Contribution of the neuropsychological assessment in concussion.

INTRODUCTION: The neuropsychological assessment is a cornerstone in the care management of concussion or mild traumatic injury. OBJECTIVE: To present the different stages of an exhaustive neuropsychological assessment exploring cognitive and behavioral domains. METHOD: Description of the value of the main tests available for behavioral and cognitive assessment. The choice of tests is based on the clinical experience and expertise of the authors. RESULTS: Questionnaires are mainly used to explore the behavioral sequelae (depression, anxiety or fatigue) and the impact of these potential difficulties in daily life. Four cognitive abilities could be impaired by concussion: attention, memory, visuospatial functions and executive functions. These abilities could be explored with "paper and pencil" tests or with computerized test batteries. While cognitive sequelae in the context of a moderate or a severe traumatic brain injury are consolidated, in the context of concussion, neuropsychological sequelae tend to resolve in a short time. As a consequence, several neuropsychological assessments could be conducting in a short period involving some methodological considerations. Moreover, as concussion could be reported in a Whiplash injury from a car crash with forensic consequences, it is crucial to propose tests to be sure that the weak performance obtained into the neuropsychological assessment is not explained by poor effort and/or malingering. DISCUSSION/CONCLUSION: This article revises these aspects of a neuropsychological assessment in the specific context of concussion.

Associations between the injustice experience questionnaire and treatment term in patients with acute Whiplash-associated disorder in Japan: Comparison with Canadian data.

INTRODUCTION: This study aimed to investigate the differences in the Injustice Experience Questionnaire (IEQ) scores during the early period after the diagnosis of Whiplash-associated disorder (WAD) between Japanese and Canadian samples, and the associations between the IEQ scores and treatment terms in Japanese patients with acute WAD. METHODS: We used secondary data for the IEQ scores of Canadian patients with acute WAD. In Japan, we collected data from 85 consecutively enrolled patients with acute WAD, and their treatment terms were collected; these referred to the number of days between the date of injury and the closure date of the insurance claim and the number of treatment visits. Before treatment, the Numeric Rating Scale, Neck Disability Index, Hospital Anxiety and Depression Scale, IEQ, and Euro Quality of Life five-dimensional questionnaire were administered. The variables were subjected to multivariate analysis with each treatment term. RESULTS: The IEQ scores were higher in Japan than in Canada. Through multiple regression analysis, IEQ scores were independently correlated with treatment terms. The optimal cutoff point of the IEQ scores for a prolonged treatment term was 21 and 22 points, respectively. CONCLUSIONS: The IEQ scores were associated with treatment terms in patients with acute WAD in Japan.

The Nature of Whiplash in a Compensable Environment: Injury, Disability, Rehabilitation, and Compensation Systems.

Synopsis Whiplash is a compensable injury in many jurisdictions, but there is considerable heterogeneity in the compensation arrangements that apply across jurisdictions, even within some countries. These compensation schemes have, however, been subject to a common set of interrelated concerns, chiefly concerning the incentives, behaviors, and outcomes that may arise when financial compensation for injuries is available to injured parties. This article provides a nontechnical overview of some of those concerns through the lens of economics: principally, insurance economics and health economics, including related subsets such as information economics and agency theory, as well as economics and the law. It notes that because it is generally infeasible to randomize the treatment (ie, compensation) via trials, analyses of observational data are necessary to discover more about the relationship between compensation and health outcomes. This poses the analytical challenge of discovering causal connections between phenomena from nonrandomized data sets. The present article calls for further research that would enable convincing causal interpretations of such relationships via the careful analysis of rich observational data sets using modern econometric methods. J Orthop Sports Phys Ther 2017;47(7):503-508. Epub 16 Jun 2017. doi:10.2519/jospt.2017.7533.

How does injury compensation affect health and disability in patients with complaints of whiplash? A qualitative study among rehabilitation experts-professionals.

PURPOSE: To explore rehabilitation professionals' opinions about the influence and the pathways of injury compensation (IC) on health and disability in patients with whiplash associated disorder (WAD). METHODS: Semi-structured interviews were performed among a purposeful selected sample of Dutch expert-professionals in the field of rehabilitation of patients with WAD. Inclusion continued until saturation was reached. Inductive and deductive thematic analyses were performed. RESULTS: Ten rehabilitation expert-professionals (five females), working as physician, psychologist or physiotherapist, were interviewed. All expert-professionals acknowledged that IC can influence rehabilitation, health and disability. The expert-professionals provided three causal pathways; a pathway through prolonged distress, a behavioral pathway, and patient characteristics that may either attenuate or worsen their response. They assess the influence of IC mainly with interview techniques. Most professionals discuss the potential influence of IC with their patients, because they want to give clear information to the patient. Some emphasize that their role is neutral in relation with the IC. Others mention that financial consequences can accompany functional improvement. CONCLUSIONS: Rehabilitation expert-professionals believe that IC may affect rehabilitation, health and disability in patients with WAD. Three pathways are mentioned by the experts-professionals. IMPLICATIONS FOR REHABILITATION: According to rehabilitation expert-professionals, an injury compensation (IC) can lead to distress, by creating a (conscious or unconscious) conflict of interests within a patient between striving for compensation on one hand, and recovery on the other hand. Patient characteristics can either attenuate or worsen IC-related distress. Reliable and valid tools need to be developed to assess the influence of IC on health, disability and rehabilitation, and to limit the negative effects. Rehabilitation professionals can discuss the possible unintended effects of IC with their patients to clarify their current situation.

Course of recovery for whiplash associated disorders in a compensation setting.

CONTEXT: The detailed course of recovery following compensable whiplash associated disorders (WAD) is not well understood. Some people recover within months and others report symptoms for extended periods. Recent research identified distinct recovery pathways. Identifying recovery pathways for people with this condition in compensable settings could assist clinical and claim management. STUDY OBJECTIVE: This study aimed to identify recovery trajectories based on disability, pain catastrophising and mental health and, secondly, to examine developmental linkages between the trajectories. STUDY DESIGN: A cohort of 246 people with compensable WAD were followed for 24 months after a motor vehicle related injury. OUTCOME MEASURES: Functional Rating Index (FRI), Pain Catastrophising Scale (PCS) and the SF36 Mental Component Score (SF 36 MCS). METHOD: Group-based trajectory analytical techniques were used to identify distinct post-injury profiles. Multinominal logistic regression modelling identified factors associated with membership of different trajectories. RESULTS: 246 people were enrolled a median of 72 days after injury. Three trajectories were identified for the measures used and their prevalences, respectively, were: for disability (FRI) they were mild (47%), moderate (31%), and severe (22%); for pain catastrophising (PCS) they were non-catastrophisers (55%), moderate-low catastrophisers (32%) and clinically significant catastrophisers (13%); and, for mental health (SF36 MCS) they were good mental health (40%), moderately low mental health (42%) and severely low mental health (18%). All groups showed no further recovery beyond 12 months after injury. The significant baseline predictors of the severe disability trajectory were: lower (that means worse) bodily pain scores (SF 36 BPS) (p≤0.01); high pain catastrophising (p≤0.01); and, self-reported fair or poor general health (p=0.03). Conditional probabilities for group membership showed that the three trajectories for both PCS and FRI were linked. Dual membership was high for the mild disability and mild pain catastrophising trajectories and, for the severe disability and clinically significant pain catastrophising trajectories. CONCLUSIONS: There is a strong and plausible association between severe disability, clinical levels of pain catastrophising and low mental health. Claimants can be identified at claim notification based on three estimated recovery trajectories. Claim and clinical interventions can be targeted to the profile within each recovery trajectory.

Associations with duration of compensation following whiplash sustained in a motor vehicle crash.

CONTEXT: Continued exposure to compensation systems has been reported as deleterious to the health of participants. Understanding the associations with time to claim closure could allow for targeted interventions aimed at minimising the time participants are exposed to the compensation system. STUDY OBJECTIVE: To identify the associations of extended time receiving compensation benefits with the aim of developing a prognostic model that predicts time to claim closure. STUDY DESIGN: Prospective cohort study in people with whiplash associated disorder. OUTCOME MEASURES: Time to claim closure, in a privately underwritten fault based third party traffic crash insurance scheme in New South Wales, Australia. METHOD: Cox proportional hazard regression modelling. RESULTS: Of the 246 participants, 25% remained in the compensation system longer than 24 months with 15% remaining longer than three years. Higher initial disability (Functional Rating Index≥25 at baseline) (HRR: 95% CI, 1.916: 1.324-2.774, p<0.001); and lower initial mental health as measured by SF-36 Mental Component Score (HRR: 95% CI, 0.973: 0.960-0.987, p<0.001) were significantly and independently associated with an increased time-to-claim closure. Shorter time to claim closure was associated with having no legal involvement (HRR: 95% CI, 1.911: 1.169-3.123, p=0.009); and, not having a prior claim for compensation (HRR: 95% CI, 1.523: 1.062-2.198, p=0.022). CONCLUSIONS: Health and insurance related factors are independently associated with time to claim closure. Both factors need to be considered by insurers in their assessment of complexity of claims. Interventions aimed at minimising the impact of these factors could reduce claimants' exposure to the compensation system. In turn insurers can potentially reduce claims duration and cost, while improving the health outcomes of claimants.

Use of antidepressant medication after road traffic injury.

OBJECTIVES: Mental ill health after road traffic injury is common, as is the use of antidepressant medication after injury. Little is known about antidepressant use by injured people prior to their injury. The aim of this study is to describe the nature and extent of antidepressant use before and after road traffic injury. METHODS: Victorian residents who claimed Transport Accident Commission (TAC) compensation for a non-catastrophic injury that occurred between 2010 and 2012 and provided consent for Pharmaceutical Benefits Scheme (PBS) linkage were included (n=734). PBS records dating from 12 months prior through to 12 months post injury were provided by the Department of Human Services (Canberra). PBS and TAC claims data were linked. RESULTS: Among participants, 12% used antidepressants before injury (84.4D efined Daily Doses/1000 person-days) and 17% used antidepressants after injury (114.1DDD/1000p-d). Only 7.7% of the injured cohort commenced antidepressant treatment post injury. Thus, of all post-injury antidepressant use, 45% could potentially be related to the incident injury, with the remaining 55% most probably a continuation of pre-injury use. Pre-injury use was more common among women (109.4 vs. 54.6 DDD/1000p-d, p<0.0001), and those with whiplash injury (119.3 vs. 73.1, p=0.03). Cyclists and motorcyclists were less likely to use antidepressants pre-injury than car drivers (18.3 vs. 16.9 vs. 109.3, respectively; p<0.001). CONCLUSIONS: Less than half of post-injury antidepressant use could potentially be attributable to the incident injury. These results highlight the importance of obtaining information on pre-injury health status before interpreting post-injury health service use to be an outcome of the injury in question.

Associations with legal representation in a compensation setting 12 months after injury.

CONTEXT: Many people with Whiplash Associated Disorder (WAD) seek treatment though a compensation system where factors such as legal involvement have been reported as having a negative impact on recovery outcomes. OBJECTIVE: To compare those with and without legal involvement in their compensation claim, and identify associations with legal involvement at 12 months post injury; and longer term disability. STUDY DESIGN: Inception cohort study. PARTICIPANTS: 246 people with WAD compensation claim. OUTCOME MEASURES: Legal involvement and Functional Rating Index at 12 months post injury. METHODS: Participants were recruited from an insurance database. Baseline health (Functional Rating Index, Pain Catastrophising Scale and SF-36), socio-economic, work capacity, and claims data were collected within three months of injury and 12 months. Logistic regression models were used to identify associations with legal involvement at 12 months; and disability (FRI) at 12 months. RESULTS: At baseline 246 participants were enrolled into the study in a median 72 days post injury. At 12 months post injury 52 (25%) had engaged a lawyer. The significant independent associations with legal involvement at 12 months were higher levels of initial disability, work disability, speaking a language other than English at home and lower levels of mental health. Specifically, the odds of lawyer involvement at 12 months post injury was 4.9 times greater for those with work disability; 2.3 times greater for those who spoke a language other than English at home. In terms of health, they had poorer mental health and for every 10 unit increase in the baseline FRI score the odds of having lawyer involvement increased by 38%. DISABILITY: at 12 months (FRI) was significantly independently associated with, PCS-helplessness (p<0.001), age (p<0.001) and prior claim (p=0.001). CONCLUSION: This study suggests the people with lawyer involvement in their claim 12 months after injury have socio-economic disadvantage, have had a prior claim and a worse baseline health profile compared to those without a lawyer. Understanding this profile could allow for improved claims processes and targeted interventions to assist this group through any perceived complexities in the system and address the underlying reasons for lawyer participation within compensation schemes.

[Comparison of two screening questionnaires for patients with low back pain. Collation of risk factors for chronification]. / Vergleich zweier Screening-Fragebogen für Patienten mit Rückenschmerzen. Erfassung von Risikofaktoren für eine Chronifizierung.

BACKGROUND: Screening for risk factors for chronic low back pain (LBP) (yellow flags) is recommended by clinical guidelines. Various questionnaires to assess yellow flags have been proposed. OBJECTIVES: The aim of this study was to compare the prognostic validity of two screening questionnaires. MATERIAL AND METHODS: This was a prospective observational study with 241 LBP patients from 9 general practitioners, 4 orthopedic surgeons and 2 pain clinics. We compared the Örebro musculoskeletal pain questionnaire (ÖMSPQ) and the Heidelberg short questionnaire (HKF-R10) which were completed by all patients at inclusion before the consultation. Primary outcomes were assessed after 3 months by mail. Clinical endpoints were pain intensity, disability and more than two follow-up consultations. RESULTS: The sensitivity of the HKF-R10 to predict the primary outcome ranged from 81 % to 88 %, while the specificity was much lower (37-47 %). The ÖMSPQ showed an opposite pattern with a low sensitivity ranging from 50 % to 58 % but a higher specificity (77-80 %). In patients initially classified as having chronic LBP (n = 81), using the questionnaires as a diagnostic tool, the sensitivity of both questionnaires increased but specificity decreased. Single items may perform better with regard to primary outcome than the sum scores. CONCLUSION: Both screening questionnaires for chronic LBP have insufficient diagnostic and prognostic validity for routine use in ambulatory care. Further studies are needed to improve diagnostic and prognostic validity and to elaborate criteria for a targeted use of screening questionnaires to guide therapeutic interventions.

When range of motion is not enough: towards an evidence-based approach to medico-legal reporting in whiplash injury.

Whiplash injury medico-legal reporting has traditionally been focused upon identifying restrictions in range of motion and identifying the presence of tender areas in the cervical spine in an effort both to diagnose the condition and to offer a prognosis. There have been considerable advances in this field over the last decade however that calls into question such a diminutive approach. This paper reviews the contemporary evidence base for the medico-legal assessment of whiplash injury and identifies a body of literature that strongly implicates a Claimant's physiological and psychological stress response as a key medico-legal marker in predicting prognosis following whiplash injury.

Verification of whiplash-associated disorders in forensic medical practice. part I--assessment of the injury circumstances and biomechanics.

For many years, researchers involved in automotive industry and forensic medicine, as well as insurance companies have shown great interest in the issues of etiology and prevention of cervical spine distortion. The etiopathogenesis of whiplash-associated disorders (WADs) remains controversial and its morphological determinants have not been explicitly determined to date. The subjective nature of complaints causes great difficulties in objective assessment of the consequences of acceleration-deceleration injuries and in verification of compensation claims. The objective of the study was to present biomechanical relationships and circumstances accompanying WADs using population-based studies, statistical data of insurance companies and analysis of recordings of event data recorders installed by vehicle producers. The knowledge of technical aspects of WAD circumstances should facilitate medical assessment of the above-mentioned consequences.

Assessment of driving-related performance in chronic whiplash using an advanced driving simulator.

Driving is often nominated as problematic by individuals with chronic whiplash associated disorders (WAD), yet driving-related performance has not been evaluated objectively. The purpose of this study was to test driving-related performance in persons with chronic WAD against healthy controls of similar age, gender and driving experience to determine if driving-related performance in the WAD group was sufficiently impaired to recommend fitness to drive assessment. Driving-related performance was assessed using an advanced driving simulator during three driving scenarios; freeway, residential and a central business district (CBD). Total driving duration was approximately 15min. Five driving tasks which could cause a collision (critical events) were included in the scenarios. In addition, the effect of divided attention (identify red dots projected onto side or rear view mirrors) was assessed three times in each scenario. Driving performance was measured using the simulator performance index (SPI) which is calculated from 12 measures. z-Scores for all SPI measures were calculated for each WAD subject based on mean values of the control subjects. The z-scores were then averaged for the WAD group. A z-score of ≤-2 indicated a driving failing grade in the simulator. The number of collisions over the five critical events was compared between the WAD and control groups as was reaction time and missed response ratio in identifying the red dots. Seventeen WAD and 26 control subjects commenced the driving assessment. Demographic data were comparable between the groups. All subjects completed the freeway scenario but four withdrew during the residential and eight during the CBD scenario because of motion sickness. All scenarios were completed by 14 WAD and 17 control subjects. Mean z-scores for the SPI over the three scenarios was statistically lower in the WAD group (-0.3±0.3; P<0.05) but the score was not below the cut-off point for safe driving. There were no differences in the reaction time and missed response ratio in divided attention tasks between the groups (All P>0.05). Assessment of driving in an advanced driving simulator for approximately 15min revealed that driving-related performance in chronic WAD was not sufficiently impaired to recommend the need for fitness to drive assessment.

What characterizes individuals developing chronic whiplash?: The Nord-Trøndelag Health Study (HUNT).

OBJECTIVE: Most individuals experiencing whiplash accidents recover rapidly. A considerable proportion, however, develop chronic symptoms. Psychological factors may slow recovery, possibly by increasing the likelihood of other symptoms being misattributed to, and amplified by the whiplash injury. We aimed to investigate how pre-injury mental and somatic symptoms, self-rated health, use of health-services and medications, health-behavior and socio-demographics predict the development of chronic whiplash. METHODS: Data from two waves of a large, population based study (HUNT2 (baseline) and HUNT3) were used. Individuals reporting no whiplash at baseline were identified in HUNT3. Characteristics reported at baseline were compared between those who had developed chronic whiplash in HUNT3 (n=199) and those who had not (n=20,600), using Pearson's chi-squared tests, independent sample t-tests and logistic regression analyses. RESULTS: Individuals developing chronic whiplash reported worse baseline health than those reporting no chronic whiplash. Poor self-rated health was a strong risk factor for subsequent chronic whiplash (OR=2.26, 95%CI: 1.68-3.04). Musculoskeletal pain also increased the risk (OR=1.21, 95%CI: 1.15-1.26), as did diffuse somatic symptoms (OR=2.09, 95%CI: 1.47-2.96), use of different health services (OR=1.31, 95%CI: 1.19-1.45), high use of medications (OR=1.28, 95%CI: 1.14-1.43) and symptoms of anxiety (OR=1.93, 95%CI: 1.39-2.68). Physical activity was protective (OR=0.67, 95%CI: 0.49-0.91). Most socio-demographic variables were not significantly associated with chronic whiplash. CONCLUSION: Poor somatic and mental pre-injury health increased the risk of subsequent chronic whiplash. This suggests that chronic whiplash is not merely an organic disorder, and highlights the importance of individual expectations, symptom reattribution and amplification in development of chronic whiplash.

Managing Injuries of the Neck Trial (MINT): a randomised controlled trial of treatments for whiplash injuries.

OBJECTIVES: To examine the clinical effectiveness of a stepped care approach over a 12-month period after an acute whiplash injury; to estimate the costs and cost-effectiveness of each strategy including treatments and subsequent health-care costs; and to gain participants' perspective on experiencing whiplash injury, NHS treatment, and recovery within the context of the Managing Injuries of the Neck Trial (MINT). DESIGN: Two linked, pragmatic, randomised controlled trials. In Step 1, emergency departments (EDs) were cluster randomised to usual care advice (UCA) or The Whiplash Book advice (WBA)/active management advice. In Step 2, participants were individually randomised to either a single session of advice from a physiotherapist or a physiotherapy package of up to six sessions. An economic evaluation and qualitative study were run in parallel with the trial. SETTING: Twelve NHS trusts in England comprising 15 EDs. PARTICIPANTS: People who attended EDs with an acute whiplash injury of whiplash-associated disorder grades I-III were eligible for Step 1. People who had attended EDs with whiplash injuries and had persistent symptoms 3 weeks after ED attendance were eligible for Step 2. INTERVENTIONS: In Step 1, the control intervention was UCA and the experimental intervention was a psycho-educational intervention (WBA/active management advice). In Step 2 the control treatment was reinforcement of the advice provided in Step 1 and the experimental intervention was a package of up to six physiotherapy treatments. MAIN OUTCOME: The primary outcome was the Neck Disability Index (NDI), which measures severity and frequency of pain and symptoms, and a range of activities including self-care, driving, reading, sleeping and recreation. Secondary outcomes included the mental and physical health-related quality-of-life (HRQoL) subscales of the Short Form questionnaire-12 items (SF-12) and the number of work days lost. RESULTS: A total of 3851 patients were recruited to Step 1 of the trial. 1598 patients attending EDs were randomised to UCA, and 2253 were randomised to WBA/active management. Outcome data were obtained at 12 months for 70% and 80% of participants at Step 1 and Step 2, respectively. The majority of people recovered from the injury. Eighteen per cent of the Step 1 cohort had late whiplash syndrome. There was no statistically or clinically significant difference observed in any of the outcomes for participants attending EDs randomised to UCA or active management advice [difference in NDI 0.5, 95% confidence interval (CI) -1.8 to 2.8]. In Step 2 the physiotherapy package resulted in improvements in neck disability at 4 months compared with a single advice session, but these effects were small at the population level (difference in NDI -3.2, 95% CI -5.8 to -0.7). The physiotherapy package was accompanied by a significant reduction in the number of work days lost at 4-month follow-up (difference -40.2, 95% CI -44.3 to -35.8). CONCLUSIONS: MINT suggests that enhanced psycho-educational interventions in EDs are no more effective than UCA in reducing the burden of acute whiplash injuries. A physiotherapy package provided to people who have persisting symptoms within the first 6 weeks of injury produced additional short-term benefits in neck disability compared with a single physiotherapy advice session. However, from a health-care perspective, the physiotherapy package was not cost-effective at current levels of willingness to pay. Both experimental treatments were associated with increased cost with no discernible gain in health-related quality of life. However, an important benefit of the physiotherapy package was a reduction in work days lost; consequently, the intervention may prove cost-effective at the societal level. TRIAL REGISTRATION: Current Controlled Trials ISRCTN33302125. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 16, No. 49. See the HTA programme website for further project information.

Toward optimal early management after whiplash injury to lessen the rate of transition to chronicity: discussion paper 5.

STUDY DESIGN: Expert debate and synthesis of research to inform future management approaches for acute whiplash disorders. OBJECTIVE: To identify a research agenda toward improving outcomes for acute whiplash-injured individuals to lessen the incidence of transition to chronicity. SUMMARY OF BACKGROUND DATA: International figures are concordant, estimating that 50% of individuals recover from pain and disability within 3 to 6 months of a whiplash injury. The remainder report continuing symptoms up to 1 to 2 years or longer postinjury. As no management approach to date has improved recovery rates, new clinical/research directions are required for early management of whiplash-injured patients. METHODS: A group of multidisciplinary researchers critically debated evidence and current research concerning whiplash from biological, psychological, and social perspectives toward informing future research directions for management of acute whiplash. RESULTS: It was recognized that effective treatments for acute whiplash are constrained by a limited understanding of causes of whiplash-associated disorders. Acute whiplash presentations are heterogeneous leading to the proposal that a research priority was development of a triage system based on modifiable prognostic indicators and clinical features to better inform individualized early management decisions. Other priorities identified included researching effective early pain management for individuals presenting with moderate to high levels of pain; development of best education/information for acute whiplash; testing the efficacy of stratified and individualized rehabilitation, researching modes of delivery considering psychosocial modulators of pain and disability; and the timing, nature, and mode of delivery of cognitive-behavioral therapies. Directions were highlighted for future biomechanical research into injury prevention. CONCLUSION: The burden of whiplash injuries, the high rate of transition to chronicity, and evidence of limited effects of current management on transition rates demand new directions in evaluation and management. Several directions have been proposed for future research, which reflect the potential multifaceted dimensions of an acute whiplash disorder.

Whiplash and the compensation hypothesis.

STUDY DESIGN: Review article. OBJECTIVE: To explain why the evidence that compensation-related factors lead to worse health outcomes is not compelling, either in general, or in the specific case of whiplash. SUMMARY OF BACKGROUND DATA: There is a common view that compensation-related factors lead to worse health outcomes ("the compensation hypothesis"), despite the presence of important, and unresolved sources of bias. The empirical evidence on this question has ramifications for the design of compensation schemes. METHODS: Using studies on whiplash, this article outlines the methodological problems that impede attempts to confirm or refute the compensation hypothesis. RESULTS: Compensation studies are prone to measurement bias, reverse causation bias, and selection bias. Errors in measurement are largely due to the latent nature of whiplash injuries and health itself, a lack of clarity over the unit of measurement (specific factors, or "compensation"), and a lack of appreciation for the heterogeneous qualities of compensation-related factors and schemes. There has been a failure to acknowledge and empirically address reverse causation bias, or the likelihood that poor health influences the decision to pursue compensation: it is unclear if compensation is a cause or a consequence of poor health, or both. Finally, unresolved selection bias (and hence, confounding) is evident in longitudinal studies and natural experiments. In both cases, between-group differences have not been addressed convincingly. CONCLUSION: The nature of the relationship between compensation-related factors and health is unclear. Current approaches to testing the compensation hypothesis are prone to several important sources of bias, which compromise the validity of their results. Methods that explicitly test the hypothesis and establish whether or not a causal relationship exists between compensation factors and prolonged whiplash symptoms are needed in future studies.

Complexities in understanding the role of compensation-related factors on recovery from whiplash-associated disorders: discussion paper 2.

STUDY DESIGN: Focused discussion. OBJECTIVE: To present some of the complexities in conducting research on the role of compensation and compensation-related factors in recovery from whiplash-associated disorders (WAD) and to suggest directions for future research. SUMMARY OF BACKGROUND DATA: There is divergence of opinion, primary research findings, and systematic reviews on the role of compensation and/or compensation-related factors in WAD recovery. METHODS: The topic of research of compensation/compensation-related factors was discussed at an international summit meeting of 21 researchers from diverse fields of scientific enquiry. This article summarizes the main points raised in that discussion. RESULTS: Traffic injury compensation is a complex sociopolitical construct, which varies widely across jurisdictions. This leads to conceptual and methodological challenges in conducting and interpreting research in this area. It is important that researchers and their audiences be clear about what aspect of the compensation system is being addressed, what compensation-related variables are being studied, and what social/economic environment the compensation system exists in. In addition, summit participants also recommended that nontraditional, sophisticated study designs and analysis strategies be employed to clarify the complex causal pathways and mechanisms of effects. CONCLUSION: Care must be taken by both researchers and their audiences not to overgeneralize or confuse different aspects of WAD compensation. In considering the role of compensation/compensation-related factors on WAD and WAD recovery, it is important to retain a broad-based conceptualization of the range of biological, psychological, social, and economic factors that combine and interact to define and determine how people recover from WAD.

[Social, economic and cultural aspects of whiplash syndrome]. / Sociale, økonomiske og kulturelle aspekter ved whiplash.

The sequelae following whiplash injuries (WL) entail considerable human costs and expenses for both treatment and social services, especially public income benefits. Frequently, many players are involved after WL and good intersectional collaboration is therefore essential to counter the WL patients' tendency not to return to their jobs. There is a need for further research i) to identify evidence-based prophylaxis and treatment, ii) to monitor medical diagnoses in relation to social benefits to support research opportunities and iii) to assess whether other social solutions comprise alternatives superior to current treatment and compensation options.