Which comes first in whiplash—the psychological or the physical symptoms?
Whiplash opponents claim that the psychological symptoms are simply the result of malingering or that the patient has 'accident neurosis.'
Those who are more sympathetic to the whiplash patients' plight believe that the psychological symptoms that so often accompany the syndrome are secondary to the pain and disability that patients' experience.
As the authors of a new landmark study write,
"The uniform pattern of psychological distress amongst patients with chronic neck pain after a whiplash injury begs an explanation. We have argued previously that the distress exhibited by these patients is consistent with a secondary reaction to their chronic pain. The characteristic components of their distress may be easily interpreted: somatisation, a realistic representation of behaviour arising from a painful neck; obsessive-compulsive behaviour arising from the care needed to avoid exacerbating this pain and to compensate for the distraction caused by this pain; and depression due to the disturbance in life-style and domestic harmony. The ultimate test of this contention would be to determine whether or not psychological distress resolves upon successful treatment of pain."
And that's exactly what these researchers did. The study began with 17 patients with a single painful cervical zygapophysial joint. All patients were given a medical assessment, a pain questionnaire, and a psychological assessment (the SCL-90-R). Then the patients were randomly divided into a neurosurgical intervention group (radiofrequency neurotomy) and a placebo neurotomy group. Neither the patients nor the physicians were aware of which treatment each patient received. (The use of radiofrequency neurotomy in the treatment of whiplash pain was discussed in the Soft-Tissue Review, Volume 2, Number 1.)
The patients were then interviewed three months after the treatment, when they were again evaluated on the same tests as from before the study.
Nine patients received the surgical procedure, and eight received the placebo treatment.
Of the nine patients who received the actual treatment, 6 (67%) reported complete pain relief and resolution of their psychological distress. Of the eight placebo patients, 3 (38%) reported pain relief and resolution of psychological distress.
Also, of the nine pain-free patients at the 3-month follow-up, all had a resolution of psychological distress. Only one of the eight patients who still had pain reported an improvement in psychological symptoms.
The authors conclude,
"What is striking in the results is that observed improvements in the psychological profile were in those subscales that are characteristically elevated in patients with whiplash injury, and which initially were elevated above the diagnostic level. This is far more consonant with the notion that psychological distress is secondary to pain than with the belief that somehow all whiplash patients have the same premorbid disposition to a characteristic psychological profile which underlies their complaint of pain. Somatisation, obsessive-compulsive behaviour, and depression can readily be seen as rational psychological responses to persisting pain that medical practitioners have not been able to diagnose or treat, and which has been attributed to malingering. These rational responses should disappear if the underlying pain is successfully treated; this is what occurred in the present study." [Emphasis added.]