54. doi: 10.1002/jmri.26567
11. Bogduk N. On cervical zygapophyseal joint pain after whiplash. Spine. (2011) 36(25S):S194–9. doi: 10.1097/BRS.0b013e3182387f1d
12. Farrell SF, Sterling M, Irving-Rodgers H, Schmid AB. Small fibre pathology in chronic whiplash-associated disorder: a cross-sectional study. Eur J Pain. (2020) 24(6):1045–57. doi: 10.1002/ejp.1549
13. White L, Smith AD, Farrell SF. Associations between resting heart rate, resting blood pressure, psychological variables and pain processing in chronic whiplash-associated disorder: a cross-sectional study. Pain Med. (2022) 19:pnac075. doi: 10.1093/pm/pnac075
14. Van Oosterwijck J, Nijs J, Meeus M, Paul L. Evidence for central sensitization in chronic whiplash: a systematic literature review. Eur J Pain. (2013) 17:299–312. doi: 10.1002/j.1532-2149.2012.00193.x
15. Stone AM, Vicenzino B, Lim EC, Sterling M. Measures of central hyperexcitability in chronic whiplash associated disorder—a systematic review and meta-analysis. Man Ther. (2013) 18:111–7. doi: 10.1016/j.math.2012.07.009
16. Bontinck J, Lenoir D, Cagnie B, Murillo C, Timmers I, Cnockaert E, et al. Temporal changes in pain processing after whiplash injury, based on Quantitative Sensory Testing: a systematic review. Eur J Pain. (2021) 26(1):227–45. doi: 10.1002/ejp.1858
17. Coppieters I, Cagnie B, Nijs J, van Oosterwijck J, Danneels L, De Pauw R, et al. Effects of stress and relaxation on central pain modulation in chronic whiplash and fibromyalgia patients compared to healthy controls. Pain Physician. (2016) 19:119–30.27008285
18. Coppieters I, De Pauw R, Caeyenberghs K, Danneels L, Kregel J, Pattyn A, et al. Decreased regional grey matter volume in women with chronic whiplash-associated disorders: relationships with cognitive deficits and disturbed pain processing. Pain Physician. (2017) 20:E1025–51. doi: 10.36076/ppj/2017.7.E1025
19. DePauw R, Coppieters I, Meeus M, Caeyenberghs K, Danneels L, Cagnie B. Is traumatic and non-traumatic neck pain associated with brain alterations? – A systematic review. Pain Physician. (2017) 20:245–60.28535548
20. Sterling M, Elliott JM, Cabot PJ. The course of serum inflammatory biomarkers following whiplash injury and their relationship to sensory and muscle measures: a longitudinal cohort study. PLoS One. (2013) 8(10):e77903. doi: 10.1371/journal.pone.0077903
21. Farrell SF, de Zoete RMJ, Cabot PJ, Sterling M. Systemic inflammatory markers in neck pain: a systematic review with meta-analysis. Eur J Pain. (2020) 24(9):1666–86. doi: 10.1002/ejp.1630
22. Campbell L, Smith A, McGregor L, Sterling M. Psychological factors and the development of chronic whiplash–associated disorder(s): a systematic review. Clin J Pain. (2018) 34(8):755–68. doi: 10.1097/AJP.0000000000000597
23. Sterling M, Jull G, Vicenzino B, Kenardy J, Darnell R. Physical and psychological factors predict outcome following whiplash injury. PAIN. (2005) 114(1–2):141–8. doi: 10.1016/j.pain.2004.12.005
24. Sterling M, Jull G, Kenardy J. Physical and psychological factors maintain long term predictive capacity following whiplash injury. Pain. (2006) 122(1–2):102–8. doi: 10.1016/j.pain.2006.01.014
25. Sterling M, Smeets R, Keijzers G, Warren J, Kenardy J, Sterling M, et al. Physiotherapist-delivered stress inoculation training integrated with exercise versus physiotherapy exercise alone for acute whiplash-associated disorder (StressModex): a randomised controlled trial of a combined psychological/physical intervention. Brit J Sport Med. (2019) 53(19):1240–7. doi: 10.1136/bjsports-2018-100139
26. Farrell SF, Campos AI, Kho PF, de Zoete RMJ, Sterling M, Rentería ME, et al. Genetic basis to structural grey matter associations with chronic pain. Brain. (2021) 144(12):3611–22. doi: 10.1093/brain/awab334
27. Farrell SF, Kho PF, Lundberg M, Campos AI, Rentería ME, de Zoete RMJ, et al. A shared genetic signature for common chronic pain conditions and its impact on biopsychosocial traits. J Pain. (2022) 14:S1526-5900(22)00431-X. doi: 10.1016/j.jpain.2022.10.005
Keywords: neck pain, chronic pain, whiplash associated disorder, whiplash injuries, physical rehabilitation
Citation: de Zoete RMJ, Coppieters I and Farrell SF (2022) Editorial: Whiplash-associated disorder—advances in pathophysiology, patient assessment and clinical management. Front. Pain Res. 3:1071810. doi: 10.3389/fpain.2022.1071810
Received: 16 October 2022; Accepted: 26 October 2022;
Published: 10 November 2022.
Edited and Reviewed by: Ke Ren, University of Maryland, United States
© 2022 de Zoete, Coppieters and Farrell. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Scott Farrell Scott.Farrell@uq.edu.au
Specialty Section: This article was submitted to Musculoskeletal Pain, a section of the journal Frontiers in Pain Research