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Neurological sequelae of minor head and neck injuries
Injury Vol. 29, No. 3, pp. 199-206, 1998 0 1998 Elsevier Science Ltd. All rights reserved Printed in Great Britain omo-1383/98 $19.00 + 0.00
ELSEVlER
PII: SOO20-1383(97)00178-2
Neurological
sequelae
of minor
head and neck
injuries Peter J. B. Landy 201 Wickham Terrace, Brisbane, Queensland, Australia The objective was to determine why some people who areinvolz7ed ir7 mi77or motor oehicle accidents, without loss of consciousness, !7azle persisti77g headaches a77d neckache, and to suggest management of tl7ese symptoms. Betzueen 1954 arid 1994, over 4400 cases were referred for medico-legal opinions. A gro7lp 17as been selected for discussion. During the period 1954-7966, 414 cases following closed head illjuries were see77with varying periods of posf traunlatic amnesia (PTA) f ram nil to greater tha77 72 17.Tl7e azrerage fin7c betwee the accident at7d fhe exami77afion was 21 mo~zths.The shortestperiod 70~s 3 monthsand the loqest 7years. The age at tl7e time of tl7e accident zjaried from 2.5 to 72years. Tl7e largest group fell betwee the ages of 20 a77d 40 years. The main complaints were headache, giddiness, loss of concentration a77d poor memory. 380 were rezliewed by questio7777aire after scttlemefit of the case. 112 cases of extensioiilflexion i77juries of tl7e r7eck were see77between 1985 and 1989 and tl7eir symptoms at7d resolution were compared with 50 cases see77oz7er the san7e period following sigr7ifica77t head or neck injury. The results shozocd that the n7ore sezlere the head or 77ecknjury, the lesslikely were the cases to suffeev symptomsof post-tmumatic headaches or persisfi77g neck symptoms. fn conclusion, while 70% of mir7or kead ar7d neck injuries settle withi a few weeks of a motor vehicle accident, about 30% contir777e to complain of headaches and/or neck pair7. TI7e prolonged management, extensive plzysiotherapy a77d slow court settlemerit lead to excessive introspectio77 a77d yrolongatio77 of symptoms. 0 1998 Elsevier Science Ltd. All rig!7ts reserved.
‘cured’ by a substantial verdict. I have added ‘substantial’ verdict as it has been shown in some cases that if the verdict is not substantial the symptoms do not disappear. The debate has ranged across the medical literature. Miller” in his Milroy lectures followed up 50 patients with the post concussional syndrome and found that on personal interview, sometime after the verdict, 48 patients had lost their symptoms. He stressed once he had convinced them that he ‘hadn’t come to take the money back’ there appeared to be no symptoms. Pearce* states that ‘few topics provoke so much controversy or heated opinion based on so little fact. Most victims of ‘whiplash’ have, however, sustained no more than a minor sprain to the soft tissues and unusually severe or protractive complaints may demand explanations which lie outside the field of organic and psychiatric illness.’ Kelly” and Mendleson” believe that the symptoms are not cured by the verdict. Kelly’s follow up was by questionnaire, not personal interview. There is no doubt that these casesengage a large quantum of time for the lawyers. It has been estimated that in some Australian States a third of the judiciary, a third of the bar and a third of solicitors are engaged at any one time in these cases. Material
Injury, Vol. 29, No. 3, 199-206,1998
Introduction Since the introduction in Germany of compensation for injuries in 1860, there has been a procession of syndromes following minor injuries, starting initially with the railway spine’, followed in the 1940s and 1950s with the ‘post-traumatic concussional syndrome’, then in the 1960s with ‘whiplash injuries of the neck, and now the extension of the ‘posttraumatic stress syndrome’ to ‘whiplash’ injuries. It has been stated by Kennedy* that ‘post concussional syndrome’ is a state of mind born of fear, kept alive by avarice, stimulated by lawyers and
Between 1954 and 1966, 414 cases following closed head injuries were seen with varying periods of posttraumatic amnesia from nil to 72 h. Symptoms considered Headache. The incidence of post-traumatic headache is outlined in Figure 1. This shows a higher incidence, almost 6:l of headache, among those who did not lose consciousness. There is a progressive fall the longer the period of post-traumatic amnesia. In the group of cases in which the period of posttraumatic amnesia is greater than 72 h, the incidence is low. Giddiness, loss of concentration and poor memory. The next group of symptoms analysed were those
200
Injury: International Journal of the Care of the Injured Vol. 29, No. 3,1998 Investigations Electroencephalograms. Electroencephalograms (EEGs) were performed in 219 cases. Seventy-four EEGs were performed where there was no post-traumatic amnesia and 65 of these were complaining of headache. Sixty-seven of the EEGs were normal and in seven cases there was a moderate amount of 4-6 cycles per second activity in the recording. In one there was a focal disturbance in the frontal region. This patient had suffered a fracture in the left frontal bone.
I-72 Iburr Treatment
Figure 1. Frequency of headaches after motor vehicular accidents related to retention of consciousness (0) and the duration of post-traumatic amnesia.
Severance of the greater occipital nerve. Fifteen cases had had their greater occipital nerve divided as treatment for their headaches. The usual history was that they had obtained relief for 2-3 months and then the headache returned.
Method
relating to giddiness, loss of memory and poor concentration (Figure 2). These symptoms were less frequent than those reported in the literature on accident neurosis. Direct questioning was avoided in eliciting these symptoms. The incidence of loss of concentration and poor memory was higher in the group with the long period of unconsciousness. The darkened squares indicate the cases in which loss of concentration and poor memory were confirmed by tests of immediate memory retention. Positional vertigo. This was regarded as distinct from giddiness. Twenty-six cases complained of this and a positive Barnay’s response was demonstrated.
A questionnaire was sent to 380 cases, when the cases were known to be settled. The following questions were asked: age, date of accident, period of unconsciousness, history of any previous head injury, if they were still complaining of headache, giddiness or loss of concentration, if not, the date at which these symptoms had ceased, the date they returned to work, if they had previously suffered from any nervous symptoms and if they had suffered from headaches prior to the accident. Replies were received from 140. It is interesting that only five were returned from the dead letter office which suggested that the remainder were either not interested in replying or had lost their symptoms. Of the 140 replies, in five cases the relatives indicated that they were deceased. Of the remaining 135,86 at the interview had complained of headaches and 17 had said the headaches had ceased. However, of the 47 who claimed they had no headaches at the interview, 18 claimed headaches at the follow up and 34 claimed giddiness who had not complained of this at the initial interview. Therefore, while it must be concluded that a questionnaire follow up is unsatisfactory, it also indicates that this group of patients are highly suggestible. Findings Time off work. Thirty-five cases who had no loss of consciousness stated that they were off work or unable to cope with their household duties for a period of 5 weeks to 4 years. The average was 7 months.
Extension/flexion (‘whiplash’) Figure 2. Frequency of giddiness and poor memory after motor vehicular accidents related to retention of consciousness (0) and duration of post-traumatic amnesia.
injuries
of the neck
In the 197Os, the complaints after minor motor vehicle accidents changed to what is referred to in legal circles as ‘whiplash.’
Landy: Neurological
A second group of cases were studied from 1985-1989. These were 112 cases referred for neck a rear end pain and headaches, usually following motor vehicle accident and were compared with 50 cases that had suffered neurological damage also referred for medico-legal reports. No follow up of these cases after settlement was attempted as a questionnaire type of follow up was regarded as unreliable. Personal
201
sequelae of minor head/neck injuries
25
T
details
Sex distribution. Forty-nine male and 63 female. There was a slight predominance of females. Age distribution. There was a lower incidence in the young and elderly with prominence in the 20-50 age group (F&WC 3). Social class. In Grade 1 there were three cases, Grade 2 there were seven cases, Grade 3 there were 28 cases, Grade 4 there were 58 cases and in Grade 5 there were 16 cases. Grade 4 predominated.
l-2
3
4-6
7-12
13-15
19-24
3
4
5
6
YMIS
MOldIS
Figure 4. Time from accident to consultation.
Clinical
details
Hospitalisation. Thirteen were admitted to hospital. Of these, 11 were there 24 h or less. Time from accident to consultation. In recent years there has been an earlier referral for assessment (Figure 4). The delays in the longer period for assessments appeared to be due to slowness of the legal profession in implementing claims and trials.
40
Time to symptoms immediate accident from 6 h of pain shoulder
30.
onset of symptoms. The varied. Seventy-five onset of symptoms, 15 and the remainder over to 4 months in one case. in the back of the neck blades.
time to onset of complained of within 4 h of the varying periods They complained or between the
Period of posMraumatic amnesia. Of 112 cases, five suffered less than 10 min of post-traumatic amnesia, four less than half an hour and two less than 2 h. There were 101 cases who did not suffer posttraumatic amnesia.
20
Pain in front of the neck. pain in their sternomastoids.
Only four complained
of
Headaches. Eighty-five of the 112 patients complained of headache. All stated that the onset of the headache was at the time of the accident.
10
Electroencephalogram. Electroencephalograms were performed in 99 cases. One showed paroxysmal activity and had a history of ‘blackouts’ prior to the accident, one had asymmetrical delta activity and two had minor changes. The EEG was normal in 95 cases.
5
11-20
Figure 3. Age
21-30
31-40
41-50
51-60
61-70
70+
Time to cessation of symptoms. Twenty-nine stated their symptoms had ceased by the end of 2 weeks and 42 by the end of 8 weeks, i.e. 71 by the end of 8 weeks and a further 17 after 4 months following the
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Injury: International Journal of the Care of the Injured Vol. 29, No. 3, 1998
accident. Of the remaining 24, symptoms resolved over 2 years in 18, and six continued to have symptoms up to 5 years after the accident. Of these, the cases who continued to have much pain and complain of restricted movement of the neck at the time of the examination, all except one, demonstrated free neck movements when distracted. Period off work. Of 112 cases, 35 lost no time from work and 49 had returned to work within 4 weeks of the accident (Figure 5). Of the 25 who were off work for one week, nine were on holidays at the time of the accident, 11 were unemployed at the time of the accident and remained unemployed, and two were malingering and had been off work for 12 months. Of the 16 who had not returned to work 6 weeks after the accident, six had a prolonged divorce action and proceedings over custody in the family court and three had business failures or problems. Vehicle
16 / 16 -. l4-
1
2
3
4
Grade
Figure 6. Social class.
details
to vehicle. The least damage was $600. The major damage was a ‘write off.’ This was usually in a car that was older than 10 years. The average damage was $2000-$3000. Seat damage. Ten stated the seat in which they were sitting was damaged as a result of the impact. Damage
Significant
head or neck injuries
Over the same period, 50 cases who suffered a significant head or neck injury and had been referred for medico-legal opinion and had a period of posttraumatic amnesia longer than 2 h were reviewed.
3:
20
,-
Clinical
findings
Age distribution. Of the 50 cases, two were under 10 years of age, 11 were between 11 and 20 years of age, 19 between the ages of 21 and 30,ll between 31 and 40, five between 41 and 50 and two between 51 and 64 years (Figure 6). Social class. In the social class, there was one in Grade 1, four in Grade 2, nine in Grade 3, 20 in Grade 4 and 16 in Grade 5. Again this displayed a predominance in classes 4 and 5 (Figure 7).
Of those sufferPeriod of post-traumatic amnesia. ing a period of post-traumatic amnesia, 14 cases suffered post-traumatic amnesia greater than 2 h, four were greater than 24 h, three greater than 48 h, three greater than 72 h, four greater than 96 h and 22 greater than 1 week.
30 2025
1616-
20
15
10
5
Under 10
0
lday
11
2
3
4 Weeks
Figure 5. Period off work.
5
fJ+j-
Figure 7. Age distribution.
21130 YEARS
Landy: Neurological sequelae of minor head/neck injuries Memory. Thirty-six which was confirmed ation (MMI) testing.
complained of poor memory, on Mini Mental Status Examin-
Neck symptoms. Only five of the 50 cases complained of neck symptoms. One of these had suffered a fractured arch at Cl and another a ‘hangmans’ fracture of the neck. Among these cases there were five cases of subdural haematomas and one was a tetraplegic. In comparing the two groups of cases, those who suffered severe head injuries did not complain of neck symptoms. Even in those who did suffer a fractured arch and a hangmans fracture, their neck symptoms settled within 3 months. abnormality was Electroencephalogram. EEG present in 20. Sixteen of these had focal spike and delta activity.
Discussion In the post-traumatic headache syndrome seen between 1954 and 1966, headache and ‘post-concussional’ symptoms occurred mainly in those patients who did not lose consciousness. The more severe the head injury, the less likely was the patient to complain of post-concussional syndrome or neck pains. Symonds’ suggested that there were minute intracranial haemorrhages that cause the problem, how ever the brain is insensitive to pain. OpenheimeP found diffuse lesions in a number of brains studied at post mortem, but these were patients who had died shortly after severe head injury. Those who argue that minor head injuries cause some brain damage do so on the basis of neuropsychological testing. Rimel” suggests that there is cognitive impairment for up to 3 months after minor head injuries. However, the criticism of this study according to Walker I0 is that 82% examined at the time of the accident had significant amounts of alcohol in their blood. Newcombe” studied the possibility of cognitive sequelae of a transient or minor nature after mild head injuries. Neuropsychological tests were selected to measure abilities often compromised after significant head injuries, namely memory and attention. In general, no significant differences were found between the experimental and the control groups. Their conclusion is that counselling of mild head injury patients may help to avert symptoms that are psychological rather than pathophysiological in origin. Hirsh et al.” believes that sprain/strain syndrome or whiplash injury is the most common cervical injury associated with rear end impact motor vehicle accidents. The result is a complex injury often associated with extensive soft tissue injury in the cervical spine. There is additional potential for long term alteration in neurogenic muscular and skeletal function. He bases his observations that following a
203
rear end impact the driver will accelerate forward because of inertia and the neck hyperextends beyond its normal range. They further state that they believe the evidence suggests that this syndrome is real if manifested by symptoms consistent with anatomic injuries sustained, and that there is potential to cause However, if the driver or significant impairment. passenger is restrained by an adequately fitting seat belt and there are neck rests in the vehicle, then the person would not move forward and hyperextend their neck. All patients except one in this series claim that they were wearing seat belts, even those who had periods of post-traumatic amnesia of up to 72 h. and Severy et al.” in 1955, using humans dummies, staged rear end collisions and recorded events with a high speed camera. They identified the sequence of hyperextension of the neck followed by flexion. With the advent of head rests, hyperextension should be prevented unless the seat breaks off its mounting. Hohl et al.” studied 146 patients involved in rear end accidents and followed up 27% of the group of which approximately 43% of the 27% had residual symptoms beyond the time of the legal settlements. They concluded that the symptoms were attributable to the original accident. Deans et al.‘” studied 137 patients attending hospital following road traffic accidents. They were subsequently contacted between l-2 years later. Sixty-two percent stated they had suffered pain in the neck at some time following the accident, compared with 30% who were noted to have pain in the neck when examined soon after the accident. Pain in the neck occurred irrespective of the direction of the impact, but was disproportionately common in rear end impacts. Patients wearing seat belts experienced pain more frequently than the unbelted patients. Schutt’” believes that many patients with whiplash type injuries may have an organic basis for their psychoneurotic symptoms. They refer to Torres and Shapiro’sI report that moderately or markedly abnormal electroencephalogram changes similar to those in 44% of those who had been unconscious after direct head trauma were found days to months after the accident in 21 of 45 patients with whiplash, but without direct head trauma. However, Jacome’“, in 68 cases, found only minimal EEG abnormalities. This would correspond with the findings in my series. There is no adequate published control group of neck injuries occurring outside compensation claims and in this group, no control group could be obtained. In this group, there was no predominance in females, which has been mentioned in other serieslh. RadanoP, in a prospective study of whiplash, suggested that psycho-social factors have ‘little power’ to explain the course of recovery from common whiplash. The Luncef~‘, commenting on their findings, suggests that difficulty with concentration and memory might also be related to the
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International
consumption of analgesic drugs and that this possibility has not yet been thoroughly investigated. Bodguk and Marscand”’ regarded the cervical zygapophyseal joints as a common source of chronic neck pain. However, intra-articular injections of betamethasone are not an effective therapy for pain in cervical zygapophyseal joints after an injury”.
Behavioural analysis of chronic pain and its management A good deal of learning takes place in the development of the chronic pain condition. Fordyce” assumesthat pain is a behaviour rather than a neurological state and points out the conditioning process relative to pain, the direct positive reinforcement of pain behaviours, the indirect positive reinforcements, i.e. negative reinforcements of pain behaviours, such as avoidance and the failure to reinforce well behaviours. The reinforcing factors in post-traumatic syndrome in my experience have been a life situation, the continuing neurological and orthopaedic examinations and continuing physiotherapy and chiropractic treatment over many months and years. There have also been significant stresses, marital, family and financial. Berry 24has also noticed similar situations in the clinical syndrome, pointing to evidence for a psychological basis for the syndrome. He also points out that the chronic syndrome is not seen in the context of a demolition derby where hundreds of ‘whiplash injuries may be witnessed in one evening of this car crashing sport. TyreP points out in learned pain behaviour, that pain is a symptom that does not necessarily indicate physical injury. While the relation between acute pain and tissue damage is close, patients with persistent pain who are referred to doctors often describe more pain than appears warranted from a pathological process. He points out that if expressions of pain produce sympathetic attention from someone important to the victim, this will encourage future complaints of pain. Complaints may also enable the victim to avoid other unpleasant activities thus further indirectly rewarding the ‘sick’ role. Behaviours that are compatible with being well are not rewarded and so tend to be extinguished. The recognition of learned pain behaviour depends on paying attention to the relationship between pain behaviours and their apparent consequences. There is no doubt that persisting complaint of pain following a neck injury and the attendant investigations, manipulations, use of cervical collars, diaries supplied by lawyers to keep a daily account of every ache and pain, frequent medical examinations, do further encourage a sick role, extinguishes positive activity and in the long term is rewarded by compensation. The medico-legal cases following minor trauma showed a distinct change in the 1970s. While
Journal
of the Care of the Injured
Vol. 29, No. 3,199s
headaches were still a symptom, giddiness and loss of concentration were rarely evident. However, neck pain, headaches and poor memory were the symptoms. In comparison, of the 50 cases who suffered significant head injuries, only five complained of neck symptoms, two of whom had suffered serious neck injuries. The force that causes periods of post-traumatic amnesia of more than 24 h would be much greater than those suffered in minor extensionjflexion injuries in rear end collisions. However, this group did not complain of neck pain. Furthermore, the presence of neck rests should prevent hyperextension. Why are some of these cases ‘not cured by the verdict’“? The neurotic personality of some of those involved, or stress factors as outlined, business failures, dissolution of marriage and custody battles during the time of the court case. Excessive introspection is often evident and elicitation of these problems requires care if one is not to be met with ‘what has it got to do with my neck?‘. Very few neurological, neurosurgical or orthopaedic reports make any reference to the life style and emotional turbulence of the claimants. Why do those with only minor head injuries and neck sprain suffer, in some cases, continuing pain and headaches? Most studies have focused on organic explanations for the continuing pain. If we accept healing times are 2 weeks for muscle sprains, 3 weeks for muscle injuries and 4-6 weeks for fractures, then other factors must be involved. A comparison is often drawn to sporting injuries where post concussional headaches are short lived. Thirty years as consultant neurologist to two large teaching hospitals produced only one case of persisting post concussional headache. Investigation revealed a subdural haematoma. Despite the many head high tackles in football, I have never encountered a case complaining of ‘whiplash.’ Recently a case was awarded damages for a posttraumatic stress syndrome following a minor neck injuryZh. Helzer et al.” examined 2493 individuals as part of a nationwide general population survey. Posttraumatic stress disorder was found in 1% of the total population, about 3.5% in civilians exposed to physical attack and in Vietnam Veterans who were not wounded, and 20% in Veterans who were wounded in Vietnam. This argues against the use of this diagnosis in those subject to minor injuries.
Conclusion Many arguments have been adduced suggesting that the persisting symptoms after minor injuries, i.e. ‘post concussional syndrome’ and ‘whiplash’, are due to organic causes. The persistence of symptoms are better explained on the behavioural concept of chronic pain, learned pain behaviour and secondary gain. The symptoms
Landy: Neurological
sequelae
of minor
head/neck
injuries
are not cured by the verdict because they are SO reinforced by prolonged treatment, multiple examinations and investigations, multiple interviews with their lawyers, as well as being given diaries to record their daily symptoms. Often they have multiple neurological and orthopaedic examinations, multiple physiotherapy and chiropractic manipulations, long delays in settlement, resentment of the other driver who has damaged or destroyed their possession: the prospect of returning to an unsatisfactory or boring job powerfully reinforces their symptoms and the ‘sick role. And finally, cure may not be effected if the plaintiff considers the settlement inadequate: ‘most of it went on lawyers and doctors fees’ is a common complaint. It is simplistic to assume that those who have maintained these symptoms for months or years, assiduously cultivated by the system which is a large industry, will be cured by a verdict.
Suggestions
(1) More
(2)
(3)
(4)
(5)
(6)
(7)
time should be devoted in medical training to this problem. It is far more common in practice than multiple sclerosis, motor neurone disease, myopathies or cerebral tumours. Acute management should be that of sprains elsewhere; ice, cervical collars used ofzly for 48-72 h and early mobilisation. Reassurance of early resolution should be reinforced and patients be encouraged to remain active in the presence of pain with early mobilisation. The term ‘whiplash’ should be avoided and replaced by ‘neck sprain.’ Medical students, specialists and physiotherapists should be taught the condition will resolve in l-6 six weeks not ‘two years.’ Prolonged physiotherapy and chiropractic treatment should be avoided. If there are any symptoms to suggest nerve root or cord compression, an early MRI should be ordered. Otherwise extensive and repeated x-ray studies should be avoided. Headaches are a common symptom in life. Ninety percent of females and 80% of males suffer headaches during their life time. Rapid legal settlement for minor head injuries and neck injuries; the paraphernalia of the court and multiple medical examinations should be curtailed. I was once the 19th medical opinion requested in one such case! Use of medical panels to determine quantum where fault has been admitted.
References 1 Erichsen J. E. Co~zc~~ssio~z of the Spitie--NerzlousShocknlid Other Obscure Injuries of the Nervous System in their Clinical and Medico-legal Aspects, Longmans, Green &
Co., London, 1882.
20.5
2 Kennedy F. The mind of the injured worker and its effect on disability periods. Compensation Medicine 1946; 1: 19-24. 3 Miller H. G. Accident neurosis. Bv. Med. 1. 1961; 1: 919-925; 992-998. 4 Pearce J. M. S. J. Neural., Neurosurg., Psychiatry 1989; 52: 1329-1331. 5 Kelly R. and Smith N. 1. R. Sot. Med. 1981; 74: 275-277. 6 Mendleson G. Not ‘cured by a verdict’. Effect of legal settlement on compensation claimants. Med. 1. Amt. 1982; 11: 132-134. 7 Symonds, C. Concussion and its sequelae. Ln?zcef 1962; l-5. T. R. Microscopic lesion of the brain 8 Oppenheimer following head injury. I. A&n)!., Ncarosur‘~., Psyclrintrrr 1968; 31: 299. 9 Rime1 R., Giordani B., Barth J. T., Boll T. J. and Jane J. A. Disability caused by minor head injury. Neurosurgery 1981; 9: 221-228. 10 Walker E. Comments. Neurosurgery 1981; 9: 228. 11 Newcombe F., Rabbitt P. and Briggs M. Minor head injury: pathophysiological or iatrogenic sequelae? 1. Neural., Ncurosurg., Psychiatry 1994; 57: 709-716. 12 Hirsh S., Hirsh P. J., Hiramoto W. and Weiss A. Whiplash syndrome, fact or fiction. Orthopaedics North America 1988; 19: 791-794. 13 Severy J. Controlled automobile rear end collision. Canadian Services Med. 1. 1955; 11: 729-759. 14 Hohl M. Soft tissue injuries of the neck in automobile accidents. 1. Barre joints Surgery 1974; 56A: 1675-1681.
15 Deans G., Magalliard J. N., Kerr M. and Rutherford W. H. Neck sprain-a major cause of disability following car accidents. Irzjllry 1987; 18: 10-12. 16 Schutt C. Neck injury to women in auto accidents. IAMA 1968; 206: 2689-2692. in 17 Torres F. and Shapiro S. K. Electroencephalograms whiplash injury. Arch. Ncurol. 1961; 5: 28-35. 18 Jacome D. E. EEG in whiplash, a reappraisal. Clin. Elect. 1987; 18: 41-45. 19 Radanov 8. Role of psychosocial stress in recovery from common whiplash. Lancet 1991; 338: 712-714. 20 Lancet Talking Points. Lancet 1991; < b338:
articular corticosteroid for chronic pain in the cervical zygapophyseal joints. N. Engl. 1. Med. 1994; 330: 1047-1050. 23 Fordyce W. An operant conditioning method for managing chronic pain. Postgrad. Med. J. 1973; 53: (6): 123-128. 24 Berry H. Psychological Aspects of Whiplash Injury; Trauma and ifs Wake. Figley C. ed. Brunner/Masel, New York, 1985, pp. 1716-1719. 25 Tyrer S. Learned pain behaviour. BY. Med. 1. 1986; 292: 1. 26 Griffin J. Q. C. Lawyers perspective of post traumatic stressdisorder. Conference with Royal Australian and New Zealand College of Psychiatrists in association with the Medico-Legal Society of Queensland, 4 December 1993.
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27 Helzer J. E., Robins L. N. and McEvoy L. Post-traumatic stress disorder in the general population: findings of the epidemiologic catchment area survey. N. En@. I. Med. 1987; 317: 1630-1634.
Paper
Journal
of the Care of the Injured
accepted
20 October
Vol. 29, No. 3,199s
1997.
Requests for reprints should be addressed to: Dr I’. J. B. Landy, 201 Wickham Terrace, Brisbane, Qld. 4000, Australia.
ELSEVlER
PII: SOO20-1383(97)00178-2
Neurological
sequelae
of minor
head and neck
injuries Peter J. B. Landy 201 Wickham Terrace, Brisbane, Queensland, Australia The objective was to determine why some people who areinvolz7ed ir7 mi77or motor oehicle accidents, without loss of consciousness, !7azle persisti77g headaches a77d neckache, and to suggest management of tl7ese symptoms. Betzueen 1954 arid 1994, over 4400 cases were referred for medico-legal opinions. A gro7lp 17as been selected for discussion. During the period 1954-7966, 414 cases following closed head illjuries were see77with varying periods of posf traunlatic amnesia (PTA) f ram nil to greater tha77 72 17.Tl7e azrerage fin7c betwee the accident at7d fhe exami77afion was 21 mo~zths.The shortestperiod 70~s 3 monthsand the loqest 7years. The age at tl7e time of tl7e accident zjaried from 2.5 to 72years. Tl7e largest group fell betwee the ages of 20 a77d 40 years. The main complaints were headache, giddiness, loss of concentration a77d poor memory. 380 were rezliewed by questio7777aire after scttlemefit of the case. 112 cases of extensioiilflexion i77juries of tl7e r7eck were see77between 1985 and 1989 and tl7eir symptoms at7d resolution were compared with 50 cases see77oz7er the san7e period following sigr7ifica77t head or neck injury. The results shozocd that the n7ore sezlere the head or 77ecknjury, the lesslikely were the cases to suffeev symptomsof post-tmumatic headaches or persisfi77g neck symptoms. fn conclusion, while 70% of mir7or kead ar7d neck injuries settle withi a few weeks of a motor vehicle accident, about 30% contir777e to complain of headaches and/or neck pair7. TI7e prolonged management, extensive plzysiotherapy a77d slow court settlemerit lead to excessive introspectio77 a77d yrolongatio77 of symptoms. 0 1998 Elsevier Science Ltd. All rig!7ts reserved.
‘cured’ by a substantial verdict. I have added ‘substantial’ verdict as it has been shown in some cases that if the verdict is not substantial the symptoms do not disappear. The debate has ranged across the medical literature. Miller” in his Milroy lectures followed up 50 patients with the post concussional syndrome and found that on personal interview, sometime after the verdict, 48 patients had lost their symptoms. He stressed once he had convinced them that he ‘hadn’t come to take the money back’ there appeared to be no symptoms. Pearce* states that ‘few topics provoke so much controversy or heated opinion based on so little fact. Most victims of ‘whiplash’ have, however, sustained no more than a minor sprain to the soft tissues and unusually severe or protractive complaints may demand explanations which lie outside the field of organic and psychiatric illness.’ Kelly” and Mendleson” believe that the symptoms are not cured by the verdict. Kelly’s follow up was by questionnaire, not personal interview. There is no doubt that these casesengage a large quantum of time for the lawyers. It has been estimated that in some Australian States a third of the judiciary, a third of the bar and a third of solicitors are engaged at any one time in these cases. Material
Injury, Vol. 29, No. 3, 199-206,1998
Introduction Since the introduction in Germany of compensation for injuries in 1860, there has been a procession of syndromes following minor injuries, starting initially with the railway spine’, followed in the 1940s and 1950s with the ‘post-traumatic concussional syndrome’, then in the 1960s with ‘whiplash injuries of the neck, and now the extension of the ‘posttraumatic stress syndrome’ to ‘whiplash’ injuries. It has been stated by Kennedy* that ‘post concussional syndrome’ is a state of mind born of fear, kept alive by avarice, stimulated by lawyers and
Between 1954 and 1966, 414 cases following closed head injuries were seen with varying periods of posttraumatic amnesia from nil to 72 h. Symptoms considered Headache. The incidence of post-traumatic headache is outlined in Figure 1. This shows a higher incidence, almost 6:l of headache, among those who did not lose consciousness. There is a progressive fall the longer the period of post-traumatic amnesia. In the group of cases in which the period of posttraumatic amnesia is greater than 72 h, the incidence is low. Giddiness, loss of concentration and poor memory. The next group of symptoms analysed were those
200
Injury: International Journal of the Care of the Injured Vol. 29, No. 3,1998 Investigations Electroencephalograms. Electroencephalograms (EEGs) were performed in 219 cases. Seventy-four EEGs were performed where there was no post-traumatic amnesia and 65 of these were complaining of headache. Sixty-seven of the EEGs were normal and in seven cases there was a moderate amount of 4-6 cycles per second activity in the recording. In one there was a focal disturbance in the frontal region. This patient had suffered a fracture in the left frontal bone.
I-72 Iburr Treatment
Figure 1. Frequency of headaches after motor vehicular accidents related to retention of consciousness (0) and the duration of post-traumatic amnesia.
Severance of the greater occipital nerve. Fifteen cases had had their greater occipital nerve divided as treatment for their headaches. The usual history was that they had obtained relief for 2-3 months and then the headache returned.
Method
relating to giddiness, loss of memory and poor concentration (Figure 2). These symptoms were less frequent than those reported in the literature on accident neurosis. Direct questioning was avoided in eliciting these symptoms. The incidence of loss of concentration and poor memory was higher in the group with the long period of unconsciousness. The darkened squares indicate the cases in which loss of concentration and poor memory were confirmed by tests of immediate memory retention. Positional vertigo. This was regarded as distinct from giddiness. Twenty-six cases complained of this and a positive Barnay’s response was demonstrated.
A questionnaire was sent to 380 cases, when the cases were known to be settled. The following questions were asked: age, date of accident, period of unconsciousness, history of any previous head injury, if they were still complaining of headache, giddiness or loss of concentration, if not, the date at which these symptoms had ceased, the date they returned to work, if they had previously suffered from any nervous symptoms and if they had suffered from headaches prior to the accident. Replies were received from 140. It is interesting that only five were returned from the dead letter office which suggested that the remainder were either not interested in replying or had lost their symptoms. Of the 140 replies, in five cases the relatives indicated that they were deceased. Of the remaining 135,86 at the interview had complained of headaches and 17 had said the headaches had ceased. However, of the 47 who claimed they had no headaches at the interview, 18 claimed headaches at the follow up and 34 claimed giddiness who had not complained of this at the initial interview. Therefore, while it must be concluded that a questionnaire follow up is unsatisfactory, it also indicates that this group of patients are highly suggestible. Findings Time off work. Thirty-five cases who had no loss of consciousness stated that they were off work or unable to cope with their household duties for a period of 5 weeks to 4 years. The average was 7 months.
Extension/flexion (‘whiplash’) Figure 2. Frequency of giddiness and poor memory after motor vehicular accidents related to retention of consciousness (0) and duration of post-traumatic amnesia.
injuries
of the neck
In the 197Os, the complaints after minor motor vehicle accidents changed to what is referred to in legal circles as ‘whiplash.’
Landy: Neurological
A second group of cases were studied from 1985-1989. These were 112 cases referred for neck a rear end pain and headaches, usually following motor vehicle accident and were compared with 50 cases that had suffered neurological damage also referred for medico-legal reports. No follow up of these cases after settlement was attempted as a questionnaire type of follow up was regarded as unreliable. Personal
201
sequelae of minor head/neck injuries
25
T
details
Sex distribution. Forty-nine male and 63 female. There was a slight predominance of females. Age distribution. There was a lower incidence in the young and elderly with prominence in the 20-50 age group (F&WC 3). Social class. In Grade 1 there were three cases, Grade 2 there were seven cases, Grade 3 there were 28 cases, Grade 4 there were 58 cases and in Grade 5 there were 16 cases. Grade 4 predominated.
l-2
3
4-6
7-12
13-15
19-24
3
4
5
6
YMIS
MOldIS
Figure 4. Time from accident to consultation.
Clinical
details
Hospitalisation. Thirteen were admitted to hospital. Of these, 11 were there 24 h or less. Time from accident to consultation. In recent years there has been an earlier referral for assessment (Figure 4). The delays in the longer period for assessments appeared to be due to slowness of the legal profession in implementing claims and trials.
40
Time to symptoms immediate accident from 6 h of pain shoulder
30.
onset of symptoms. The varied. Seventy-five onset of symptoms, 15 and the remainder over to 4 months in one case. in the back of the neck blades.
time to onset of complained of within 4 h of the varying periods They complained or between the
Period of posMraumatic amnesia. Of 112 cases, five suffered less than 10 min of post-traumatic amnesia, four less than half an hour and two less than 2 h. There were 101 cases who did not suffer posttraumatic amnesia.
20
Pain in front of the neck. pain in their sternomastoids.
Only four complained
of
Headaches. Eighty-five of the 112 patients complained of headache. All stated that the onset of the headache was at the time of the accident.
10
Electroencephalogram. Electroencephalograms were performed in 99 cases. One showed paroxysmal activity and had a history of ‘blackouts’ prior to the accident, one had asymmetrical delta activity and two had minor changes. The EEG was normal in 95 cases.
5
11-20
Figure 3. Age
21-30
31-40
41-50
51-60
61-70
70+
Time to cessation of symptoms. Twenty-nine stated their symptoms had ceased by the end of 2 weeks and 42 by the end of 8 weeks, i.e. 71 by the end of 8 weeks and a further 17 after 4 months following the
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Injury: International Journal of the Care of the Injured Vol. 29, No. 3, 1998
accident. Of the remaining 24, symptoms resolved over 2 years in 18, and six continued to have symptoms up to 5 years after the accident. Of these, the cases who continued to have much pain and complain of restricted movement of the neck at the time of the examination, all except one, demonstrated free neck movements when distracted. Period off work. Of 112 cases, 35 lost no time from work and 49 had returned to work within 4 weeks of the accident (Figure 5). Of the 25 who were off work for one week, nine were on holidays at the time of the accident, 11 were unemployed at the time of the accident and remained unemployed, and two were malingering and had been off work for 12 months. Of the 16 who had not returned to work 6 weeks after the accident, six had a prolonged divorce action and proceedings over custody in the family court and three had business failures or problems. Vehicle
16 / 16 -. l4-
1
2
3
4
Grade
Figure 6. Social class.
details
to vehicle. The least damage was $600. The major damage was a ‘write off.’ This was usually in a car that was older than 10 years. The average damage was $2000-$3000. Seat damage. Ten stated the seat in which they were sitting was damaged as a result of the impact. Damage
Significant
head or neck injuries
Over the same period, 50 cases who suffered a significant head or neck injury and had been referred for medico-legal opinion and had a period of posttraumatic amnesia longer than 2 h were reviewed.
3:
20
,-
Clinical
findings
Age distribution. Of the 50 cases, two were under 10 years of age, 11 were between 11 and 20 years of age, 19 between the ages of 21 and 30,ll between 31 and 40, five between 41 and 50 and two between 51 and 64 years (Figure 6). Social class. In the social class, there was one in Grade 1, four in Grade 2, nine in Grade 3, 20 in Grade 4 and 16 in Grade 5. Again this displayed a predominance in classes 4 and 5 (Figure 7).
Of those sufferPeriod of post-traumatic amnesia. ing a period of post-traumatic amnesia, 14 cases suffered post-traumatic amnesia greater than 2 h, four were greater than 24 h, three greater than 48 h, three greater than 72 h, four greater than 96 h and 22 greater than 1 week.
30 2025
1616-
20
15
10
5
Under 10
0
lday
11
2
3
4 Weeks
Figure 5. Period off work.
5
fJ+j-
Figure 7. Age distribution.
21130 YEARS
Landy: Neurological sequelae of minor head/neck injuries Memory. Thirty-six which was confirmed ation (MMI) testing.
complained of poor memory, on Mini Mental Status Examin-
Neck symptoms. Only five of the 50 cases complained of neck symptoms. One of these had suffered a fractured arch at Cl and another a ‘hangmans’ fracture of the neck. Among these cases there were five cases of subdural haematomas and one was a tetraplegic. In comparing the two groups of cases, those who suffered severe head injuries did not complain of neck symptoms. Even in those who did suffer a fractured arch and a hangmans fracture, their neck symptoms settled within 3 months. abnormality was Electroencephalogram. EEG present in 20. Sixteen of these had focal spike and delta activity.
Discussion In the post-traumatic headache syndrome seen between 1954 and 1966, headache and ‘post-concussional’ symptoms occurred mainly in those patients who did not lose consciousness. The more severe the head injury, the less likely was the patient to complain of post-concussional syndrome or neck pains. Symonds’ suggested that there were minute intracranial haemorrhages that cause the problem, how ever the brain is insensitive to pain. OpenheimeP found diffuse lesions in a number of brains studied at post mortem, but these were patients who had died shortly after severe head injury. Those who argue that minor head injuries cause some brain damage do so on the basis of neuropsychological testing. Rimel” suggests that there is cognitive impairment for up to 3 months after minor head injuries. However, the criticism of this study according to Walker I0 is that 82% examined at the time of the accident had significant amounts of alcohol in their blood. Newcombe” studied the possibility of cognitive sequelae of a transient or minor nature after mild head injuries. Neuropsychological tests were selected to measure abilities often compromised after significant head injuries, namely memory and attention. In general, no significant differences were found between the experimental and the control groups. Their conclusion is that counselling of mild head injury patients may help to avert symptoms that are psychological rather than pathophysiological in origin. Hirsh et al.” believes that sprain/strain syndrome or whiplash injury is the most common cervical injury associated with rear end impact motor vehicle accidents. The result is a complex injury often associated with extensive soft tissue injury in the cervical spine. There is additional potential for long term alteration in neurogenic muscular and skeletal function. He bases his observations that following a
203
rear end impact the driver will accelerate forward because of inertia and the neck hyperextends beyond its normal range. They further state that they believe the evidence suggests that this syndrome is real if manifested by symptoms consistent with anatomic injuries sustained, and that there is potential to cause However, if the driver or significant impairment. passenger is restrained by an adequately fitting seat belt and there are neck rests in the vehicle, then the person would not move forward and hyperextend their neck. All patients except one in this series claim that they were wearing seat belts, even those who had periods of post-traumatic amnesia of up to 72 h. and Severy et al.” in 1955, using humans dummies, staged rear end collisions and recorded events with a high speed camera. They identified the sequence of hyperextension of the neck followed by flexion. With the advent of head rests, hyperextension should be prevented unless the seat breaks off its mounting. Hohl et al.” studied 146 patients involved in rear end accidents and followed up 27% of the group of which approximately 43% of the 27% had residual symptoms beyond the time of the legal settlements. They concluded that the symptoms were attributable to the original accident. Deans et al.‘” studied 137 patients attending hospital following road traffic accidents. They were subsequently contacted between l-2 years later. Sixty-two percent stated they had suffered pain in the neck at some time following the accident, compared with 30% who were noted to have pain in the neck when examined soon after the accident. Pain in the neck occurred irrespective of the direction of the impact, but was disproportionately common in rear end impacts. Patients wearing seat belts experienced pain more frequently than the unbelted patients. Schutt’” believes that many patients with whiplash type injuries may have an organic basis for their psychoneurotic symptoms. They refer to Torres and Shapiro’sI report that moderately or markedly abnormal electroencephalogram changes similar to those in 44% of those who had been unconscious after direct head trauma were found days to months after the accident in 21 of 45 patients with whiplash, but without direct head trauma. However, Jacome’“, in 68 cases, found only minimal EEG abnormalities. This would correspond with the findings in my series. There is no adequate published control group of neck injuries occurring outside compensation claims and in this group, no control group could be obtained. In this group, there was no predominance in females, which has been mentioned in other serieslh. RadanoP, in a prospective study of whiplash, suggested that psycho-social factors have ‘little power’ to explain the course of recovery from common whiplash. The Luncef~‘, commenting on their findings, suggests that difficulty with concentration and memory might also be related to the
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consumption of analgesic drugs and that this possibility has not yet been thoroughly investigated. Bodguk and Marscand”’ regarded the cervical zygapophyseal joints as a common source of chronic neck pain. However, intra-articular injections of betamethasone are not an effective therapy for pain in cervical zygapophyseal joints after an injury”.
Behavioural analysis of chronic pain and its management A good deal of learning takes place in the development of the chronic pain condition. Fordyce” assumesthat pain is a behaviour rather than a neurological state and points out the conditioning process relative to pain, the direct positive reinforcement of pain behaviours, the indirect positive reinforcements, i.e. negative reinforcements of pain behaviours, such as avoidance and the failure to reinforce well behaviours. The reinforcing factors in post-traumatic syndrome in my experience have been a life situation, the continuing neurological and orthopaedic examinations and continuing physiotherapy and chiropractic treatment over many months and years. There have also been significant stresses, marital, family and financial. Berry 24has also noticed similar situations in the clinical syndrome, pointing to evidence for a psychological basis for the syndrome. He also points out that the chronic syndrome is not seen in the context of a demolition derby where hundreds of ‘whiplash injuries may be witnessed in one evening of this car crashing sport. TyreP points out in learned pain behaviour, that pain is a symptom that does not necessarily indicate physical injury. While the relation between acute pain and tissue damage is close, patients with persistent pain who are referred to doctors often describe more pain than appears warranted from a pathological process. He points out that if expressions of pain produce sympathetic attention from someone important to the victim, this will encourage future complaints of pain. Complaints may also enable the victim to avoid other unpleasant activities thus further indirectly rewarding the ‘sick’ role. Behaviours that are compatible with being well are not rewarded and so tend to be extinguished. The recognition of learned pain behaviour depends on paying attention to the relationship between pain behaviours and their apparent consequences. There is no doubt that persisting complaint of pain following a neck injury and the attendant investigations, manipulations, use of cervical collars, diaries supplied by lawyers to keep a daily account of every ache and pain, frequent medical examinations, do further encourage a sick role, extinguishes positive activity and in the long term is rewarded by compensation. The medico-legal cases following minor trauma showed a distinct change in the 1970s. While
Journal
of the Care of the Injured
Vol. 29, No. 3,199s
headaches were still a symptom, giddiness and loss of concentration were rarely evident. However, neck pain, headaches and poor memory were the symptoms. In comparison, of the 50 cases who suffered significant head injuries, only five complained of neck symptoms, two of whom had suffered serious neck injuries. The force that causes periods of post-traumatic amnesia of more than 24 h would be much greater than those suffered in minor extensionjflexion injuries in rear end collisions. However, this group did not complain of neck pain. Furthermore, the presence of neck rests should prevent hyperextension. Why are some of these cases ‘not cured by the verdict’“? The neurotic personality of some of those involved, or stress factors as outlined, business failures, dissolution of marriage and custody battles during the time of the court case. Excessive introspection is often evident and elicitation of these problems requires care if one is not to be met with ‘what has it got to do with my neck?‘. Very few neurological, neurosurgical or orthopaedic reports make any reference to the life style and emotional turbulence of the claimants. Why do those with only minor head injuries and neck sprain suffer, in some cases, continuing pain and headaches? Most studies have focused on organic explanations for the continuing pain. If we accept healing times are 2 weeks for muscle sprains, 3 weeks for muscle injuries and 4-6 weeks for fractures, then other factors must be involved. A comparison is often drawn to sporting injuries where post concussional headaches are short lived. Thirty years as consultant neurologist to two large teaching hospitals produced only one case of persisting post concussional headache. Investigation revealed a subdural haematoma. Despite the many head high tackles in football, I have never encountered a case complaining of ‘whiplash.’ Recently a case was awarded damages for a posttraumatic stress syndrome following a minor neck injuryZh. Helzer et al.” examined 2493 individuals as part of a nationwide general population survey. Posttraumatic stress disorder was found in 1% of the total population, about 3.5% in civilians exposed to physical attack and in Vietnam Veterans who were not wounded, and 20% in Veterans who were wounded in Vietnam. This argues against the use of this diagnosis in those subject to minor injuries.
Conclusion Many arguments have been adduced suggesting that the persisting symptoms after minor injuries, i.e. ‘post concussional syndrome’ and ‘whiplash’, are due to organic causes. The persistence of symptoms are better explained on the behavioural concept of chronic pain, learned pain behaviour and secondary gain. The symptoms
Landy: Neurological
sequelae
of minor
head/neck
injuries
are not cured by the verdict because they are SO reinforced by prolonged treatment, multiple examinations and investigations, multiple interviews with their lawyers, as well as being given diaries to record their daily symptoms. Often they have multiple neurological and orthopaedic examinations, multiple physiotherapy and chiropractic manipulations, long delays in settlement, resentment of the other driver who has damaged or destroyed their possession: the prospect of returning to an unsatisfactory or boring job powerfully reinforces their symptoms and the ‘sick role. And finally, cure may not be effected if the plaintiff considers the settlement inadequate: ‘most of it went on lawyers and doctors fees’ is a common complaint. It is simplistic to assume that those who have maintained these symptoms for months or years, assiduously cultivated by the system which is a large industry, will be cured by a verdict.
Suggestions
(1) More
(2)
(3)
(4)
(5)
(6)
(7)
time should be devoted in medical training to this problem. It is far more common in practice than multiple sclerosis, motor neurone disease, myopathies or cerebral tumours. Acute management should be that of sprains elsewhere; ice, cervical collars used ofzly for 48-72 h and early mobilisation. Reassurance of early resolution should be reinforced and patients be encouraged to remain active in the presence of pain with early mobilisation. The term ‘whiplash’ should be avoided and replaced by ‘neck sprain.’ Medical students, specialists and physiotherapists should be taught the condition will resolve in l-6 six weeks not ‘two years.’ Prolonged physiotherapy and chiropractic treatment should be avoided. If there are any symptoms to suggest nerve root or cord compression, an early MRI should be ordered. Otherwise extensive and repeated x-ray studies should be avoided. Headaches are a common symptom in life. Ninety percent of females and 80% of males suffer headaches during their life time. Rapid legal settlement for minor head injuries and neck injuries; the paraphernalia of the court and multiple medical examinations should be curtailed. I was once the 19th medical opinion requested in one such case! Use of medical panels to determine quantum where fault has been admitted.
References 1 Erichsen J. E. Co~zc~~ssio~z of the Spitie--NerzlousShocknlid Other Obscure Injuries of the Nervous System in their Clinical and Medico-legal Aspects, Longmans, Green &
Co., London, 1882.
20.5
2 Kennedy F. The mind of the injured worker and its effect on disability periods. Compensation Medicine 1946; 1: 19-24. 3 Miller H. G. Accident neurosis. Bv. Med. 1. 1961; 1: 919-925; 992-998. 4 Pearce J. M. S. J. Neural., Neurosurg., Psychiatry 1989; 52: 1329-1331. 5 Kelly R. and Smith N. 1. R. Sot. Med. 1981; 74: 275-277. 6 Mendleson G. Not ‘cured by a verdict’. Effect of legal settlement on compensation claimants. Med. 1. Amt. 1982; 11: 132-134. 7 Symonds, C. Concussion and its sequelae. Ln?zcef 1962; l-5. T. R. Microscopic lesion of the brain 8 Oppenheimer following head injury. I. A&n)!., Ncarosur‘~., Psyclrintrrr 1968; 31: 299. 9 Rime1 R., Giordani B., Barth J. T., Boll T. J. and Jane J. A. Disability caused by minor head injury. Neurosurgery 1981; 9: 221-228. 10 Walker E. Comments. Neurosurgery 1981; 9: 228. 11 Newcombe F., Rabbitt P. and Briggs M. Minor head injury: pathophysiological or iatrogenic sequelae? 1. Neural., Ncurosurg., Psychiatry 1994; 57: 709-716. 12 Hirsh S., Hirsh P. J., Hiramoto W. and Weiss A. Whiplash syndrome, fact or fiction. Orthopaedics North America 1988; 19: 791-794. 13 Severy J. Controlled automobile rear end collision. Canadian Services Med. 1. 1955; 11: 729-759. 14 Hohl M. Soft tissue injuries of the neck in automobile accidents. 1. Barre joints Surgery 1974; 56A: 1675-1681.
15 Deans G., Magalliard J. N., Kerr M. and Rutherford W. H. Neck sprain-a major cause of disability following car accidents. Irzjllry 1987; 18: 10-12. 16 Schutt C. Neck injury to women in auto accidents. IAMA 1968; 206: 2689-2692. in 17 Torres F. and Shapiro S. K. Electroencephalograms whiplash injury. Arch. Ncurol. 1961; 5: 28-35. 18 Jacome D. E. EEG in whiplash, a reappraisal. Clin. Elect. 1987; 18: 41-45. 19 Radanov 8. Role of psychosocial stress in recovery from common whiplash. Lancet 1991; 338: 712-714. 20 Lancet Talking Points. Lancet 1991; < b338:
articular corticosteroid for chronic pain in the cervical zygapophyseal joints. N. Engl. 1. Med. 1994; 330: 1047-1050. 23 Fordyce W. An operant conditioning method for managing chronic pain. Postgrad. Med. J. 1973; 53: (6): 123-128. 24 Berry H. Psychological Aspects of Whiplash Injury; Trauma and ifs Wake. Figley C. ed. Brunner/Masel, New York, 1985, pp. 1716-1719. 25 Tyrer S. Learned pain behaviour. BY. Med. 1. 1986; 292: 1. 26 Griffin J. Q. C. Lawyers perspective of post traumatic stressdisorder. Conference with Royal Australian and New Zealand College of Psychiatrists in association with the Medico-Legal Society of Queensland, 4 December 1993.
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27 Helzer J. E., Robins L. N. and McEvoy L. Post-traumatic stress disorder in the general population: findings of the epidemiologic catchment area survey. N. En@. I. Med. 1987; 317: 1630-1634.
Paper
Journal
of the Care of the Injured
accepted
20 October
Vol. 29, No. 3,199s
1997.
Requests for reprints should be addressed to: Dr I’. J. B. Landy, 201 Wickham Terrace, Brisbane, Qld. 4000, Australia.