European Journal of Neurology 2008, 15: 12221230 doi:10.1111/j.1468-1331.2008.02301.

Clinical assessment of prognostic factors for long-term pain and handicap

after whiplash injury: a 1-year prospective study
H. Kascha, E. Qeramaa,b, A. Kongstedc, T. Bendixc, T. S. Jensena and F. W. Bachd
a
Danish Pain Research Center, Department of Neurology, Aarhus University Hospital, Aarhus, Denmark; bDepartment of Neurophysiology,
Aarhus University Hospital, Aarhus, Denmark; cBack Center Funen, Ringe, The University of Southern Denmark; and dDepartment of
Neurology, Aarhus University, Aalborg, Denmark

Keywords:
headache, neck pain,
prognostic factors,
prospective studies, risk
factors, whiplash injuries
Received 29 January 2008
Accepted 14 July 2008
Background and purpose: Physical mechanisms are the possible factors involved in the
development and maintenance of long-term handicaps after acute whiplash injury.
This study prospectively examined the role of active neck mobility, cervical and extra-
cervical pains, as well as non-painful complaints after a whiplash injury as predictors
for subsequent handicap. Methods: Consecutive acute whiplash patients (n = 688)
were interviewed and examined by a study nurse after the median of 5 days after
injury, and divided into a high- or a low-risk group by an algorithm based on pain
intensity, number of non-painful complaints and active neck mobility [active cervical
range of motion (CROM)]. All 458 high-risk patients and 230 low-risk patients
received mailed questionnaires after 3, 6 and 12 months. Two examiners examined all
high-risk patients (n = 458) and 41 consecutive low-risk patients at median 11, 109,
380 days after injury. The main outcome measures were: handicaps, severe headaches,
neck pain and neck disability. Results: The relative risk for a 1-year disability
increased by 3.5 with initial intense neck pain and headaches, by 4.6 times
with reduced CROM and by four times with multiple non-painful complaints.
Conclusion: Reduced active neck mobility, immediate intense neck pain and
headaches and the presence of multiple non-painful complaints are the important
prognostic factors for a 1-year handicap after acute whiplash.

insurance claims, it was found that passive coping

Introduction
Whiplash injury to the cervical spine is a common
condition following car accidents. In the acute phase,
whiplash injury is characterized by local neck pain,
headache, reduced neck mobility and a series of
unspecic neurological symptoms, which usually dis-
appear [1,2]. A proportion of patients, however, de-
velop a long-term condition known as a chronic
whiplash-associated disorder (WAD) [3] with persisting
painful and non-painful neurological symptoms [35],
but the reported frequency of long-term disability varies
considerably from 0% in Lithuania and Greece to more
than 75% in studies from UK and Sweden [612].
Whilst pain and other immediate non-painful symp-
toms may be linked to strain of soft tissue after acute
whiplash injury [4], recent questionnaire studies nd
that other prognostic factors are important in long-
term outcome. For whiplash patients involved in
strategies [13], female gender [14], intense and long-
standing pain and insurance compensation [14] are risk
factors for long-term sick-listing [3,14,15].
In a previous study of 141 acute whiplash injured
patients, which focused on physical factors, we found
reduced active neck mobility (cervical range-of-mo-
tion), intense neck pain, headache and a high number of
non-painful complaints to be risk factors for develop-
ment of chronic handicap [16]. To test the validity and
clinical signicance of these prognostic factors, we
performed a large scale prospective clinical study to
examine whether allocation of acute whiplash patients
to either a high- or a low-risk group by means of simple
assessment of pain, non-painful neurological symp-
toms, and neck mobility will result in substantially
dierent clinical outcomes.
Methods

Correspondence: Dr H. Kasch, Danish Pain Research Center, Study population

Department of Neurology, Aarhus University Hospital
Noerrebrogade 44, Building 1A, DK-8000 Aarhus, Denmark (tel.:
+45 89493382; fax: +45 89493300; e-mail: Helge.Kasch@
dadlnet.dk).
The study was planned as part of a two-centre (The
Danish Pain Research Centre, Aarhus University
Hospital, and The Danish Back Research Centre,

 2008 The Author(s)

1222 Journal compilation  2008 EFNS
 Clinical assessment of prognostic factors after whiplash injury
Funen Hospital/University of Southern Denmark)
prospective interventional three parallel group trial in
which immobilization or active mobilization was com-
pared with advice to act-as-usual. Emergency units and
general practitioners located in four counties, repre-
senting approximately 1.7 million inhabitants, referred
acute whiplash patients to the study. Enrolment took
place between May 2001 and June 2003.
The inclusion criteria were age 1870 years; exposure
to a rear- or frontal-end car collision; WAD [3] symp-
toms within 3 days post-injury (WAD grade IIII [3]);
participants understood written and verbal Danish; and
inclusion performed within 10 days after injury.
The exclusion criteria were injuries with fractures or
dislocations (WAD grade IV); trauma other than the
whiplash including cerebral concussion; pre-existing
signicant somatic or psychiatric disease and signicant
headache and neck pain; known alcohol- or drug abuse.
Signicant previous pain conditions were in detail:
disability pension because of headache; neck pain;
shoulder pain or low back pain; sick leave for more
than 3 months duration during last year because of
neck pain, headache, low back pain or shoulder-pain
condition; regularly prescribed analgesic medication or
other regular interventional therapy for chronic pain
condition. Average neck-pain and/or headache during
the last 6 months rated from 3 to 10 on an 11-Point
Visual Analogue Scale (VAS) Box Scale.
The study was approved by the local ethical com-
mittees and conducted in accordance with the Helsinki
II Declaration. Each participant, who gave permission
to be contacted when seen in the emergency unit or by
the general practitioner, received verbal and written
information about the study by the study nurse before
giving verbal and written consent to participation.
Determination of risk status
The criteria for high- and low-risks were determined a
priori and have been previously described [17]. Briey,
these risk factors were combined into a risk score. To be
included in the high-risk group, the risk score had to be
4. The scoring was as follows:
(a) Active neck mobility, total CROM which included
the following six directions of movement; exion;
extension; right and left latero-exion, and right and
left rotation [16] (range below 200 = 10 points; 200
220 = 8 points; 221240 = 6 points; 241260 =
4 points; 261280 = 2 points; above 280 = 0 points).
(b) 11-Box VAS present neck pain/headache (02 =
0 points; 34 = 1 point; 58 = 4 points; 910 = 6
points). On this scale 0 denotes no pain and 10 denotes
worst imaginable pain.
(c) Female gender (yes = 1 point, no = 0 points).
 2008 The Author(s)
Journal compilation  2008 EFNS European Journal of Neurology 15, 12221230
1223
(d) Number of non-painful symptoms (02 = 0 points;
35 = 1 point; 611 = 3 points) where 0 denotes no
pain and 10 denotes worst imaginable pain, where
minimum was having no non-painful complaints and
maximum was having 11 of 11 possible non-painful
complaints.
As shown, VAS scores >4 and total CROM <240
were considered high-risk on its own.
Data collection
Questionnaires were lled in at baseline and after 3, 6,
and 12 months after the injury by all participants.
Frequency and intensity of neck pain, headache and
non-painful symptoms were recorded at each time-
point, and neck pain and headache were scored on a 11-
Point VAS. A record of the previous symptoms, disease,
medication, and socio-demographic and injury related
factors were also obtained at baseline. Results from
SF-36, Symptom Check List 90 Revised (SCL-90R),
Coping Strategies Questionnaire [18] and Impact of
Event Questionnaire [19] are reported elsewhere.
Clinical assessment
At the rst examination, all patients underwent struc-
tured neurological examination of cranial nerves and
upper and lower extremities including assessment of
tendon reexes, sensory function and muscle strength at
baseline and at 3 and 12-month follow-ups.
Active neck mobility (exion, extension, left and
right rotation and lateral-exion) was assessed with a
CROM Device (Performance Attainment Associates,
Roseville, MN, USA) as previously described [20,21].
During neck movement in all of six directions, the
examiner asked the patient whether pain was elicited by
that particular movement, and if so, whether pain oc-
curred in the neck region or in a region remote from the
neck.
Methodical palpation was performed at nine sites
bilaterally: (i) the anterior and (ii) posterior part of the
temporal muscle, (iii) the masseter muscle, (iv) the
lateral pterygoid muscle, (v) the sternocleid at inser-
tion point and (vi) the sternocleid at its belly, (vii) the
suboccipital muscle, (viii) trapezius at its superior part
and (ix) the rhomboid muscle along the medial border
of scapula. From 0 to 4 points was given at each site
according to the American College of Rheumatology
(ACR) criteria [22]. 0 = (no pain) denial of tenderness,
1 = (mild pain) complaint of pain without grimace,
inch or withdrawal, 2 = (moderate pain) plus
grimace or inch, 3 = (severe pain) plus marked inch
or withdrawal, 4 = (unbearable pain) patient is
untouchable, withdraws without palpation.
1224 H. Kasch et al.
Patients were blinded with respect to assignment to
the high- or low-risk groups, and patients were not
aware of any division being made. Initial assessment
was performed after the median of 5 days by the study
nurse and included examination and division into high-
and low-risk groups. At this point, the study nurse
knew if the patient belonged to the high- or the low-risk
groups.
Based on these ndings, a division into a low- and a
high-risk group by means of a block randomization
took place using the software program MINIMIZE to
ensure that the two low-risk treatment groups (verbal
info or booklet) and the three high-risk treatment
groups (McKenzie physiotherapy [23], verbal info or
sti neck collar [24]) were balanced according to the
following items [gender (0/1), age categories (1830;
3145, 4655 and 5670), VAS pain (02; 34; 57 and After 12 months, neck pain and headache were rated on
810) and CROM (300+; 250299; 200249 and 0
199).
In the high-risk group, if randomized to immobili-
zation, a sti neck collar was mounted, and the patient
was instructed how to use it for 14 days and was
enabled to receiving active physiotherapy after 2 weeks
being in contact with the study physiotherapists
to receive advice and also to assess compliance. If
randomized to active mobilization, the patient was
scheduled to meet the study physiotherapist, and, based
on the principles for McKenzie treatment, to receive
active mobilization (mechanical diagnosis and therapy
[MDT] including two weekly contacts for a maximum
of 6 weeks). In this group, compliance was also evalu-
ated. There was no dierence regarding compliance in
the mobilization and immobilization groups.
When high-risk patients were seen in the following
2 weeks, 3 months and 12 months after injury, the
examiners at the research centres were blindfolded to
whether the patient was receiving immobilization,
mobilization or verbal information as treatment.
The high-risk patients receiving active treatment were
guided in this respect by the physiotherapists, who also
made a standardized evaluation of the patient regarding
compliance to active treatment.
At the Back Research Centre, further 41 consecutive
low-risk patients were examined by the same means as
high-risk patients.
There was no dierence regarding answering ques-
tionnaires or drop-outs between the three high-risk
groups and the two low-risk groups or between high-
and low-risk patients.
Primary outcome measure
Handicaps after 12 months were assessed based on the
presence of: more than 3 months sick leave during the
Journal compilation  2008 EFNS European Journal of Neurology 15, 12221230
last 6 months, work inability during the last month, or
not working anymore because of the accident [16]. The
number of days with handicap was computed by means
of questionnaire data after 3, 6 and 12 months post-
injury. Days with sick leave were counted as full days
and days with reduced working hours were counted as
half days. If the patient could manage full time, but had
changed functions after injury, it was counted as full-
working hours. Patients who did not work prior to
injury (on leave, unemployed, disability pension and
retired) were not considered in the calculated risk for
handicap, but were included in computation of
secondary outcome measures.
Secondary outcome measures
11-Point Box Scales (0 = no pain, 10 = worst imag-
inable pain) pain scores from 0 to 4 were considered as
minimal pain and from 5 to 10 were considered con-
siderable pain [25].
Neck disability after 12 months was assessed by
means of the Copenhagen Neck Disability Scale [26],
where scores from 0 to 6 were dened as minimal neck
disability and from 7 to 30 were considered consider-
able neck disability.
Statistical analysis
Data analysis was made using SPSS 11.0 (SPSS Inc.,
Chicago, IL, USA), STATA 8.0 (Circle Systems Inc,
Seattle, WA, USA), and Microsoft Excel 2002 for
Windows. Data were analysed and investigators re-
mained blindfolded until the analysis of the treatment
eect had been performed.
KaplanMeier (KM) survival analysis was applied to
determine recovery rates in the high- and low-risk strata
based on the primary end-point handicap and the three
secondary end-points: severe neck pain, severe head-
aches and persistent neck disability. For computational
reasons, it was assumed that each participant was
handicapped and had considerable neck pain and
headache and considerable disability at time of injury,
which was deemed day 0 (for KM plots and Cox
regression analysis). For the preparation of the Cox
regression, time-to-event was chosen as time-parameter.
Following pairs of events (i) and time-to event (ii) were
chosen:
(1) (i) Status change from handicap to recovery and (ii)
days until recovery from handicap.
(2) (i) Status change from severe headache (VAS: 510)
to less severe headache or pain-free at the following
time-points and (ii) days until recovery from severe
headache.
 2008 The Author(s)
 Clinical assessment of prognostic factors after whiplash injury
(3) (i) Status change from severe neck pain (VAS 510)
to less severe pain or pain-free at consecutive time-
points, and (ii) days until recovery from severe neck
pain.
The following prognostic factors were evaluated in the
Cox regression analysis:
Factor 1: Total cervical range of motion, three catego-
ries: (0240; 241280; 281+) [16].
Factor 2: Initial Neck pain VAS010, three categories: 0
2; 35; 610.
Factor 3: Initial Headache VAS010, three categories: 0
2; 35; 610.
Factor 4: Initial number of non-painful symptoms
(range 011), three categories: 02; 35; 611.
Factor 5: Number of movement directions with local
pain during CROM test (02; 34; 56).
Factor 6: Total palpation pain score, neck and jaw
muscle-pairs (012; 1324; 2548).
Factor 7: Female gender (Y/N).
Factor 8: Age, three categories (1830; 3150; 5170).
Factor 9: Reported Seriousness of Car accident (mild,
moderate, severe).
Factor 10: Initial VAS score of being back at work after
6 weeks (0 = most likely; 10 = most unlikely, three
categories (02; 35; 610).
Results
A total of 1495 [F/M: 898/597] acute patients were
contacted from emergency units and general practi-
tioners and 680 eligible acute whiplash patients [443/
252] gave informed consent to participate. Six-hun-
dred patients [353/247] were not eligible for partici-
pation, but from this group, we followed-up 52
patients with previous moderate neck pain (VAS < 4)
according to the principles in the low-risk group (to
be published elsewhere) and 200 [102/98] declined
participation. The majority of this group declined
because of lack of time, vacation and no interest in
treatment intervention. Patients were divided accord-
ing to a previously described stratication procedure
[17] into a high-risk group of 458 [328/130] patients,
and a low-risk group consisting of 230 patients [110/
120]. See owchart in Fig. 1. The two treatments were
not superior to acting as usual in high-risk patients,
for details refer to [17] and the acting as usual mes-
sage given by booklet or verbally did not inuence
recovery end-points in low-risk patients, for details
refer to [27]. Twenty-three of 688 whiplash patients
fullled the criteria for WAD grade III (F/M:19/7;
age 37.2 2.2); none of these had areexia or hyp-
oexia, but were mainly characterized by diuse
muscle weakness in upper and/or lower extremities at
the rst examination.
 2008 The Author(s)
Journal compilation  2008 EFNS European Journal of Neurology 15, 12221230
1225
Table S1 shows the socio-demographic comparison
of the high- and low-risk groups by means of a Krus-
kalWallis test which showed that patients were less
vocationally trained in the high-risk group
(P < 0.002). There was no age dierence or dierence
on actual occupation, marital status, or the number of
children at home.
As would be expected, the initial examination and
pain scores found that high-risk patients had higher
number of painful neck movements (06 directions)
during active cervical range of motion (P < 0.001), a
signicantly higher total tenderness scores by muscle
palpation (P < 0.001), a higher number of painful
symptoms (P < 0.001), a higher intensity (P < 0.001)
and frequency (P < 0.001) of painful symptoms and a
higher intensity of non-painful symptoms (P < 0.007).
Major properties of high- and low-risk groups are
shown in detail in Table S2 and details on development
in painful and non-painful neurological symptoms are
provided in Fig. S1.The intensity of non-painful
symptoms as well as the frequency of these symptoms
diered between recovered and handicapped patients as
shown in Figs S1b and d. The results also show that not
only intensity and frequency of cognitive symptoms are
higher in the non-recovered patients from the rst
examination, especially fatigue, irritability, concentra-
tion problems and memory disturbances, but also sleep
disturbances are present from very early after injury
(for all disabilities listed, P < 0.001).
Figures S1a and d show that not only neck pain and
headache, but also shoulder pain, arm pain, low back
pain, but not jaw pain diered signicantly in patients
with disability as compared with recovered whiplash
patients after rst examination. The dierence was even
more pronounced after 1 year, and after 1-year handi-
capped also diered signicantly from recovered
regarding intensity and frequency of jaw pain.
As part of the algorithmic procedure for dividing
patients by means of risk criteria, high-risk patients had
reduced CROM, high neck pain and headache intensity
as well as frequency of multiple non-painful symptoms.
The relative risk for 1-year disability by means of
either handicap, continuous signicant neck pain or
neck disability was assessed for various prognostic
factors. Gender (rr: 1.6; CI95: 0.99; 2.5) was not a sig-
nicant risk factor for being handicapped after 1 year,
but women were in the risk group for neck disability (rr:
1.3; CI95: 1.0; 1.7) and long-term neck pain (rr: 1.5;
CI95: 1.2; 1.9). The relative risk in the high-risk group
for a 1-year handicap was more than 10-fold (rr: 10.5;
CI95: 3.9; 28.2). Initial high neck pain intensity was
associated with 3.5-fold risk increase (rr: 3.5; CI95: 2.2;
5.5), as was headache intensity (rr: 3.7; CI95: 2.4; 5.7).
Reduced active cervical range of motion was associated
1226 H. Kasch et al.

From emergency units and GPs

n = 1495 F/M [898/597]

Ineligible:
n = 540 [311/229]
Declined participation
n = 200 [102/98]
Protocol violation
n = 15 [11/4]

Baseline evaluation

n = 740 [474/266]

Previous neckpain but < 4 onVAS

n = 52 [36/16]
Reported elsewhere

Low risk group High risk group

n = 230 [110/120] n = 458 [328/130]

Three months questionnaire Three months follow-up, + questionnaire

n = 187 n = 329

Six months questionnaire Six months questionnaire

n = 165 n = 329

12 months questionnaire/interview 12 months follow-up, questionnaire or

n = 215 interview, n = 410
Drop outs, n = 55 [34/21]
Drop outs Excluded due to other disease, accident
n = 15 n = 13 [8/5]
Figure 1 Flowchart of whiplash study.

with a 4.6-fold risk increase for chronic handicap. A
four-fold increase for handicap was seen with initial
high palpation tenderness score (rr: 4.0; CI95: 1.9; 8.5).
Figures 2ad: KM plots showing development in
recovery after the injury. Fig. 2a shows that 1-year
handicap was found in 19.3% of high-risk patients
(17.1; 21.8) and in 2.4% (1.8; 2.9) of low-risk patients
after 1 year, and that patients in the high-risk group
had signicantly slower recovery from handicap
(Fig. S1a: Log Rank: 110; P < 0.001), from high
intensity neck pain (Fig. S1b: Log Rank: 155.96;
P < 0.001), and high intensity headache (Fig. S1c: Log
Rank: 40.99; P < 0.001) and from neck disability
(Fig. S1d: Log Rank: 95.81; P < 0.001).
A Cox-regression analysis showed that gender was not
a signicant risk factor for being handicapped, but was a
risk factor for the development of long-term severe
headache (P < 0.01) or neck pain (P < 0.004). The
presence of initial severe neck pain and headache was risk
factors for being handicapped (P < 0.01 and P < 0.02).
Severe initial neck pain was associated with long-term
severe neck pain, but not associated with the develop-
ment of a long-term and severe headache, severe initial
headache was associated with long-term headache, but
not associated with a long-term severe neck pain.
A large number of non-painful symptoms at rst
examination were a risk factor for a long-term handicap
(P < 0.007), but not associated with a long-term
headache or neck pain. Initial reduction of active neck
mobility was a signicant risk factor for a long-term
handicap (P < 0.0001), but not associated with long-
term neck pain or headache.
The best prognostic marker for a long-term handicap
or changed work function after 1 year was active cer-

 2008 The Author(s)

Journal compilation  2008 EFNS European Journal of Neurology 15, 12221230

(a) 100
80
Handicapped (%)
60
40
20
0 0
0 100
Figure 2 (a) Time to recovery from
handicap after acute whiplash injury in
high- and low-risk whiplash patients (c) 100
[KaplanMeier (KM) plot]. (b) Time to
recovery from severe neck pain after acute 80
Headache (%)
whiplash injury in high- and low-risk
60
whiplash patients (KM plot). (c) Time to
recovery from severe headache after acute 40
whiplash injury in high- and low-risk
whiplash patients (KM plot). (d) Time to 20
recovery from severe neck-related disabil-
0 0
ity after acute whiplash injury in high- and 0 100
low-risk whiplash patients (KM plot). Time to recovery (days)
vical range of motion with an accuracy of 74%, whereas
high initial neck pain score and headache score revealed
an accuracy of 65% and 69% respectively.
Log-minus-log (LML) curves were made for each of
the six prognostic factors, and the time-dependent
covariance of each factor was examined before running
the Cox regression analysis. There was no signicant
time-dependency of factors (SPSS TIME PROGRAM:
a = 0.05; b = 0.10), LML-graphs showed parallel
curves for the split factors in all plots.
Discussion
This prospective study of acute whiplash injured per-
sons showed that patients with a reduced active neck
mobility, high intensity of neck pain and headache and
multiple non-painful symptoms carry a 10-times raised
risk for the development of chronic WADs. In the
high-risk group one out of ve as compared to one out
of 40 in the low-risk group were handicapped 1 year
after injury and the recovery rates for the high- and
the low-risk groups diered remarkably according to
the a priori chosen 1-year end-points: handicap,
severe neck pain and headache and neck disability
(Figs S1ad).
Previous studies have observed similar ndings
[28,29]; however, this study is the rst to test the sig-
nicance of a priori identied prognostic factors.
There are neither clinical nor paraclinical measures
of the chronic WAD syndrome [30], but we used
return-to-work and daily activity as our primary end-
point because they are rather robust and less aected
 2008 The Author(s)
Journal compilation  2008 EFNS European Journal of Neurology 15, 12221230
Clinical assessment of prognostic factors after whiplash injury 1227
(b) 100
80
Neck Pain (%)
60
40
20
200 300 400 0 100 200 300 400
Time to recovery (days) Time to recovery (days)
(d) 100
Neck Disability (%)
80
60
40
20
200 300 400 0 100 200 300 400
Time to recovery (days)
by bias than subjective symptoms. It may be argued
that handicap in our study terms can be caused by
other factors than the injury itself, for example
psychological [3133], legislative [14,34] and socio-
demographic factors [11,35]. Nevertheless, the fact
that the same measure and assessment in the present
study were performed as early as ve 5 days after
injury in both the high- and the low-risk groups
which were similar in terms of socio-demographic
ndings suggests that disabilities are linked to the
whiplash injury per se.
We have previously shown that reduced active neck
mobility (active CROM) was related to handicap [16]
and was a clinical sign in acute whiplash patients, but
reduced CROM was not present in acute ankle injured
patients [20]. This study conrms these preliminary
results. Reduced active neck mobility is not a biome-
chanical test per se, but is probably to be inuenced by
both physical and psychological factors. Whether the
presence of reduced active CROM is related to tissue
damage or is a pseudo-biomechanical nding inu-
enced by pain-related fear [36,37] is an interesting
possibility open for discussion and further studies.
However, focal neck pain and sensitization [3840] or
pre-existing pain [41] may also play a role for initial
neck disability. In this study, neck pain, pain elicited
by CROM testing, reduced pain threshold and muscle
tenderness, high intensity and frequency of painful and
non-painful symptoms are all factors that contribute
to long-term handicap. Reported severity of injury was
not related to recovery rate in this study and previous
studies [28,42]. However, the fact that patients with
1228 H. Kasch et al.
initial reduced cervical range of motion had a
4.6 times higher risk for disabilities after 1 year, pa-
tients with high initial neck pain and headache inten-
sity were associated with a 3.5 times higher risk for
long-term handicap and those with a high number of
non-painful symptoms were associated with about
4.0 times raised risk for a long-term handicap may
indicate that nociceptive sensitization could therefore
be one of the several features involved in the devel-
opment of chronic WAD [2,3840,43,44]. In this
study, however, in parallel to the development of
painful symptoms and a spread of pain, we also found
non-painful symptoms to predict long-term handicap,
which may further involve somatization or other
psychological phenomena [33,45]. Non-painful symp-
toms may also reect alterations in pain processing by
means of primary or secondary sensitization of the
nociceptive system [46], referred sensory disturbances
are seen in deep muscle pain [40,44].
It may be speculated that the interventions applied in
the high-risk group could bias the results of this study
towards a more severe outcome in patients receiving
active mobilization or immobilization compared with a
verbal stay active message. Patients exposed to an
active treatment either it be immobilization or active
mobilization after an injury could be more prone to
catastrophizing [13,45], or just more worried about
being injured. However, we nd this unlikely in this
study, as the interventions did not signicantly aect
the outcome parameters as they have been reported
previously [17]. Neither was a verbal stay-active mes-
sage given by the study nurse in the low-risk group
superior to a booklet [27].
In addition, the patients were blind-folded regarding
high- or low-risk category of the patient. This large
clinical study is consistent with formerly proposed risk
factors [16]. Previous studies have also found pain
intensity and non-pain symptoms to be of importance
for non-recovery [4749]. On the basis of previous
studies [4,49,50], we included female gender as a risk
factor in this study when dividing them into high- or
low-risk groups and also in our work, female gender
was found to be a relative risk factor for long-term neck
disability and severe neck pain, but not for long-term
handicap, the former being in concordance with general
population studies [5153].
There are no objective parameters to document
handicap in whiplash, so the present results are poten-
tially open to bias. We consider this less probably for the
following reasons: (i) return to daily activity was based
on a standardized semi-structured interview/question-
naire applied 6 and 12 months after the injury. All pain
and muscle tenderness assessments and the CROM test
were carried out prior to the time of assessment; (ii)
Journal compilation  2008 EFNS European Journal of Neurology 15, 12221230
work capability is an assessor of independent parameter
and is not sensitive to investigator bias; (iii) the CROM
test has previously been found to be a reproducible test
with a low variation coecient [20].
Conclusion
This study substantiates previous suggestions that ini-
tially reduced active neck mobility, high neck pain and
headache intensity, as well as multiple non-painful
symptoms are associated with a high-risk for a long-
term handicap after acute whiplash injury. These data,
because of the prospective character of the study and a
priori dened risk factors, indicate that symptoms and
signs associated with acute whiplash injury are impor-
tant determinants for the development of a long-term
handicap.
Acknowledgements
Participants were recruited with the help of sta at the
emergency units in hospitals in the four former counties
of Viborg, Aarhus, Vejle and Funen during enrolment
period. Statistical consulting was provided from the
Department of Statistics, University of Southern Den-
mark on designing the study. Financial support was
provided by an unrestricted grant from Insurance and
Pensions in Denmark.
Supporting Information
Additional Supporting Information may be found in
the online version of this article.
Figure S1 (a) Pain presentation 5 days after acute
whiplash injury. (b) Non-pain symptom presentation
5 days after acute whiplash injury. (c) Pain presentation
1 year after acute whiplash injury. (d) Non-pain
symptom presentation 1 year after acute whiplash in-
jury. Frequencies of symptoms are shown in percent-
ages SD (from 0% to 100%). Intensities of
symptoms both painful and non-painful symptoms
represent a four-point ordinal scale from 0 = none,
1 = mild, 2 = moderate and 3 = severe, grading the
severity of that symptom in relation to the injury.
Table S1 Socio-demographic factors in acute high- and
low-risk whiplash patients.
Table S2 Initial properties and assessment in acute
high- and low-risk whiplash patients.
Please note: Wiley-Blackwell are not responsible for
the content or functionality of any supporting materials
supplied by the authors. Any queries (other than
missing material) should be directed to the corre-
sponding author for the article.
 2008 The Author(s)
 Clinical assessment of prognostic factors after whiplash injury
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