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3 1148 Pobereskin 1147 People involved in rear end collisions reported to the police 644 (56%) Did not respond 503 (44%) Respondents 112 (22%) No early 391 (78%) Early 76 (19.5%) Non-respondents at 1 year 315 (80.5%) Respondents at 1 year 151 (48%) No late 164 (52%) Late Figure 1 The disposition of the cohort. Employment outcomes and crash related factors Of the 447 people who reported being employed at the time of the index accident, 111 (25%) had some time off work: 68 (61%) had a month or less off and a further 27 (24%) had between 1 and 6 months off. Two people (2%) had between 6 and 12 months off work and 14 (13%) were still off work at 1 year. The proportion of struck cars that were drivable increased with vehicle size from mini (57.8%) to small (60.3%) and large (71.7%) (p = 0.01, x 2 for trend). Conversely, the drivability of the striking car decreased from mini (69.4%) to small (58.6%) and large (57.9%) (p = 0.03, x 2 for trend). There was no difference in striking speeds between the car classes. Striking speeds were significantly higher when the struck car was not drivable (mean (SD): 32.2 (13.78) mph) than when it was (26.8 (10.61) mph) (p,0.005, t test). There was no correlation between initial neck VAS scores and striking speeds (Pearson correlation = ). There was no relationship between striking speeds and the number of days the participant had neck pain (ANOVA, p = 0.11). Similarly, Table 1 Characteristics of the cohort Characteristic (number missing data) Respondents, n (%) Non-respondents, n (%) p Value Total 503 (44%) 644 (56%) Female 332 (66%) 352 (55%),0.005* Age, median (IQ range) 43 (31 55) 34.5 (24 45),0.005À BMI, median (range) 25.7 ( ) Previous neck pain 89 (17.7%) Current smoker (7) 101 (20.1%) Married 362 (72%) Occupation (17) Unemployed or housewife 44 (8.7%) Unskilled 120 (23.9%) Semi-skilled 185 (36.8%) Skilled 61 (15.1%) Professional or managerial 76 (15.1%) Visited casualty 330 (65.6%) Visited GP 364 (72.4%) Car size (4) Mini 173 (34.7%) Small 174 (34.9%) Large 152 (30.5%) Headrest present 460 (91.5%) Correct headrest position (111) 197 (39.2%) Aware of collision 121 (24.1%) Head turned 156 (31%) Struck car driveable 314 (62.4%) Striking car driveable 310 (61.6%) Struck car stationary 399 (79.3%) Striking speed, mph (23), mean (SD) 28.8 (12.1) *x 2 ; ÀMann Whitney U. BMI, body mass index; SD, standard deviation.

4 Whiplash 1149 Table 2 Early outcomes Outcome Number (%) Early 391 (77.7%) Headache 226 (44.9%) Arm pain 148 (29.4%) Low back pain 142 (28.2%) Concentration problems 170 (33.8%) Memory problems 93 (18.5%) Dizziness 103 (20.5%) Neck pain severity* Mild 101 (25.8%) Moderate 185 (47.3%) Severe 48 (12.2%) *Only those still having neck pain at first questionaire. there was no association between striking speeds and neck pain severity initially or at 1 year or neck VAS scores at 1 year. Outcomes in those seeking compensation A total of 236 (75%) responders at 1 year were seeking compensation. A total of 204 (86.4%) answered a questionnaire at 2 years and 70 of these (34.3%) had settled their claim. Those that settled and those that had not were virtually identical in age (mean (SD): 43.4 (15.3) years and 42.5 (14.1) years, respectively) and gender (75.7% and 72.4% female, respectively). At 2 years people who had settled were more likely to have neck pain at least once a week (70%) than those that had not settled (56.7%) (p = 0.064). Neck VAS scores (median, IQ range) were very similar at 18 ( ) and 17.5 (8 27), respectively. DISCUSSION The nosological validity of as a traumatic injury has been under increasing attack in recent years. 2 Stover reviewed the literature in 1996 and suggested that the Bradford-Hill criteria for assessing the association of an environmental factor with a disease were poorly fulfilled in the case of. 3 In particular, he was disturbed that there is no evidence of a dose-response relationship between the severity of the trauma and subsequent symptoms. In so far as this cohort represents the experience of people involved in rear end collisions in the United Kingdom, the Table 4 Final model with six independent predictors of early Variable Odds ratio (95% CI) Likelihood ratio x 2 * Age ( ) Previous neck pain 8.32 ( ) Occupational class 8.49 Professional and managerial 1.00 Semi-skilled or skilled 2.01 ( ) Unemployed or unskilled 0.97 ( ) Car size 7.98 Mini 1.00 Small 1.74 ( ) Large 2.29 ( ) Struck car stationary 2.15 ( ) 7.39 *Obtained as the change in the model deviance (22log(likelihood)) that results when each covariate is removed from the full six covariate model. 95% CI, 95% confidence interval. analysis suggests that demographic variables are the most important in predicting early neck pain. At 1 year the severity of the initial neck pain is highly associated with chronic neck pain as is the presence of a compensation suit. There is little evidence that the severity of the impact predicts the early onset of neck pain or pain at 1 year. The primary strength of this study is that it takes as its sampling frame all those exposed to a specific mechanism of injury known to be associated with. As any insurance claim requires a police report, virtually all rear end collisions should have been captured. With all that has been written about, it is surprising that the present study is the first to use multivariant analysis to investigate such a cohort. The most commonly quoted previous studies are all potentially biased as the cohorts were drawn from those attending casualty, 4 6 or their GP, 7 8 or for tertiary opinions or medico-legal reports The study s other strength is the size of the cohort. Except for those using routinely collected insurance company data, most previous studies have included less than 100 people. The primary limitation of this study is the response rate of 44% to the original request to take part. It is difficult to see how this can be improved upon without a change in the attitude of the public to medical research. In contrast to Table 3 Potential predictors of early Characteristic (number missing data) No early, n (%) Early, n (%) p Value Total number 112 (22%) 391 (78%) Female 67 (59.8%) 265 (67.8%) 0.117* Age, median (IQ range) 52 ( ) 40 (30 53),0.005À BMI, median (IQ range) 25.8 ( ) 25.7 ( ) 0.650À Previous neck pain 4 (3.6%) 85 (21.7%),0.005* Current smoker (7) 19 (17.3%) 82 (21.2%) 0.362* Married 85 (75.9%) 277 (70.8%) 0.294* Occupation (17) 0.088* Unemployed or unskilled 43 (40.2%) 121 (31.9%) Semi-skilled or skilled 42 (39.3%) 204 (53.8%) Professional or managerial 22 (20.6%) 54 (14.2%) Car size (4) 0.033* Mini 48 (44%) 125 (32.1%) Small 37 (33.9%) 137 (35.1%) Large 24 (22%) 128 (32.8%) Headrest present 103 (92%) 357 (91.3%) 0.826* Aware of impending collision 26 (23.2%) 95 (24.3%) 0.813* Head turned 26 (23.2%) 130 (33.2%) 0.043* Struck car driveable 64 (57.1%) 250 (63.9%) 0.190* Striking car driveable 65 (58%) 245 (62.7%) 0.375* Struck car stationary 75 (67%) 324 (82.9%),0.005* Speed difference (15), mean (SD) 27.2 (12.7) 29.1 (11.9) 0.307` *x 2 ; ÀMann Whitney U; `Student s t test. BMI, body mass index.

5 1150 Pobereskin Table 5 Potential predictors of late No late Late Characteristic (number missing data) Number (%) Number (%) p Value Total number 151 (48%) 164 (52%) Female 100 (66.2%) 119 (72.6%) 0.222* Age, mean (SD) 41.9 (15.9) 43.8 (14.2) 0.293` BMI, median (IQ range) 26.1 ( ) 25.7 ( ) 0.660À Previous neck pain 27 (17.9%) 43 (26.2%) 0.075* Current smoker (5) 27 (18.1%) %) 0.354* Married 111 (72.8%) 118 (72%) 0.859* Seeking compensation 81 (53.6%) 155 (94.5%),0.005* Occupation (10) 0.800* Unemployed or unskilled 47 (32%) 54 (34.2%) Semi-skilled or skilled 78 (53%) 82 (51.9%) Professional or managerial 22 (15%) 22 (13.9%) Car size 0.073* Mini 61 (40.4%) 47 (28.7%) Small 51 (33.8%) 61 (37.2%) Large 39 (25.8%) 56 (34.1%) Aware of collision 39 (25.8%) 41 (25%) 0.866* Head turned 45 (29.8%) 62 (37.8%) 0.134* Struck car driveable 93 (61.6%) 107 (65.2%) 0.501* Striking car driveable 85 (56.3%) 110 (67.1%) 0.049* Struck car stationary 134 (88.7%) 132 (80.5%) 0.043* Striking speed (12), mean (SD) 30.1 (12.5) 29 (11.6) 0.420` Initial days of pain/week, mean (SD) 2.6 (2.8) 5.3 (2.1),0.005` Initial neck VAS score, median (IQ range) 18 (2 34) 44 ( ),0.005À Initial headache 52 (34.4%) 111 (67.7%),0.005* Initial arm pain 27 (17.9%) 81 (49.4%),0.005* Initial low back pain 42 (27.8%) 54 (32.9%) Initial concentration problems 48 (31.8%) 73 (44.5%) 0.020* Initial memory problems 25 (16.6%) 42 (25.6%) 0.050* Initial dizzyness 32 (21.2%) 44 (26.8%) 0.243* *x 2 ; ÀMann Whitney U; `Student s t test. BMI, body mass index. previous studies, however, the characteristics of those who participated and those that did not are clearly understood. Non-responders, as in many studies, were younger than responders and more likely to be male. The response rate in this study is lower than previous more biased samples in the literature of and the results will be less generalisable as a consequence. There was no association between gender and outcomes so the fact that males were less likely to respond should have made no difference. Age had no correlation with late neck pain but early neck pain risk seemed to decrease with increasing age so that the results here may actually underestimate the proportion with neck pain early on. Until this study there was no information about what proportion of people exposed to rear end collisions sought medical attention. In this population about three quarters of people went to their GP and two thirds attended casualty. Not surprisingly, these groups represent the more seriously injured end of the spectrum. About a tenth of people seek no medical help, and yet almost 40% of this group report having early neck pain. Table 6 Final model with five independent predictors of late Variable Odds ratio (95% CI) Likelihood ratio x 2 * Neck VAS score 1.03 ( ) Compensation claim 4.09 ( ) 9.72 Struck car stationary 0.31 ( ) 8.28 Arm pain 2.23 ( ) 6.93 Days of neck pain/week 1.18 ( ) 5.98 *Obtained as the change in the model deviance (22log(likelihood)) that results when each covariate is removed from the full five covariate model. 95% CI, 95% confidence interval. The forces transmitted to the cervical spine in this situation are complex and difficult to measure outside a crash laboratory. Factors related to seat and bumper construction as well as car crumple zones can, of course, influence the forces involved. Nevertheless, it is surprising that it has not been possible to relate estimated striking speeds to early or to any measure of neck pain severity either early on or at 1 year. This is not the first time this has been reported. In a study of 173 people who attended casualty after rear end collisions, Kasch et al reported no relationship between striking speeds and neck mobility, neck pain, or headache. 12 They also found no relationship between car weight differences and any of the above factors. Estimations of striking speeds may clearly be inaccurate. If any bias exists, however, one would expect those more severely injured to be more likely to overestimate speed differences than those with minor injuries. The fact that car drivability was associated logically with estimated striking speeds suggests some validity for the measure. Previous studies have suggested a number of crash related factors that influence outcome, including rotation of the head and lack of awareness of the collision, 8 and presence of a seat belt. 13 In this cohort the influence of seat belts could not be studied as everyone reported using them. If neck pain following rear end collision arises from specific traumatic pathophysiological mechanisms, it would seem logical on anatomic and physiologic grounds that rotation of the head and lack of awareness of the impending collision would increase risk of acute symptoms. In this study, neither of these factors were predictive. In the present cohort, two accident related factors, car size and the struck car being stationary, were minor contributors to the model of early pain. The fact that driving a large car increased risk seems counterintuitive, however, a greater proportion of large cars were drivable after the accident. This may imply that large cars are less likely to deform and

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