Whiplash in reverse

Most people know nothing about quantum mechanics or how a microwave oven works. Generally however, people don’t express strong opinions on either of these topics, which probably saves lots of pointless, frustrating conversations for people who did physics at Uni. The same is not true regarding Whiplash. It seems ownership of a car and/or a neck qualifies one for a strongly-held belief regarding the how, the who, the why and the what-I’d-do-if-it-were-up-to-me.

To be fair, it is a perplexing condition; peoples’ symptoms follow variable courses, the scientific literature reveals divides in the thinking of researchers, opinions among clinicians vary, the popular media has a go, insurance companies have a particular interest and regulatory authorities can also become involved. In the interests of adding some data from a real, live, apparently well-conducted study I’d like to highlight something recently published in Spine which looks to undress some of the issues surrounding Whiplash.

As a little bit of background, previous studies have reported an association between whiplash injuries and psychological variables, the prevailing hypothesis being that the pain and symptoms associated with the physical injury result in psychological distress. This particular study used a large ongoing population survey in Norway to look at whether levels of anxiety and depression at one point in time predict whether or not someone is likely to report a Whiplash injury in the 11 years that followed. This is interesting because it really gives us a chance to get at the chicken or egg question. After controlling for age, gender and alcohol-problems they found that higher levels on their depression and anxiety measure do in fact increase the likelihood that a person will report a whiplash injury down the track (Odds Ratio 1.6).

In their interpretation, the authors discuss several slightly, but importantly, different ways of accounting for their findings. Most significantly they cannot say whether previous anxiety/depression level makes it more likely that someone will actually have a whiplash injury or whether it makes them likely to attribute neck symptoms to whiplash (significant, given that estimates of 12-month prevalence of non-specific neck pain run somewhere around the 30% mark). They also point out that they cannot exclude the possibility of bidirectional causality and that there may be confounding factors that were not adjusted for at baseline.

Taking care to note that the only thing I know about my microwave is that it makes last-night’s pizza taste better, it seems to me that these findings might nestle quite nicely amongst some of the interests of those frequenting this forum. The interaction between psychological state and symptoms might fall into the domain of central sensitivity, alternately (or perhaps complementary) maybe the interaction between psychological traits and cognitive appraisal is a factor here. What if we were to take this one step further though? We are pretty comfortable with the idea of some people being more susceptible to certain health conditions e.g. cancer, schizophrenia, addiction, Alzheimer’s – but what about musculoskeletal conditions?

Over to you neuroscientists and clinicians!

Before I go, here is a list of some of the things this study isn’t saying: Whiplash doesn’t involve some kind of physical/anatomical trauma, people with whiplash injuries are just depressed/anxious, whiplash injury symptoms are just in the head, people with whiplash injuries having nothing wrong with them, people with whiplash injuries are motivated by compensation and there would be no whiplash if it weren’t compensated…(have I missed any?)

About Steve Kamper

Having completed Physiotherapy at USyd and a PhD at the George Institute in Sydney, Steve is currently “working” in Amsterdam at the EMGO+ Institute on an NHMRC fellowship. The thing Steve likes most about being funded by a government fellowship are the endless opportunities to remind mates that they are, in fact paying for every beer he has. Work involves research into the influence of patient expectations on outcome, back and neck pain, outcome measurement and the ongoing search for European conferences to ensure all holidays are tax deductible. Steve likes to spend his spare-time running around next to canals, riding his bike, giving blank looks to people who ask questions in Dutch and making sure he gets at least twice the recommended daily dose of ICECReam (www.theicecream.org/).



Mykletun A, Glozier N, Wenzel HG, Overland S, Harvey SB, Wessely S, & Hotopf M (2011). Reverse Causality in the Association Between Whiplash and Symptoms of Anxiety and Depression: The HUNT Study. Spine, 36 (17), 1380-6 PMID: 21217426




  1. Interesting study. As a clinician that treats these injuries it is always interesting to watch patients recover while others do not. All disease or injury has a chemical, physical and psychological component. But, if you look at the patho-physiology, all have a common denominator that is biochemical. I am not sure what this really means, but I suspect it is reasonable to deduce that biochemical changes are affected by drugs and/or chemical response of physical medine and treatments;ie. manipulation.

    Pain is defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”.

    This study shows that the “pre whiplash” (event / injury) psychological status is an important factor when evaluating a patient. And that the assurance that most “soft tissue” injuries heal well (grade 1 & 2 is very important to these types of patients. “This is the first published study with a prewhiplash prospective evaluation of psychological status.”

    In the literature you also see this as a criteria for spine surgery outcomes as well. As with disability & impairment. Some people can have severe impairment but do not let it become a disability. While others can have no impairment but report severe disability. Why?

    “The mind is the most powerful tool we have in medicine. The only problem is that we lost the instruction manual.” Dr. Chris Connelly

  2. Thanks for pointing out an interesting paper. I am not that surprised about these findings either. We carried out a large RCT investing the managment of acute whiplash injuries. As part of this research I interveiwed 20 patients. One of the questions I asked them was why they went to the Emergency Department following their injury. The most common response was that they were worried about their symptoms. It makes sense that individuals who already suffer from anxiety and depression would be worried about an injury and, therefore, likely to present with a whiplash injury. I think this has some important clincial implications to think about. We know that psychological distress is a risk factor for poor outcome following whiplash which we have previously thought was associated with the injury. If patients who present with recent whiplash injuries are coming along with pre-existing anxiety or depression then making sure we are addressing the psychosocial early would seem to be very important. I think there is a tendancy when patients present with acute injuries for clinicians to manage in a more biomedical way. I think that finding ways to balance early injury management with a biopsychosocial approach often reserved for chronic patients is a real challenge to clinicians but something that needs to be thought about.

  3. These results don’t surprise me. The most interesting thing to me in treating whiplash as a massage therapist has been that the particular sets of symptoms — which muscles and motions hurt, and which trigger points seem the most troublesome — are exactly the same as those of people who just wake up with a stiff neck. If I didn’t know the etiology, in other words, I wouldn’t guess it. It looks like the same problem presenting the same way. Which makes me wonder if “whiplash” is not so much a free-standing injury, so to speak, as the straw that breaks the camel’s back. And we already knew that psychological distress predisposes people to wake up with a bad neck.