Research Review By Dr. Jeff Muir©


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Date Posted:

April 2020

Study Title:

Exposure to a Motor Vehicle Collision and the Risk of Future Neck Pain: A Systematic Review and Meta-Analysis


Nolet PS, Emary PC, Kristman VL, Murnaghan K, Zeegers MP, Freeman MD

Author's Affiliations:

Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands; Department of Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada; School of Kinesiology, Lakehead University, Thunder Bay, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Health Sciences, Lakehead University, Thunder Bay, Ontario, Canada; Division of Human Sciences, Northern Ontario School of Medicine, Lakehead University, Thunder Bay, Ontario, Canada; and Institute for Work and Health, Toronto, Ontario, Canada

Publication Information:

Physical Medicine and Rehabilitation 2019 Nov; 11(11): 1228-1239.

Background Information:

Neck pain is the fourth leading cause of years lived with disability (1), with a point prevalence of 4.9% (2). Often a chronic condition (3), neck pain represents a significant economic burden on health care systems (2) and patient quality of life (4).

Neck pain is common following motor vehicle accidents (MVAs), and the question of whether neck pain suffered as a result of an MVA is a causal factor for long-term neck pain remains unanswered. Neck pain is known to persist for up to one year following MVA and injury status at the time of the accident is also known as a predictor of injury risk. There is little in the literature, however, regarding the predictability of neck pain following MVA-related neck injury. The objective of this study was to review and meta-analyze the available data in order to estimate the risk for an association between MVA-exposure to neck pain and future neck pain.

Pertinent Results:

Study Characteristics:

8 studies met the inclusion criteria. Studies represented a variety of settings, including primary care and emergency departments, insurance and injury databases, police records and the general population. Time since MVA in the included studies extended to up to 4 years. Exposure to neck injury was determined as a question on intake/history forms or on insurance/police reports. Neck pain outcomes were measured variably using self-reported or validated questionnaires.

Risk of Bias Assessment:

Risk of bias (RoB) was evaluated based on 6 domains: study participation, study attrition, MVA exposure, neck pain measurement, study confounding and statistical analysis/reporting. One study was rated as having low RoB in all domains. The remaining studies demonstrated moderate RoB in 1-2 domains, with neck pain measurement (n = 4) and control for confounding factors (n = 4) representing the domains most commonly noted. One study was excluded after critical appraisal, as it noted high RoB in several domains, including attrition and confounding factors.

Summary of Evidence:

Exposure to neck injury in MVA vs. no neck injury in MVA:
The association between MVA-related neck injury and future neck pain was examined in hypothesis-generating studies (n = 2), exploratory studies (n = 3) and confirmatory studies (n = 1). A positive association was noted in the hypothesis-generating studies (odds ratio [OR] = 2.95; [95% CI: 1.97-4.42] (5) and OR = 9.2; [95% CI: 4.2-20.1] (6)), as well as the exploratory studies (adjusted relative risk [RR] = 2.7; 95% CI: 2.1-3.5 (5); adjusted OR (males) = 4.0; 95% CI: 2.1-7.5 and adjusted OR (females) = 2.1; 95% CI: 1.3-3.3) (7) and adjusted OR = 5.34 (95% CI: 1.9-15.0) (8). The single confirmatory study (9) also showed a positive correlation: adjusted Hazard Rate Ratio (HRR) = 2.14 (95% CI: 1.12-4.10).

Although tests for heterogeneity indicated significant heterogeneity amongst these studies (Q = 20.4 (DF 5, p = 0.001); I2 = 75.5% (95% CI: 44.6%-89.1%), meta-analysis of the results showed a combined positive association between MVA-related neck injury and future neck pain (RR = 2.3, 95% CI: 1.8-3.1, p = 0.001).

Meta-regression comparing results of studies from differing sources demonstrated a difference between studies from hospitals and primary care populations compared to those from insurance and injury databases (coefficient 0.602, SE 0.219; 95% CI: 0.173-1.0316, Z = 2.75, p = 0.006). Results from hospital studies did not differ significantly from those from the general population (coefficient 0.497, SE 0.419; 95% CI: 0.325-1.318, Z = 1.18, p = 0.236). No difference was noted based on the follow-up period amongst studies (coefficient − 0.0037, SE 0.0269; 95% CI: −0.057-0.049, Z = −0.14, p = 0.8907).

Exposure to an MVA compared to no exposure to an MVA:
Two studies examining the association between exposure to an MVA and future neck pain found no association between exposure to a rear-end collision where injury to the participant was unknown (OR = 0.62; 95% CI: 0.41-0.94) (10) or where no insurance claim was filed (RR = 1.3; 95% CI: 0.8-2.0) (5).

Clinical Application & Conclusions:

This study found that there is an increased risk of future neck pain in patients who have previously suffered MVA-related neck injury. The authors estimate that 57% of the cause of ongoing neck pain in patients having suffered a neck injury in an MVA can be associated with the initial MVA injury. They further noted that, in cases where no MVA-related neck injury was reported, or where no insurance claim was filed, no association existed between exposure to an MVA and future neck pain.

EDITOR’S NOTE: As clinicians, this means we must delineate between exposure to prior MVA without neck pain and exposure that resulted in neck pain. The latter, according to the results of this study, would, to a decent degree, help explain a current neck pain complaint, while the former would not. This finding could have implications not only for clinical practice, but also medicolegal and insurance claims/cases.

Study Methods:

Several databases were searched: PUBMED, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, SPORTDISCUS, and MEDLINE (EBSCO).

Eligibility for Study Inclusion:
2 authors independently screened relevant articles, with a third reviewer independently screening citations where consensus could not be reached. Specific eligibility criteria included:
  • Studies with participants aged 16+ who were involved in an MVA and included an appropriate control group,
  • English language, published since 1998, in a peer-reviewed journal,
  • Examining the association between MVA-related neck injury and future neck pain, and
  • Use a case-control or cohort design.
Data Extraction:
One reviewer created evidence tables while a second screened the tables for accuracy.

Methodological Quality:
Risk of bias was assessed by 2 reviewers using the Quality in Prognosis Studies (QUIPS) appraisal tool modified for risk studies (12).

Data Synthesis and Analysis:
Between group/intervention differences were determined for each outcome. When possible, data was pooled for meta-analysis, using standard meta-analytic tests for heterogeneity (Q-value and I2 statistic).

Study Strengths / Weaknesses:

  • Very strong, comprehensive search criteria designed by health science librarian.
  • Inclusion of several, varied databases.
  • Independent reviewers screened eligible studies.
  • Critical appraisal via the QUIPS assessment tool was used.
  • Studies limited to English language only
  • Studies limited to those published after 1998.
  • Heterogeneity amongst studies may limit the strength of the conclusions.

Additional References:

  1. Vos T, Flaxman AD, Naghavi M, et al. Years lived with disability (YLD’s) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the global burden of disease study 2010. Lancet 2012; 380: 2163-2196.
  2. Hoy D, March L, Woolf A, et al. The global burden of neck pain: estimates from the global burden of disease 2010 study. Ann Rheum Dis 2014; 73(7): 1309-1315.
  3. Côté P, Cassidy JD, Carroll LJ, Kristman VL. The annual incidence and course of NP in the general population; a population-based cohort study. Pain 2004; 112: 267-273.
  4. Nolet PS, Côté P, Kristman VL, Rezai M, Carroll LJ, Cassidy JD. Is NP associated with worse health-related quality of life 6 months later? A population-based cohort study. Spine J 2015; 15(4): 675-684.
  5. Berglund A, Alfredsson L, Cassidy JD, Jensen I, Nygren A. The association between exposure to a rear-end collision and future neck or shoulder pain: a cohort study. J Clin Epidemiol 2000; 53(11): 1089-1094.
  6. Tournier C, Hours M, Charnay P, Chossegros L, Tardy H. Five years after the accident, whiplash casualties still have poorer quality of life in the physical domain than other mildly injured casualties: analysis of the ESPARR cohort. BMC Public Health 2016; 16: 13.
  7. Freeman MD, Croft AC, Rossignol AM, Centeno CJ. Chronic neck pain and whiplash: case-control study of the relationship between acute whiplash injuries and chronic NP. Pain Res Manag 2006;11(2):79-83.
  8. Vos CJ, Verhagen AP, Passchier J, Koes BW. Impact of motor vehicle accidents on NP and disability in general practice. Br J Gen Pract 2008; 58: 624-629.
  9. Nolet PS, Côté P, Cassidy JD, Carroll LJ. The association between a lifetime history of a neck injury in a motor vehicle collision and future NP: a population-based cohort study. Eur Spine J 2010; 19(6): 972-981.
  10. Obelieniene D, Schrader H, Bovim G, Miseviciene I, Sand T. Pain after whiplash: a prospective controlled inception cohort study. J Neurol Neurosurg Psychiatry 1999; 66: 279-283.