The development of psychological changes following whiplash injury Michele Sterling a, * , Justin Kenardy b , Gwendolen Jull a , Bill Vicenzino a a The Whiplash Research Unit, Department of Physiotherapy, The University of Queensland, St Lucia, Brisbane, Qld 4072, Australia b Department of Psychology, The University of Queensland, Brisbane, Qld 4072, Australia Received 11 May 2003; received in revised form 19 August 2003; accepted 17 September 2003 Abstract Psychological distress is a feature of chronic whiplash-associated disorders, but little is known of psychological changes from soon after injury to either recovery or symptom persistence. This study prospectively measured psychological distress (General Health Questionnaire 28, GHQ-28), fear of movement/re-injury (TAMPA Scale of Kinesphobia, TSK), acute post-traumatic stress (Impact of Events Scale, IES) and general health and well being (Short Form 36, SF-36) in 76 whiplash subjects within 1 month of injury and then 2, 3 and 6 months post- injury. Subjects were classified at 6 months post-injury using scores on the Neck Disability Index: recovered (, 8), mild pain and disability (10 – 28) or moderate/severe pain and disability (. 30). All whiplash groups demonstrated psychological distress (GHQ-28, SF-36) to some extent at 1 month post-injury. Scores of the recovered group and those with persistent mild symptoms returned to levels regarded as normal by 2 months post-injury, parallelling a decrease in reported pain and disability. Scores on both these tests remained above threshold levels in those with ongoing moderate/severe symptoms. The moderate/severe and mild groups showed elevated TSK scores at 1 month post-injury. TSK scores decreased by 2 months in the group with residual mild symptoms and by 6 months in those with persistent moderate/severe symptoms. Elevated IES scores, indicative of a moderate post-traumatic stress reaction, were unique to the group with moderate/severe symptoms. The results of this study demonstrated that all those experiencing whiplash injury display initial psychological distress that decreased in those whose symptoms subside. Whiplash participants who reported persistent moderate/severe symptoms at 6 months continue to be psychologically distressed and are also characterised by a moderate post-traumatic stress reaction. q 2003 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. Keywords: Psychological distress; Whiplash-associated disorders; Post-traumatic stress 1. Introduction Whiplash-associated disorders (WAD) is a complex condition involving disturbances in motor function, nociceptive processing and psychological distress (Curatolo et al., 2001; Moog et al., 2002; Nederhand et al., 2002; Sterling et al., 2002). Whilst much of this evidence has been gained from investigation of those with chronic WAD, it is becoming apparent that some of these changes are present soon after injury and are likely to be important in the transition to either recovery or symptom persistence. Motor and sensory disturbances develop soon after injury and persist in those with poor recovery (Sterling et al., 2003a,b). Whilst psychological factors are believed to be important in the transition from acute to chronic spinal pain (Linton, 2000), this has not been well investigated in WAD. Investigation of psychological factors to date suggests that the psychological distress seen later in the chronic stage of WAD is most likely a consequence of ongoing pain and disability (Gargan et al., 1997; Radanov et al., 1995). Gargan et al. (1997) showed normal levels of psychological distress within a week of injury that became elevated at 3 months post-injury in association with restricted neck movement. This view is supported by other prospective studies where delayed recovery follow- ing whiplash injury could not be predicted from psycho- logical factors such as personality traits or self-rated well being but was related to injury severity (Borchgrevink et al., 1997; Radanov et al., 1995). A recent large cross- sectional study showed an association between anxiety and depression with pain and disability in whiplash patients whose accidents occurred over 2 years previously but not in those with acute injury, suggesting that symptom persistence is the trigger for psychological distress (Wenzel et al., 2002). 0304-3959/$20.00 q 2003 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.pain.2003.09.013 Pain 106 (2003) 481–489 www.elsevier.com/locate/pain * Corresponding author. Tel.: þ 61-7-3365-4568; fax: þ61-7-3365-2775. E-mail address: m.sterling@shrs.uq.edu.au (M. Sterling).