Skip to content
Accessible Unlicensed Requires Authentication Published by De Gruyter June 17, 2019

Acceptance: a factor to consider in persistent pain after neck trauma

Sophia Åkerblom, Johan Larsson, Eva-Maj Malmström, Elisabeth Persson and Hans Westergren


Background and aims

Studies on the interaction between acceptance and pain-related processes after neck trauma are to our knowledge sparse and such treatment strategies are rarely incorporated in management and treatment of posttraumatic neck pain. Thus, the aim of the present study is to investigate how acceptance relates to persistent pain in patients after neck trauma, when controlling for the influence of other psychological factors, trauma characteristics and demographic variables.


Consecutive patients with persistent pain and disability after neck trauma (n = 565) were assessed by a multi-professional team at a specialized pain rehabilitation clinic. Separate regression analyses were conducted with three outcomes: pain distribution, pain interference, and pain severity. Predictors were age, sex, education, time since trauma, type of trauma, anxiety, depression, and acceptance.


Acceptance was the only factor associated with all outcomes, and patients with lower acceptance displayed more widespread pain and greater interference and severity of pain. The results also showed that higher depression was associated with worse pain interference and severity, whilst anxiety only mattered significantly for pain severity and not for pain interference. Female sex was related to more widespread pain and greater pain interference.


Overall acceptance stood out as the most important factor for the different outcomes and lower acceptance was associated with more widespread pain distribution and greater pain interference and severity.


The findings of this study add to a growing body of literature confirming that the development of chronicity after neck trauma should be understood as a multidimensional process, best described by a biopsychosocial model. The results also suggest that psychological factors and especially acceptance might be important processes with implications for enhanced recovery after neck trauma.


We wish to thank registered nurse Nina Wätthammar for extracting data from the patient records.

  1. Authors’ statements

  2. Research funding: The study was supported by Skåne University Hospital, Lund, Sweden and the Swedish Association for Survivors of Accident and Injury (RTP-research fund), Stockholm, Sweden.

  3. Conflict of interest: No conflicts of interest to declare.

  4. Informed consent: Informed consent was obtained from all participants.

  5. Ethical approval: The study design and protocol were reviewed and approved by the Regional Ethical Review Board in Lund, Sweden (ref: 2014/34 and 2016/484).


[1] Styrke J, Stalnacke BM, Bylund PO, Sojka P, Bjornstig U. A 10-year incidence of acute whiplash injuries after road traffic crashes in a defined population in northern Sweden. PM R 2012;4:739–47.Search in Google Scholar

[2] Carroll LJ, Holm LW, Hogg-Johnson S, Côté P, Cassidy JD, Haldeman S, Nordin M, Hurwitz EL, Carragee EJ, van der Velde G, Peloso PM, Guzman J. Course and prognostic factors for neck pain in whiplash-associated disorders (WAD): results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and its Associated Disorders. Spine 2008;33(Suppl):S83–92.Search in Google Scholar

[3] Westergren H, Larsson J, Freeman M, Carlsson A, Jöud A, Malmström E-M. Sex-based differences in pain distribution in a cohort of patients with persistent post-traumatic neck pain. Disabil Rehabil 2017;40:1–10.Search in Google Scholar

[4] Kasch H, Turk C, Jensen T. Whiplash injury: perspectives on the development of chronic pain, 1st ed. Philadelphia: Wolters Kluwer Health, 2016.Search in Google Scholar

[5] Walton DM, Carroll LJ, Kasch H, Sterling M, Verhagen AP, Macdermid JC, Gross A, Santaguida PL, Carlesso L. An overview of systematic reviews on prognostic factors in neck pain: results from the international collaboration on neck pain (ICON) project. Open Orthop J 2013;7:494–505.Search in Google Scholar

[6] Ritchie C, Sterling M. Recovery pathways and prognosis after whiplash injury. J Orthop Sports Phys Ther 2016;46:851–61.Search in Google Scholar

[7] Williamson E, Williams MA, Gates S, Lamb SE. Risk factors for chronic disability in a cohort of patients with acute whiplash associated disorders seeking physiotherapy treatment for persisting symptoms. Physiotherapy 2015;101:34–43.Search in Google Scholar

[8] Côté P, Soklaridis S. Does early management of whiplash-associated disorders assist or impede recovery? Spine 2011;36(Suppl):S275–S9.Search in Google Scholar

[9] Williamson E, Williams M, Gates S, Lamb SE. A systematic literature review of psychological factors and the development of late whiplash syndrome. Pain 2008;135:20–30.Search in Google Scholar

[10] Carstensen TBW, Frostholm L, Oernboel E, Kongsted A, Kasch H, Jensen TS, Fink P. Post-trauma ratings of pre-collision pain and psychological distress predict poor outcome following acute whiplash trauma: a 12-month follow-up study. Pain 2008;139:248–59.Search in Google Scholar

[11] Sterling M, Jull G, Vicenzino B, Kenardy JR. Physical and psychological factors predict outcome following whiplash injury. Pain 2005;114:141–8.Search in Google Scholar

[12] Andersen TE, Karstoft KI, Brink O, Elklit A. Pain-catastrophizing and fear-avoidance beliefs as mediators between post-traumatic stress symptoms and pain following whiplash injury – a prospective cohort study. Eur J Pain 2016;20:1241–52.Search in Google Scholar

[13] Sullivan MJL, Scott W, Trost Z. Perceived injustice: a risk factor for problematic pain outcomes. Clin J Pain 2012;28:484–8.Search in Google Scholar

[14] Carroll LJ, Liu Y, Holm LW, Cassidy JD, Côté P. Pain-related emotions in early stages of recovery in whiplash-associated disorders: their presence, intensity, and association with pain recovery. Psychosom Med 2011;73:708–15.Search in Google Scholar

[15] Carroll LJ, Cassidy JD, Côté P. The role of pain coping strategies in prognosis after whiplash injury: passive coping predicts slowed recovery. Pain 2006;124:18–26.Search in Google Scholar

[16] Shearer HM, Carroll LJ, Wong JJ, Côté P, Varatharajan S, Southerst D, Sutton DA, Randhawa KA, Yu H, Mior SA, van der Velde GM, Nordin MC, Stupar M, Taylor-Vaisey AL. Are psychological interventions effective for the management of neck pain and whiplash-associated disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Spine J 2016;16:1566–81.Search in Google Scholar

[17] Vowles KE, Witkiewitz K, Sowden G, Ashworth J. Acceptance and commitment therapy for chronic pain: evidence of mediation and clinically significant change following an abbreviated interdisciplinary program of rehabilitation. J Pain 2014;15:101–13.Search in Google Scholar

[18] Wicksell RK, Olsson GL, Hayes SC. Psychological flexibility as a mediator of improvement in acceptance and commitment therapy for patients with chronic pain following whiplash. Eur J Pain 2010;14:1059.e1–11.Search in Google Scholar

[19] Åkerblom S, Perrin S, Rivano Fischer M, McCracken LM. The relationship between posttraumatic stress disorder and chronic pain in people seeking treatment for chronic pain: the mediating role of psychological flexibility. Clin J Pain 2018;34:487–96.Search in Google Scholar

[20] Åkerblom S, Perrin S, Rivano Fischer M, McCracken LM. The mediating role of acceptance in multidisciplinary cognitive-behavioral therapy for chronic pain. J Pain 2015;16:606–15.Search in Google Scholar

[21] Baranoff J, Hanrahan SJ, Kapur D, Connor JP. Acceptance as a process variable in relation to catastrophizing in multidisciplinary pain treatment. Eur J Pain 2013;17:101–10.Search in Google Scholar

[22] Wicksell RK, Ahlqvist J, Bring A, Melin L, Olsson GL. Can exposure and acceptance strategies improve functioning and life satisfaction in people with chronic pain and whiplash-associated disorders (WAD)? A randomized controlled trial. Cogn Behav Ther 2008;37:169–82.Search in Google Scholar

[23] Zetterqvist V, Holmstrom L, Maathz P, Wicksell RK. Pain avoidance predicts disability and depressive symptoms three years later in individuals with whiplash complaints. Acta Anaesthesiol Scand 2017;61:445–55.Search in Google Scholar

[24] Fish RA, McGuire B, Hogan M, Stewart I, Morrison TG. Validation of the Chronic Pain Acceptance Questionnaire (CPAQ) in an Internet sample and development and preliminary validation of the CPAQ-8. Pain 2010;149:435–43.Search in Google Scholar

[25] McCracken LM, Morley S. The psychological flexibility model: a basis for integration and progress in psychological approaches to chronic pain management. J Pain 2014;15:221–34.Search in Google Scholar

[26] Hann KE, McCracken LM. A systematic review of randomized controlled trials of acceptance and commitment therapy for adults with chronic pain: outcome domains, design quality, and efficacy. J Context Behav Sci 2014;3:217–27.Search in Google Scholar

[27] Williams AC, Eccleston C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev 2012;11:CD007407.Search in Google Scholar

[28] Swedish Quality Registry for Pain Rehabilitation. Available at: . Accessed: 3 Jul 2017.Search in Google Scholar

[29] Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiat Scand 1983;67:361–70.Search in Google Scholar

[30] Lisspers J, Nygren A, Soderman E. Hospital Anxiety and Depression Scale (HAD): some psychometric data for a Swedish sample. Acta Psychiat Scand 1997;96:281–6.Search in Google Scholar

[31] Baranoff J, Hanrahan S, Kapur D, Connor J. Validation of the chronic pain acceptance questionnaire-8 in an Australian pain clinic sample. Int J Behav Med 2014;21:177–85.Search in Google Scholar

[32] Rovner GS, Arestedt K, Gerdle B, Börsbo B, McCracken LM. Psychometric properties of the 8-item Chronic Pain Acceptance Questionnaire (CPAQ-8) in a Swedish Chronic pain cohort. J Rehabil Med 2014;46:73–80.Search in Google Scholar

[33] Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, Tugwell P, Campbell SM, Abeles M, Clark P, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990;33:160–72.Search in Google Scholar

[34] Kerns RD, Rudy TE, Turk DC. The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain 1985;23:345–56.Search in Google Scholar

[35] Nyberg VE, Novo M, Sjolund BH. Do Multidimensional Pain Inventory scale score changes indicate risk of receiving sick leave benefits 1 year after a pain rehabilitation programme? Disabil Rehabil 2011;33:1548–56.Search in Google Scholar

[36] R Core Team. R: a language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing, 2016.Search in Google Scholar

[37] Harrell FE. RMS: regression modeling strategies, 2017.Search in Google Scholar

[38] Cook AJ, Meyer EC, Evans LD, Vowles KE, Klocek JW, Kimbrel NA, Gulliver SB, Morissette SB. Chronic pain acceptance incrementally predicts disability in polytrauma-exposed veterans at baseline and 1-year follow-up. Behav Res Ther 2015;73:25–32.Search in Google Scholar

[39] Ruiz-Párraga GT, López-Martínez AE. The contribution of posttraumatic stress symptoms to chronic pain adjustment. Health Psychol 2014;33:958–67.Search in Google Scholar

[40] Ruiz-Párraga GT, López-Martínez AE. The role of experiential avoidance, resilience and pain acceptance in the adjustment of chronic back pain patients who have experienced a traumatic event: a path analysis. Ann Behav Med 2015;49:247–57.Search in Google Scholar

[41] McCracken LM, Gutiérrez-Martínez O. Processes of change in psychological flexibility in an interdisciplinary group-based treatment for chronic pain based on acceptance and commitment therapy. Behav Res Ther 2011;49:267–74.Search in Google Scholar

[42] McCracken LM, Eccleston C, Vowles KE. Acceptance-based treatment for persons with complex, long standing chronic pain: a preliminary analysis of treatment outcome in comparison to a waiting phase. Behav Res Ther 2005;43:1335–46.Search in Google Scholar

[43] Vowles KE, Wetherell JL, Sorrell JT. Targeting acceptance, mindfulness, and values-based action in chronic pain: findings of two preliminary trials of an outpatient group-based intervention. Cogn Behav Pract 2009;16:49–58.Search in Google Scholar

[44] Walton DM, Macdermid JC, Giorgianni AA, Mascarenhas JC, West SC, Zammit CA. Risk factors for persistent problems following acute whiplash injury: update of a systematic review and meta-analysis. J Orthop Sports Phys Ther 2013;43:31–43.Search in Google Scholar

[45] Kullgren ASSH, Krafft M. Development of whiplash associated disorders for male and female car occupants in cars launched since the 80s in different impact directions. IRCOBI Conference; Gothenburg, 2013.Search in Google Scholar

[46] Fillingim RB, King CD, Ribeiro-Dasilva MC, Rahim-Williams B, Riley JL III. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain 2009;10:447–85.Search in Google Scholar

[47] Carlsson A, Chang F, Lemmen P, Kullgren A, Schmitt KU, Linder A, Svensson MY. Anthropometric specifications, development, and evaluation of EvaRID – a 50th percentile female rear impact finite element dummy model. Traffic Inj Prev 2014;15:855–65.Search in Google Scholar

[48] Eek F, Axmon A. Gender inequality at home is associated with poorer health for women. Scand J Public Health 2015;43:176–82.Search in Google Scholar

[49] Vernon H, Guerriero R, Kavanaugh S, Soave D, Moreton J. Psychological factors in the use of the neck disability index in chronic whiplash patients. Spine (03622436) 2010;35:E16–21.Search in Google Scholar

[50] Westergren H, Freeman MD, Malmström E-M. The whiplash enigma: still searching for answers. Scand J Pain 2014;5:226–8.Search in Google Scholar

Received: 2019-02-06
Revised: 2019-05-03
Accepted: 2019-05-08
Published Online: 2019-06-17
Published in Print: 2019-10-25

©2019 Scandinavian Association for the Study of Pain. Published by Walter de Gruyter GmbH, Berlin/Boston. All rights reserved.