Elsevier

The Spine Journal

Volume 8, Issue 2, March–April 2008, Pages 311-319
The Spine Journal

Clinical Study
Validity of self-reported history in patients with acute back or neck pain after motor vehicle accidents

https://doi.org/10.1016/j.spinee.2007.04.008Get rights and content

Abstract

Background context

Determining the presence of comorbid conditions in patients with persistent axial pain after motor vehicle accident (MVA) is important to direct appropriate care and as a public health measure against future traffic injuries. In the clinical care of patients after MVA, they are usually asked about previous axial pain problems and relevant comorbid conditions (psychological distress and drug and alcohol abuse). The accuracy of self-reported previous axial pain history and comorbid conditions after MVA has not been systematically evaluated but has been assumed to be high.

Purpose

To establish the validity of certain elements of the self-reported history in patients with back or neck pain attributed to an MVA.

Study design

A validation study of crucial elements of the patient history obtained after MVA using internal (chart audit) and external (age- and sex-matched population data) as gold standard references.

Patient sample

Medium-sized (n>400) clinical cohort of patients without fracture or dislocation seen within 3 months after an MVA in a university spine clinic.

Outcome measures

Responses to standardized questionnaires included previous back or neck pain, previous psychological distress, previous illicit drug usage, previous alcohol abuse, other chronic pain conditions, perceived fault of the MVA, and whether a compensation claim has been filed.

Methods

A consecutive cohort of patients seen from 1998 to 2004 for evaluation of back or neck/shoulder pain reportedly caused by an MVA was enrolled. All clinic patients completed standardized questionnaires. The prevalence of self-reported pre-MVA axial pain and at-risk conditions (drug, alcohol, and psychological problems) and control conditions (hypertension and diabetes) were compared against the age- and sex-matched prevalence determined by the 2005 US Department of Health and Human Services National Surveys on Drug Use and Health (external gold standard). Randomly selected previous medical records were also audited (internal gold standard) and compared with post-MVA description of preaccident health.

Results

Four hundred twenty-two subjects were enrolled, and random audits of 100 subjects were completed. In 68% of the random audits, comorbid conditions denied in the postaccident history (previous axial pain, drug or alcohol abuse, and psychological diagnoses) were documented. In subjects perceiving the MVA to be another's fault (but not their own), the reported prevalence of previous axial pain was markedly below matched data for population prevalence and audited data. Similar findings were observed for psychological problems, illicit drug use, and alcohol abuse. In subjects pursuing compensation claims and retaining an attorney, 80% had significant past axial pain history or serious comorbidities in their records not disclosed in the spine clinic evaluation. In subjects reporting that the MVA was either one's “own fault” or “no one's fault,” this effect was seen but was smaller in all dimensions.

Conclusions

In patients being seen for continued pain related to an MVA, the validity of self-reported previous axial pain and comorbid conditions appeared poor. The self-reported prevalence of previous axial pain and drug, alcohol, and psychological problems is much less than the documented prevalence in prior medical records. These rates were also markedly below the expected prevalence in age- and sex-matched populations. This effect was seen most prominently in patients perceiving the accident to be another party's fault and in those filing compensation claims. The failure to appreciate previous axial pain problems and drug, alcohol, and psychological problems may compromise patient care and public health opportunities.

Introduction

The history taken in the evaluation of axial pain syndromes is usually expected to provide valuable information regarding diagnosis, treatment options, and prognosis for recovery. Numerous studies have found that a past history of axial pain in the neck or back is a strong predictor of poor outcomes for de novo episodes of axial pain [1], [2], [3], [4]. Similarly, certain patient-specific comorbidities such as depression, drug abuse, alcoholism, and psychological distress have also been associated with future axial pain episodes, pain severity, and prolonged illness [3], [5], [6], [7], [8]. A history of drug or alcohol abuse when seen in the context of motor vehicle accidents (MVAs) is also associated with future serious MVA injuries including an increased risk of future MVA-related spinal cord injury or death [9], [10], [11].

However, the validity of the self-reported history in this setting has not been established. Previous work has questioned the validity of self-reported history in patients seeking orthopedic care after an MVA [12]. Patients may be distracted by the current accident and not recall pertinent medical conditions. Also, the legal implications of drug or alcohol use in the setting of MVA may affect the candor of disclosure as well. Finally, the settlement of compensation claims may depend on a medical apportionment of responsibility for damages claimed to have resulted from the injury as opposed to preexisting conditions or concurrent illness. Nonetheless, in the current literature, the self-reported history in this setting is assumed to have high validity and accepted as true until proven otherwise.

In this study, we attempted to study the validity of self-reported patient histories in patients with axial pain complaints after MVA. In this way, we hoped to provide the clinician with an indication of the expected validity of responses in this group. If the validity of a certain variable (eg, previous axial pain) was found to be very high, clinicians could have a strong confidence in the self-reported responses and proceed with treatment decisions on that basis. If, on the other hand, the validity of responses in another dimension (eg, illicit drug use) were found to be poor, the clinician's assumption may need to be tempered by that knowledge.

To our knowledge, this is the first study to systematically examine this question of self-reported history validity in back and neck pain patients after MVA.

Section snippets

Study design

This study was a prospective cohort study designed to systematically evaluate the validity of self-reported patient histories of axial pain and drug, alcohol, and psychological problems in the subgroup of trauma patients without serious bony, disc, or ligamentous injuries who continued to have axial pain complaints over the 3 months after an MVA. Self-reported responses to standardized questionnaires were compared with internal and external criterion standards including an (1) an audit of

Results

Over 4 years, 452 patients meeting the entry criteria were seen, and adequate intake data were recorded in 422 subjects (93%). Of these, 155 reported the MVA collision was either their own fault or no one's fault (“no fault”), and 267 reported the MVA was another's fault (“perceived fault”). The two subgroups differed significantly in whether a lawyer had been retained at the time of the clinic visit; whether a compensation claim had been filed; whether the patient had been admitted to

Discussion

Most MVAs do not result in serious injury. Most people never seek medical care, and transient symptoms go unreported. For the minority of people seen for medical evaluation of back or neck pain after MVA, the initial workup is usually directed to identify serious spinal and neurological injuries. Fortunately, fracture or dislocation of the spine is uncommon even in persons presenting to an emergency department after MVA, and most patients with these serious injuries are rapidly identified by

Conclusions

In patients being seen for continued pain related to an MVA, the validity of self-reported previous axial pain and comorbid conditions appeared poor. The self-reported prevalence of previous axial pain and drug, alcohol, and psychological problems is much less than the documented prevalence in prior medical records. These rates were also markedly below the expected prevalence in age- and sex-matched populations. This effect was seen most prominently in patients perceiving the accident to be

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