The initial level of pain after a whiplash injury, as well as psychological factors such as having positive expectations for getting better, best predict who will recover promptly from whiplash, according to research presented this week at the World Congress on Neck Pain in Los Angeles.

Researchers also released task force findings on the best assessment and treatment of whiplash and other neck pain.

Whiplash is an injury to the neck that usually occurs because of sudden extension and flexion, often during an auto accident. Most whiplash victims recover in a few months, but many report recurring pain a year or more later.

Whiplash is reported in about 2 million insurance claims per year in the U.S., according to the Insurance Institute for Highway Safety. Recently, researchers have begun to focus more on predictors of recovery.

Whiplash Recovery: Initial Pain as a Predictor

The level of pain three weeks after a whiplash injury is "the single most important predictor of who recovers in a timely manner," says David Walton, PT, a researcher at The University of Western Ontario in London, Ontario, Canada. He reviewed 14 published studies including more than 3,000 whiplash patients and presented his findings at the Congress.

Those who rate their pain as less than 5 on a commonly used 10-point pain scale are more likely to recover quickly, he tells Todo en Medicamentos.

Whiplash Recovery: Expectations Count

A person’s expectations of recovery from whiplash also matter, says Lena Holm, DrMedSc, a research fellow at the Institute of Environmental Medicine at Karolinska Institutet in Stockholm, Sweden.

With her colleagues, she evaluated the recovery expectations of more than 1,000 insurance claimants who filed a neck injury claim after a car collision to one of two insurance companies in Sweden between January 2004 and January 2005.

Three weeks after the injury, Holm’s team asked the claimants how likely they felt they would recover fully. At six months, they compared the disability level of the participants with expectations.

"Expectations had a big impact," she tells Todo en Medicamentos, even after adjusting for physical symptoms and other factors. Those who felt initially that they wouldn’t make a full recovery were more than four times as likely to be in the group of the "more disabled" participants at six months than those who felt more positively about their chances for a recovery, she says.

Other Predictors of Recovery

Those prone to catastrophic thinking also fare poorly, Walton found in his analysis of 14 studies.

"These are the people who can’t get the pain out of their mind, who believe this is the worst thing that has ever happened to them," he says.

Feeling down or blue immediately after a whiplash injury is common, says Leah Phillips, a PhD student and researcher at the University of Alberta, Edmonton, Canada. The depressed feeling is more likely to persist in those under age 50 with less education and income, she found in a survey of nearly 5,500 adults in Saskatchewan who had suffered whiplash injuries between 1997 and 1999.

Those who had more initial neck pain and low back pain, as well as higher levels of anxiety right after the injury, were also more likely to keep reporting the depressed feeling during the one-year follow-up, she says.

She wasn’t measuring true clinical depression, she says, but asked at each follow up whether the patients had a depressed mood. "It could develop into clinical depression," she says.

Whiplash Treatment: Neck Collar Treatment Not Helpful

Wearing a neck collar to immobilize the area after whiplash injury is outdated, says Sylvia Schick, MPH, a researcher at the Institute for Legal Medicine at Ludwig Maximilians Universitat in Munich, Germany.

Many physicians still prescribe the device, Schick says, but her comparison study of those who wore the collar with those who did not shows it is not useful.

Using the data base of a large insurance company in Germany, Schick and her colleagues compared the results of 31 whiplash patients treated without a neck collar and 40 with the neck collar. Both groups got about the same length and quality of treatment, she says, although those treated with the collar were also more likely to get pain-killing drugs.

No differences were found between groups in reports of neck pain or stiffness, she says. Those who wore the collar actually were absent longer from work than those who did not wear it. One study limitation, says Schick, was lack of information about how long the collars were worn.

More information at Todo en Medicamentos.

Spurred by patient deaths and life-threatening side effects, the FDA today issued its second warning about misuse of skin patches containing the pain killer fentanyl.

Fentanyl is a prescription opioid drug. Fentanyl skin patches are sold under the brand name Duragesic and in four generic products.

Today’s FDA warning is specific to fentanyl patches — not other forms of fentanyl — and applies to Duragesic and generic fentanyl patches.

The FDA’s key message: Fentanyl skin patches must be prescribed and used exactly as directed, and only by patients whose bodies have become able to tolerate opioids, reducing the risk of serious side effects.

Second Fentanyl Patch Warning

“Unfortunately, we still do continue to see cases of patients using the product incorrectly and prescribers prescribing the product incorrectly,” Bob Rappaport, director of the FDA’s division of anesthesia, analgesia, and rheumatology products, said in a news conference.

“Some of these cases have resulted in life-threatening events and some even in death,” says Rappaport, adding that the FDA will provide the number of those cases in the next week or so.

Some cases are related to prescribers who prescribe the patches for patients who aren’t opioid-tolerant. In other cases, patients use the patches incorrectly.

“For instance, they cannot be used in a setting where they would be exposed to heat, such as with a heating pad or a hot tub or a heated water bed,” says Rappaport. “That increases the amount of the drug that’s absorbed from the patch and can cause a life-threatening situation.”

Patients and prescribers need to fully understand how to use fentanyl patches, says Rappaport.

Fentanyl Overdose Symptoms

The FDA wants doctors and patients to learn the symptoms of fentanyl overdose, including:

• Trouble with breathing, or slow or shallow breathing
• Slow heartbeat
• Severe sleepiness
• Cold, clammy skin
• Trouble with walking or talking
• Feeling faint, dizzy, or confused

Patients using the fentanyl patch who experience those symptoms should get medical attention right away, says the FDA.

Patients or caregivers should call the patient’s doctor immediately if the patient’s temperature exceeds 102 degrees while wearing a fentanyl patch, the FDA notes.

More information at Todo en Medicamentos.