Motor vehicle collisions : Medical, psychosocial, and legal consequences

Melanie Duckworth and I go back a long way. We met while attending grad￾uate school at the University of Georgia. We both had Dr. Henry E. Adams as

a mentor. Although he has since passed on, we continue to be indebted to him.

He signifi cantly infl uenced us as researchers, clinicians, and as individuals.

Both Melanie and I completed our internships through the Brown University

Internship Consortium. Internship was instrumental in my becoming a pain psy￾chologist and in Melanie ’ s pursuit of research related to trauma. After graduate

school, we took separate paths. She accepted a faculty position at the University

of Houston, where she pursued her interest in the study of trauma, and I accepted

a position at the London Health Sciences Centre in Ontario, Canada.

We stayed in touch over the years and we had many conversations about

trauma. I once made the comment to her that motor vehicle collisions (MVCs)

lead to consequences that injured persons experienced as traumatic. We then

began to think of developing a clinical data set based on psycholegal assessments

that I had been conducting. We also noticed certain gaps in motor vehicle colli￾sion research literature, gaps that might be addressed by our research targeting

MVC-related chronic pain and trauma.

Melanie then accepted a faculty position at the University of Nevada in Reno.

She set up a laboratory investigating chronic pain and trauma in the MVC con￾text. Our shared interest in the physical and psychological consequences of MVCs

resulted in increased research collaboration and an increased desire to create a

context in which we might bring greater attention to MVCs and the multiple and

complex outcomes that are experienced by persons injured in MVCs. Through a

series of discussions, we identifi ed a number of MVC topics that we considered

essential elements of a comprehensive review of the MVC experience. William

O ’ Donohue, a colleague of Melanie ’ s, played an invaluable role in encourag￾ing the creation of a book proposal, in guiding Melanie and I through the book

xvii

Preface

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proposal submission process, and in working with us throughout the entire writ￾ing and editing process. The book proposal was accepted by Elsevier Publishing

and we were fortunate enough to have a distinguished group of researchers agree

to contribute their expertise to the book project. We hope that readers of the book

are as impressed with their contributions as we are. We also hope that persons

injured in MVCs benefi t most from the information contained in this book.

In addition to thanking all the contributors, we would like to thank Dan

Morgan and Diana Jones at Elsevier for their input in the initial drafts of the book

proposal. Their contributions certainly resulted in a more refi ned and focused

book. We would also like to thank Nikki Levy and Barbara Makinster for their

fi nal editorial comments and for their help in bringing this book to completion.

Tony Iezzi , Ph.D.

xviii Preface

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Arthur Ameis MultiDisciplinary Assessment Centre, 3200 Dufferin st, suite

500, Toronto, ON. M6A 3B2, AA.

V. Lynn Ashton British Columbia Mental Health & Addiction Services,

Research Department Administration Building, 2601 Lougheed Highway

Coquitlam, BC V3C 4J2, Canada.

J. Gayle Beck Department of Psychology, University at Buffalo – SUNY, Park

Hall, Buffalo, NY 14260, U.S.A.

Brian L. Brooks British Columbia Mental Health & Addiction Services,

Research Department Administration Building, 2601 Lougheed Highway

Coquitlam, BC V3C 4J2, Canada.

Richard A. Bryant School of Psychology, University of New South Wales,

Sydney, NSW 2052, Australia.

Mark Creamer Australian Centre for Posttraumatic Mental Health, Department

of Psychiatry, University of Melbourne, PO Box 5444, West Heidelberg,

Victoria, 3081, Australia.

Matthew O. Dolich Department of Surgery, University of California, Irvine, 333

City Boulevard West, Suite 705, Orange CA 92868-3298, U.S.A.

Melanie P. Duckworth Department of Psychology/MS298, University of

Nevada, Reno NV 89557, U.S.A.

Robert J. Gatchel Department of Psychology, College of Science, University

of Texas at Arlington, 313 Life Science, Building 501, S. Nedderman Drive,

Arlington, TX 76019-0528, U.S.A.

Murray J. Girotti Department of Surgery, Rm E1-129, London Health Sciences

Centre, Victoria Hospital, 800 Commissioner’s Rd E, London Ont, N6A 5W9.

Vithya Gnanakumar c/o Keith A. Sequeira, Parkwood Hospital, 801

Commissioners Road East, London, ON. N6C 5J1, Canada.

Edward J. Hickling Department of Psychology, University of Albany, State

University of New York, 1400 Washington Avenue, Albany, NY 12222, U.S.A.

List of CONTRIBUTORS

xix

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Graham Hole Department of Psychology, Pevensey Building 1 2B23, University

of Sussex, Falmer, East Sussex BN19QH, England.

David B. Hoyt Department of Surgery, University of California, Irvine, 333 City

Boulevard West, Suite 700, Orange CA 92868-3298, U.S.A.

Tony Iezzi Behavioral Medicine Service, London Health Sciences Centre, 375

South Street, London, ON. N6A 4G5, Canada.

Grant L. Iverson Department of Psychiatry, University of British Colombia &

British Columbia Mental Health & Addiction Services, 2255 Wesbrook Mall,

Vancouver, BC V6T 2A1, Canada.

Sara Jacoby Surgical Intensive Care Unit, Hospital of the University of

Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, U.S.A.

Nancy D. Kishino West Coast Spine Restoration Center, Riverside, CA 92507,

U.S.A.

Eric R. Kuhn VA Sierra Pacifi c Mental Illness Research, Education, and

Clinical Center, 3801 Miranda Ave, Palo Alto, CA 94306, U.S.A.

Dara Lambe Lerners LLP Barristers and Solicitors, 80 Dufferin Avenue, P.O.

Box 2335, London, ON. N6A 4G4, Canada.

Michael Lewandowski Pain Assessment Resources, 4790 Caughlin Parkway,

Suite 173, Reno, NV 89519, U.S.A.

Greta Ludwig Australian Centre for Posttraumatic Mental Health, University

of Melbourne, National Trauma Research Institute, P.O. Box 5444, West

Heidelberg, VIC. 3081, Australia.

Michael F. Martelli Concussion Care Centre of Virginia, Ltd, Tree of Life

Services, Inc. 3721 Westerre Parkway, Suite B, Richmond, VA. 23233.

Meaghan L. O ’ Donnell Australian Centre for Posttraumatic Mental Health,

University of Melbourne, National Trauma Research Institute, P.O. Box 5444,

West Heidelberg, VIC. 3081, Australia.

William T. O ’ Donohue Department of Psychology/MS298, University of

Nevada, Reno, NV 89557-0062, U.S.A.

Neil G. Parry Department of Surgery, University of Western Ontario, Victoria

Hospital Room E2-217, London Health Sciences Centre, 800 Commissioners

Road, London, ON. N6A 5W9, Canada.

Jason Pretty c/o Keith A. Sequeira, Parkwood Hospital, 801 Commissioners

Road East London, ON. N6C 5J1, Canada

Therese S. Richmond School of Nursing Research Director, Firearm & Injury

Center at Penn, University of Pennsylvania, 420 Guardian Drive, Philadelphia,

PA 19104-6096, U.S.A.

James P. Robinson University of Washington School of Medicine, UWMC

Roosevelt Pain Center, Box 356044, 1959 NE Pacifi c Street, Seattle, WA

98195, U.S.A.

xx List of Contributors

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Harpreet Sangha c/o Keith A. Sequeira, Parkwood Hospital, 801

Commissioners Road East London, ON. N6C 5J1, Canada.

Stephen Schenke Lerners LLP Barristers and Solicitors, 80 Dufferin Avenue,

P.O. Box 2335, London, ON. N6A 4G4, Canada.

Keith A.J. Sequeira Department of Physical Medicine and Rehabilitation,

University of Western Ontario, Parkwood Hospital and St. Joseph ’ s Hospital,

801 Commissioners Road East London, ON. N6C 5J1, Canada.

Joanne E. Taylor School of Psychology, Massey University, Private Bag 11-

222, Palmerston North, North Island, New Zealand.

Robert Teasell c/o Keith A. Sequeira Parkwood Hospital, 801 commissioners

Road East London, ON. N6C 5J1, Canada.

Brian R. Theodore Department of Psychology, College of Science, University

of Texas at Arlington, Arlington, TX 76019, U.S.A.

Dennis C. Turk John and Emma Bonica Professor of Anesthesiology and

Pain Research, Department of Anesthesiology, Box 356540, University of

Washington, Seattle, WA 98195, U.S.A.

Nathan D. Zasler Concussion Care Centre of Virginia, Ltd, Tree of Life

Services, Inc. 3721 Westerre Parkway, Suite B, Richmond, VA. 23233.

List of Contributors xxi

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In Section I , Duckworth, Iezzi, and O’Donohue use the

Introduction chapter to provide an overview of the structure and

content of the book. The chapters are ordered to provide a chrono￾logical account of the assessment and treatment of collision-related

physical and psychological injuries, with chapters grouped into sec￾tions that address the scope and signifi cance of motor vehicle colli￾sions (MVCs); the immediate physical and psychological aftermath

of MVCs; primary care management of acute injury, pain, emotional

distress and impairment; specialized management of chronic physical

and psychological consequences of MVCs; and those medicolegal

issues relevant to determining the extent of physical and psychologi￾cal injuries and to securing care and compensation for such injuries.

SECTION

I

Scope and

Signifi cance of

Motor Vehicle

Collisions

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2 Motor Vehicle Collisions

In Predictors of Motor Vehicle Collisions (Chapter 2), Hole begins his

discussion of the predictors of MVCs with a review of those factors

that represent some of the more signifi cant challenges to MVC risk

estimation. Hole provides a review of current data pertaining to a

variety of driving behaviors and individual variables that are thought

to infl uence driving risk and the underscores complexity involved in

evaluating MVC risk related to the presence of multiple, interacting

MVC predictors.

The predictors of MVCs that are reviewed in Chapter 2 include:

alcohol; fatigue; youth, gender, and inexperience; personality; older

age; and driving distractions. Hole identifi es alcohol as the most

infl uential predictor of MVC involvement. Fatigue is identifi ed as an

MVC risk factor that is particularly problematic for urban drivers and

commercial truck drivers. Young drivers aged 16 to 20 years experi￾ence the highest rate of MVC-related deaths and injuries. Hole notes

that driving errors are more common among women than men and do

not decrease with age; driving lapses are equally common among men

and women and increase with age; and driving violations are commit￾ted more often by men than women, decline with age, and are associ￾ated with a two- to four-fold increase in MVC-related injuries. Hole

reviews research related to sensation-seeking, anger and aggression,

and desire for control, and while acknowledging the potential impor￾tance of personality characteristics to driving behavior, Hole points to

research that examines multiple personality characteristics as hold￾ing more promise. In discussing the contribution of advanced age to

MVC risk, Hole acknowledges the age-related changes in visual acu￾ity that might contribute to increased MVC risk and identifi es those

visually complex MVC circumstances (e.g., left turn at intersection)

that combine with visual acuity changes to result in this age-related

increase in MVC risk. Driving distractions are gaining research atten￾tion due the established association between driving distractions and

collisions, with driving distractions accounting for 10–30% of MVCs.

SEC1-I045048.indd 2 EC1-I045048.indd 2 4/21/2008 12:47:17 PM /21/2008 12:47:17 PM

INTRODUCTION

Most persons are unprepared for their fi rst involvement in a motor vehicle col￾lision (MVC). Fortunately, 86% of persons involved in an MVC will exper ience

only damage to their vehicles ( Blincoe et al., 2002 ). However, the other 14% of

persons involved in an MVC will experience, to some degree, pain and injury,

medical costs, lost time from work, functional and lifestyle impairment, psycho￾logical distress, and systems stress (e.g., insurance and legal). The ripple effect

of an MVC will also entail involvement with a number of health professionals,

including general practitioners, medical specialists, nurses, physiotherapists,

occupational therapists, kinesiologists, speech therapists, rehabilitation consult￾ants, psychologists, psychiatrists, and social workers. Persons involved in MVCs

will also have to contend with insurance and legal representatives.

Although MVCs may occur less frequently and may be less traumatic than

other events, MVCs may be the single most signifi cant type of traumatic event

when frequency and impact are considered together ( Norris, 1992 ). MVCs lead

to signifi cant medical, psychosocial, and legal consequences. According to the

National Highway Traffi c Safety Administration (NHTSA; Blincoe et al., 2002 ),

MVCs are the leading cause of death among individuals between the ages of

1 and 34 years and the eight leading cause of death across all ages. For every

MVC fatality, there are approximately 79 individuals who require medical atten￾tion in emergency departments.

1

Melanie P. Duckworth *

, Tony Iezzi †

and William T. O ’ Donohue *

* Department of Psychology/MS298, University of Nevada, Reno, Nevada, U.S.A.

† Behavioral Medicine Service, London Health Sciences Centre, London, Ontario, Canada

3

Introduction

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4 Motor Vehicle Collisions

The NHTSA reported the total economic cost of MVCs in the United States

for the year 2000 to be 230.6 billion dollars ( Blincoe et al., 2002 ), this over￾whelming fi gure accounted for primarily by medical costs ($32.6 billion), work￾place productivity losses ($61.0 billion), household productivity losses ($20.2

billion), and insurance and legal costs ($27.7 billion). Although the cost for

MVC-related pain and suffering can range from several thousand dollars to many

millions (e.g., fatality), the average cost for pain and suffering is approximately

$19,000 per injured person. The World Health Organization has estimated that

by the year 2020 MVCs will rank second only to heart disease and depression

in terms of disability ( Murray & Lopez, 1996 ). Across the world, the cost of

MVCs has been estimated at 1% of the gross national product regardless of the

development or motorization of a country ( Elvik, 2000 ). The insurance industry

reports that higher health care costs, more litigious attitudes, and higher awards

for pain and suffering account for greater claim costs faced by insurance com￾panies and are leading to signifi cant changes in the laws governing insurance

coverage ( Connolly, 2004 ).

In addition, there are demographic trends that suggest concerns with the priv￾ilege of driving across the world. Motor vehicle use on a larger scale in devel￾oping countries has been associated with a dramatic increase in MVC-related

deaths and injuries ( Peden et al., 2001 ). In developing countries, road users

such as pedestrians, bicyclists, and motorcyclists are especially vulnerable when

involved in collisions ( Nantulya & Reich, 2002 ).

Over the past 10 years there has been a burgeoning of research related to

MVCs and the physical and psychological consequences of MVC involve￾ment. Accident Analysis and Prevention and Traffi c Injury Prevention are peer￾reviewed journals that focus specifi cally on injury and damages incurred in

vehicle crashes and on efforts related to MVC prevention, epidemiology, and

policy-making. Other peer-reviewed journals such as The Journal of Trauma and

Injury examine trauma and injury in general and in the context of MVCs.

Among the research publications examining the psychological consequences

of MVCs are two well-recognized books that examine psychological trauma in

the MVC context ( Blanchard & Hickling, 1997, 2004 ; Hickling & Blanchard,

1999 ). Blanchard and Hickling ’ s (1997, 2004) After the Crash: Psychological

Assessment and Treatment of Survivors of Motor Vehicle Accidents is a seminal

source in this area. The book presents fi ndings from a series of MVC studies

performed by Blanchard, Hickling and other colleagues, these studies represent￾ing one of the earliest programmatic investigations of the psychological reper￾cussions of MVC involvement. In The International Handbook of Road Traffi c

Accidents and Psychological Trauma: Current Understanding, Treatment and Law ,

Hickling and Blanchard (1999)present an in depth analysis of Posttraumatic

Stress Disorder (PTSD) occurring in the MVC context, with 18 of 26 chapters

addressing factors related to PTSD. In the remaining chapters of the book, the

authors expand their examination of MVC consequences to encompass traumatic

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Introduction 5

brain injury occurring consequent to MVCs as well as the legal issues that are

relevant to the assessment and management of MVC-related physical and psy￾chological sequelae. More recent book publications have adopted this style of

analysis, addressing the interacting infl uences of PTSD, injury, and pain follow￾ing traumatic injury ( Koch et al., 2006 ). Other book publications have empha￾sized the complexity of evaluating and managing such co-morbid conditions and

determining causality in the context of litigation ( Young et al., 2006, 2007 ).

While these books and other publications related to traumatic injury serve

as good sources of information regarding certain aspects of the MVC experi￾ence, there is no resource that comprehensively evaluates the medical, psycho￾social, and legal consequences of MVC involvement. The current book is such

a resource. This book provides the reader with a comprehensive review of the

MVC experience, with chapters conceived and ordered to provide a chrono￾logical journey from the moment of initial emergency department evaluation

and treatment of physical injuries to resolution of litigation. Also unique to the

current undertaking is the inclusion of clinicians and researchers representing a

diversity of physical and mental health specialties as well as the law. As a result,

the book captures the MVC experience from a multidisciplinary perspective that

should appeal to physicians, psychologists, psychiatrists, rehabilitation special￾ists, allied mental health professionals, allied medical disciplines, and even legal

specialists. The book chapters will proceed from the emergency room, to the ini￾tial visits to the family physician ’ s offi ce, to managing chronic physical and psy￾chological symptoms, and to managing medicolegal issues.

The book is organized into six sections. Section I of the book focuses on

the scope and signifi cance of MVCs. Following this introductory chapter,

Graham Hole presents a review of the various predictors of MVC involvement.

In Predictors of Motor Vehicle Collisions (Chapter 2), Hole examines the infl u￾ence of perceptual factors (e.g., vision), attentional factors (e.g., in-vehicle dis￾tractions), perception of risk factors (e.g., sensation-seeking), and other factors

(e.g., age, fatigue, and substances) on MVC risk and MVC involvement. While a

cursory appraisal of the MVC risk factors covered within this chapter might sug￾gest a standard review of the more common predictors of MVCs, Hole discusses

these common predictors at a level of analysis that allows for more accurate

MVC prediction and that serves to inform MVC risk reduction efforts. The con￾tent and tone of Hole ’ s chapter matches that of his 2007 book, The Psychology

of Driving , and suggests his commitment to examining both the physics and the

psychology of driving and to presenting this information in a manner that maxi￾mally infl uences public discourse related to MVC risk reduction.

Section II focuses on the immediate aftermath of MVCs. The emergency

department is usually the point of entry for individuals injured in an MVC.

Emergency department evaluation of physical injuries is undertaken to establish

the potential threat conveyed by each injury and to prioritize intervention based

on that threat assessment. More invasive diagnostic and treatment procedures

CH01-I045048.indd 5 H01-I045048.indd 5 4/21/2008 12:48:22 PM /21/2008 12:48:22 PM

6 Motor Vehicle Collisions

usually require hospitalization of the injured person and simultaneous manage￾ment of injuries and associated pain and disability. In Assessment of Physical

Injury, Acute Pain and Disability Consequent to Motor Vehicle Collisions

(Chapter 3), Neil Parry and Murray Girotti review the care requirements and

challenges that occur in assessing physical injury, acute pain, and disability

occurring consequent to MVC involvement. These authors identify health care

team members tasked with assessing and managing traumatic injuries and chron￾icle the procedures used in identifying and treating life-threatening and non-life

threatening injuries. As trauma surgeons, these authors bring their clinical expe￾rience to bear in describing the more routinely encountered traumatic injuries, in

describing the utility of the primary and secondary surveys in evaluating and pri￾oritizing injuries, and in relating traumatic injuries to the type and dynamics of

MVCs. In Treatment of Physical Injury, Acute Pain, and Disability Consequent

to Motor Vehicle Collisions (Chapter 4), Matthew Dolich and David Hoyt review

the range of treatments employed in the emergency management of traumatic

injuries and the often associated experiences of acute pain and disability. Using

a combination of text descriptions and pictorial illustrations, these authors place

the reader squarely into the world of traumatic injury, make understandable the

immediate and long-term recovery requirements and challenges faced by patients

who sustain traumatic injuries, and render predictable the pain and impairment

that occur consequent to certain traumatic injuries. In addition to being distin￾guished trauma surgeons, Murray Girotti, in his role as Medical Director of the

Trauma Program at London Health Sciences Center, and David Hoyt, in his

role as Chair of Surgery at University of California, Irvine Medical Center and

School of Medicine, are medical educators who signifi cantly infl uence both clin￾ical practice and clinical research related to the occurrence and the management

of traumatic injuries.

After medical stabilization of injuries, injured persons start to deal with psy￾chological reactions experienced in response to the MVC and aftermath of MVC

involvement. In Emergency Department Trauma: The Immediate Aftermath of

Motor Vehicle Collisions (Chapter 5), Theresa Richmond and Sara Jacoby allow

the reader to accompany emergency services staff from the site of the collision to

the emergency department, providing informed recommendations regarding health

care decisions that are to be made at different points on this journey. Unique

to this more medically focused chapter is the emphasis these authors place on the

assessment and management of psychological reactions occurring in response

to the MVC, the associated injuries, and the emergency department procedures

employed to manage such injuries. In writing this chapter, Richmond draws upon

her clinical experience and the respected body of research she has produced that

examines the relation between physical and psychological variables in the ini￾tial stages of MVC-related injury and the strength of these relations in predicting

impairment and disability at subsequent points in the recovery timeline.

The psychological reactions that may be experienced in the immediate after￾math of an MVC are varied and multiple; however, the psychological reactions

CH01-I045048.indd 6 H01-I045048.indd 6 4/21/2008 12:48:22 PM /21/2008 12:48:22 PM

Introduction 7

that have been most studied are those that suggest extreme stress. Among the

most well-known and prolifi c researchers of extreme stress reactions occurring

as an immediate consequence of MVC involvement is Richard Bryant. In Acute

Stress Disorder Consequent to Motor Vehicle Collisions (Chapter 6), Bryant

focuses on the assessment and management of acute stress reactions occurring

within 2 days to 4 weeks following a traumatic collision. Bryant and his col￾leagues have been instrumental in promoting the recognition and treatment of

acute stress disorder.

Section III focuses on the transfer of MVC patient care from the hospi￾tal to the primary care setting. The management of physical and psychological

sequelae requires the assistance of a variety of primary care providers, including

medical specialists, physiotherapists, occupational therapists, and representatives

of other disciplines. Early management of physical injuries and their associ￾ated functional consequences is extremely important. Initially, most injured per￾sons expect that they will recover fully from their injuries. With the passage of

time, a proportion of injured persons will come to realize that they will have to

endure residual physical and psychological consequences into the distant future.

Early and accurate messages about the physical and psychological consequences

of MVC-related injuries can profoundly infl uence an injured person ’ s ability

to cope with these consequences. The primary aim of Section III is to provide

primary care providers with an array of strategies for (1) maximizing patient

recovery from physical injury, acute pain, and impairment; (2) minimizing the

occurrence of clinically signifi cant distress reactions in response to physical

injury, acute pain, and impairment; (3) minimizing the impact of distress reac￾tions on pain and recovery of physical function; and (4) minimizing the likeli￾hood that acute experiences of pain and impairment will transition into chronic

experiences of pain and impairment through the interacting infl uences of physi￾cal and psychological symptoms.

In Managing MVC-Related Sequelae in the Primary Care Setting: Normalizing

Experiences of Acute Pain and Injury-Related Impairment (Chapter 7), Keith

Sequeira, Harpreet Sangha, Vithya Gnanakumar, Jason Pretty, and Robert Teasell

address patients ’ experiences of acute pain and functional impairment occurring

within the fi rst weeks and months following physical injury. These authors pro￾vide an overview of the mechanisms involved in soft tissue injuries that occur

consequent to MVC involvement and the treatments to be employed in manag￾ing these injuries and the associated pain and discomfort. They outline strategies

that primary care providers can used to normalize and manage the more acute

experiences of injury-related pain and impairment and to offset more problem￾atic responses to pain and impairment occurring in the fi rst 6 months post-injury.

Sequeira and colleagues provide recommendations for management of both pain

and physical impairment, reviewing medical strategies and behavioral strategies

for reducing pain and increasing physical function. Particularly appreciated is

the emphasis these authors place on evaluating and establishing the clinical rel￾evance of comorbid physical and psychiatric conditions.

CH01-I045048.indd 7 H01-I045048.indd 7 4/21/2008 12:48:22 PM /21/2008 12:48:22 PM

8 Motor Vehicle Collisions

Melanie Duckworth, Tony Iezzi, and Michael Lewandowski have constructed

Managing MVC-Related Sequelae in the Primary Care Setting: Normalizing

Experiences of Emotional Distress (Chapter 8) to serve as a guide for primary care

providers in recognizing and normalizing the emotional distress that is often asso￾ciated with traumatic injury and in determining the referral needs of injured per￾sons who are beginning to evidence signs of clinically signifi cant psychological

distress. Primary care providers are uniquely positioned to reduce the likelihood

that acute experiences of pain, impairment, and emotional distress will develop into

chronic, maladaptive experiences of pain, impairment, and distress that will sig￾nifi cantly and persistently impact the injured person ’ s lifestyle and quality of life.

When injuries are extensive, when full recovery is not predicted, and when injury￾related pain is expected, the primary care provider can serve as the most powerful

voice in establishing with the injured person a new set of functional expectations,

a set of functional expectations that allows the injured person to live as full and as

normal a life as possible in spite of persisting pain and functional limitations.

There are a number of physical and psychological conditions that are part of

a less than optimal recovery from MVC-related injuries. Section IV focuses on

the assessment and management of MVC-related consequences that are persistent

and that have broad-ranging impacts on the injured person ’ s life. Pain is an injury￾related symptom that may persist beyond “ recovery from injury ” and transition

from an acute circumstance to a chronic condition. Although most health care pro￾fessionals would acknowledge that pain is a multidetermined phenomenon that is

understood best from a biopsychosocial perspective, it is still one of the more frus￾trating clinical presentations that injured persons experience and that health care

providers are called upon to manage. In Assessment of Patients with Whiplash￾Associated Disorders Consequent to Motor Vehicle Collisions: A Comprehensive

Approach (Chapter 9), Dennis Turk and James Robinson establish whiplash as

the most common type of injury sustained in an MVC and forward a conceptual

model for assessing the pain behaviors evidenced by an individual, emphasiz￾ing the multidimensional nature of pain and the biomedical, psychological, and

socioenvironmental factors that infl uence pain behaviors. They then review the

procedures involved in comprehensively evaluating whiplash-associated disorders

and provide clear recommendations for prioritizing and interpreting assessment

fi ndings. In Treatment of Chronic Pain Consequent to Motor Vehicle Collisions

(Chapter 10), Robert Gatchel, Brian Theodore, and Nancy Kishino acknowledge

the limited number of studies that address the treatment of pain in the MVC con￾text and establish the applicability of the general chronic pain treatment literature

to the treatment of chronic pain occurring consequent to MVCs. Of course, our

selection of these authors for coverage of the assessment and treatment of MVC￾related pain should be immediately obvious to the reader. As individuals who have

devoted their entire careers to the study of pain, Dennis Turk and Robert Gatchel

are two of the foremost authorities on the assessment and treatment of pain.

Traumatic brain injuries, whether mild or severe, are characterized by cogni￾tive changes that are long-lasting, have pervasive effects on overall functioning,

CH01-I045048.indd 8 H01-I045048.indd 8 4/21/2008 12:48:22 PM /21/2008 12:48:22 PM

Introduction 9

and that require signifi cant adjustment. The general traumatic brain injury litera￾ture is very extensive and includes a substantial number of studies that address

traumatic brain injury occurring consequent to MVC involvement. In Cognitive

Impairment Consequent to Motor Vehicle Collisions: Foundations for Clinical

and Forensic Practice (Chapter 11), Grant Iverson, Brian Brooks, and Lynn

Ashton describe the myriad of factors that infl uence an individual ’ s report of

neurocognitive impairment, provide information related to defi nitions and cat￾egories of cognitive impairment, and review assessment procedures used in diag￾nosing cognitive disorders. These authors then describe the many MVC-related

conditions that contribute separately and interactively to cognitive impairment

and the many pre-existing conditions that may contribute to MVC risk and to

cognitive impairment following an MVC. Iverson, Brooks, and Ashton use their

extensive knowledge related to malingering to guide the reader ’ s use and inter￾pretation of neurocognitive assessment data in clinical and forensic settings.

MVC involvement may result in a variety of distress reactions, the type and

intensity of these distress reactions determined by parameters of the collision; the

number and severity of physical injuries and impairments; the level of pain that

accompanies injuries; and the level of compromise to various lifestyle domains

and overall quality of life. In Psychological Conditions Associated with Motor

Vehicle Collisions (Chapter 12), Melanie Duckworth presents a comprehensive

review of the wide range of psychological conditions that are associated with

MVCs and the resulting injuries and impairments. Duckworth devotes attention

to those psychological conditions that are frequently part of the MVC experience

but are less represented among studies of psychological distress reactions occur￾ring consequent to MVCs. Characteristic features and MVC context-specifi c

prevalence data are provided for psychological conditions. These psychological

conditions are also discussed in terms of their relation to MVC-related injury and

impairment, pain and suffering, lifestyle impairment, disability, and litigation.

Some of the most highly respected trauma researchers review issues relevant

to the assessment and treatment of PTSD occurring consequent to MVC involve￾ment. In PTSD and Associated Mental Health Consequences of Motor Vehicle

Collisions (Chapter 13), Meaghan O ’ Donnell, Mark Creamer, and Greta Ludwig

establish the prevalence of PTSD and other forms of psychopathology that occur

following MVCs, outline the course of MVC-related traumatic stress symptoms,

and describe the impact of traumatic stress symptoms on the quality of life and

functional status of traumatized individuals. These authors also provide a review

of the pretrauma, peritrauma, and posttrauma factors that are considered most

predictive of posttrauma psychopathology. In Treatment of Posttraumatic Stress

Disorder Consequent to Motor Vehicle Collisions: Contributions from a Clinical

Science (Chapter 14), Edward Hickling, Eric Kuhn, and Gayle Beck go far beyond

the standard review of PTSD treatments. These authors establish the features of

MVC-related PTSD, physical and psychological conditions common to the MVC

experience and establishing the infl uence of such conditions on the expression,

intensity, and course of PTSD symptoms. Hickling, Kuhn, and Beck then provide

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