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Pain after whiplash
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    This latest study from Lithuania1 is an answer to many questions—namely, that the previous difficulties that these researchers had with identifying the late whiplash syndrome in Lithuania is that they were not looking “in the right place”. As it turns out, the problem is that Lithuanians simply are not behaving the way many in western countries expounding myths of whiplash would like. There are some methodological issues which can be considered, as below, but the lesson of discarding “unsightly” data because it is too disturbing to one’s personal view and vested interest in the whiplash controversy has already been taught elsewhere.2 Suffice it to say that the truth has been laid bare and we (those of us struggling with epidemic proportions of the late whiplash syndrome in our own countries) now need to enlighten ourselves and put this data to practical use in helping whiplash patients rather than resisting the inevitable.

    After completion of the first historical cohort study, this more recent study selects an entirely separate, distinct sample of these “misbehaving” Lithuanians, but in a more intriguing fashion. This is the first true inception cohort study wherein people who have not been preselected by their attendance at emergency departments, or contaminated by therapists or lawyers, can be studied to appreciate the natural evolution of the injury which underlies whiplash associated disorders grades 1 and 2. This is the study’s greatest strength. The study has, however, its limitations.

    The first consideration is that there were 98 accident victims who reported acute symptoms, and thus were at risk for the late whiplash syndrome. How does this compare with other studies documenting the natural evolution of the late whiplash syndrome? The Swiss study may be useful for comparison because it too has only 117 subjects, yet is much quoted. Setting aside for the moment that the Swiss study is hampered by the selection atrocity of advertising for subjects, and has a host of other reportedly fatal faults3, and giving some benefit of the doubt, the study is said to be an accurate representation of the state of affairs in Switzerland at that time. Yet, in Switzerland, not even 60% manage to recover fully by 3 months and many of these were reporting total disability during that time, whereas the Lithuanians fully recover in 4 weeks or less, with little or no therapy, and no disability. Studies in other western countries disclose an even greater contrast, with 50%–70% of patients reporting pain even after 3–6 months, despite the fact that all these studies are examining the same grades (1 and 2) of whiplash associated disorders.4 5 Thus, while the sample size is small in this Lithuanian study, it is comparable with others reporting the prognosis of whiplash, and yet gives a different picture of outcome.

    A second consideration is that perhaps these Lithuanians are in very minor collisions. True, some of their vehicles were completely wrecked, but perhaps the vehicles were not very good quality and so were easily damaged. Perhaps that is why this cohort had such a good outcome and only minor injuries. This is an unhelpful consideration however, as studies in Canada have shown that those with absolutely no vehicle damage, in very low velocity collisions, are just as likely to report chronic pain as those in more severe collisions.4 5Lithuanians seem to behave appropriately then for minor collisions (if that is what they indeed had), but Canadians seem unable to behave appropriately. Again, another cultural rift in the rate of recovery from whiplash injury is demonstrated.

    Thirdly, there are sex differences and even differences in seat belt usage between this population and some others, but even then, it does not seem to matter what sex, age, and use of seat belts there is in other western countries, none of these preclude chronic pain. In Lithuania, those who were female, and who did not wear seat belts, still insisted on behaving as the rest of the cohort.

    Finally, perhaps the Lithuanians simply refuse to report their chronic pain, and chronic pain cannot be studied in other cultures in this way. The Lithuanians have no reluctance to report acute pain, but perhaps for some reason wish to “suffer in silence” in spite of chronic pain and disability. This would be a potential flaw if it was not simultaneously shown in this study that the general Lithuanian population reports the same prevalence, frequency, and character of neck pain and headache as does the general population in western countries.1 6 If there were study design barriers to identifying symptoms, the control population would have grossly underreported their symptoms. Indeed, chronic pain can and is reported by studies in many different cultures and languages, including Japan, France, Italy, and others. If researchers in these non-English speaking populations can use simple questionnaires to document the late whiplash syndrome so effectively there, then the same should be possible in Lithuania.

    And so, despite the potential limitations of this study as outlined, there is no way to get around the stark realisation that the natural history of the acute whiplash injury in Lithuania is a benign syndrome with 4 weeks or less of pain. Equally compelling is the fact that Lithuania is not the only place where researchers are having difficulty identifying epidemics of chronic pain. Recovery from acute whiplash injury without neurological injury or fracture routinely occurs within 4–6 weeks in Germany4 and Greece.5 The time has thus come for a reconciliation of these epidemiological observations with our own experience of late whiplash syndrome in western countries. The truth has been laid bare and it is our responsibility to utilise this truth to help prevent the chronic pain and the suffering we otherwise encounter.7 8


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