Whiplash Associated Disorder: The pathway from acute to chronic pain (Hours 5-6) James J. Lehman, DC, FACO Associate Professor of Clinical Sciences Director of Community Health Clinical Education University of Bridgeport Learning Objectives Able to demonstrate: Clinical plan to evaluate and manage a post-traumatic, whiplash type injury Appropriate interview process to commence differential diagnosis process Appropriate evaluation process to rule-in and rule-out diagnoses A differential diagnosis that includes a working diagnosis A continuum of diagnosis as patient progresses with care Therapeutic recommendations Prognosis Patient Presentation 56 y/o male chiropractor, self-employed, multidisciplinary clinic with health and disability insurance. Presenting with an acute, exacerbation of neck pain and unilateral upper extremity paresthesias in the C6 dermatome. Past history of side impact motor vehicle collision (MVC) with whiplash injury some 20 years earlier. Resulted in fractured teeth, spinal and hand strain/sprain injuries, confusion and short-term memory loss. He has experienced daily neck pain and stiffness since the MVC with episodic neck/arm pain with paresthesias. Radiographic and MRI studies demonstrated degenerative disc and joint disease at the levels of C5-6-7. 1
How Do You Determine the Prognosis With this Whiplash Type Injury? How Do You Grade the Injury? Is the Whiplash Type Injury in a Chronic or Acute State? 2
How Do You Determine if the Patient Will Develop a Chronic Pain Condition? Differential Diagnosis Process Intake form with pertinent data regarding injury Medical records from ER or other providers Patient interview or history taking Create list of potential diagnoses Physical examination Rule-in and rule-out diagnoses Specialized imaging including MRI and Spinal Motion Studies Working diagnosis (es) Pathoanatomical Lesions in the Whiplash Injury 1. Cervical Facet joints (Zygapophyseal Joints) 2. Dorsal Root Ganglion (DRG) and Nerve Roots 3. Cervical Ligaments 4. Intervertebral Disc Injuries 5. Muscle Injuries 6. Fractures 3
Persistent Pain: A Chronic Illness Acute pain usually goes away after an injury or illness resolves. But when pain persists for months or even years, long after whatever started the pain has gone or because the injury continues, it becomes a chronic condition and illness in its own right. A Call to Revolutionize Chronic Pain Care in America: An Opportunity in Health Care Reform. The Mayday Fund. November 4, 2009. Amended March 4, 2010. National Pain Strategy Chronic pain - Pain that occurs on at least half the days for six months or more. Facet Joint Injury Model Studies employing the cervical facet joint injury model have identified the occurrence of hemarthrosis, capsular damage, joint fractures, and capsular rupture. Joslin CC, Khan SN, Bannister GC. Long-term disability after neck injury: a comparative study. J Bone Joint Surg Br. 2004;86:1032-1034. 4
Cervical Facet Injury Model Clinical support for a facetogenic model of persistent pain generation in whiplash can be found in the literature. Lord SM, Barnsley L, Wallis BJ, Bogduk N. Chronic cervical zygapophysial joint pain after whiplash. A placebo-controlled prevalence study. Spine. 1996;21:1737-1744; discussion 1744-1735. Cervical Facet Injury Model As a result of facet joint injury, whiplash patients frequently encounter, headaches, back and shoulder pain in addition to neck pain. Elliot JM, et al. Characterization of Acute and Chronic Whiplash-Associated Disorders. Journal of Orthopaedic & Sports Physical Therapy, 2009, Volume: 39 Issue: 5 Pages: 312-323. Cervical Facet Joint Injury and Referred Pain The most common facets to be injured and highest prevalence of joint pain are at C2/C3 and C5/C6 which frequently results in referred pain. Lord SM, Barnsley L, Wallis BJ, Bogduk N. Chronic cervical zygapophysial joint pain after whiplash. A placebo-controlled prevalence study. Spine. 1996;21:1737-1744; discussion 1744-1735. 5
Dorsal Root Ganglion (DRG) Compression and Soft Tissue Changes Largely undetected May contribute to adaptation in the overall functioning of the cervical DRG May predispose an individual to abnormal, centrally mediated pain processing. (5, 6) Cervical Ligamentous Sprain Injuries Possible injury to mechanoreceptive and nociceptive nerve endings leading to pain, inflammation and chronic pain syndrome Tominaga Y, Ndu AB, Coe MP, et al. Neck ligament strength is decreased following whiplash trauma. BMC Musculoskelet Disord. 2006;7:103. Radiographic Examination When is it appropriate to order a radiographic cervical spine joint motion study, also known as cervical spinal motion fluoroscopy? 6
James A. Mertz, DC, DACBR Cervical Spine Motion Fluoroscopy Behrouz Alizadeh Savareh, Yousef Sadat, Azadeh Bashiri, Mehraban Shahi, and Nasrin Davaridolatabadi. The design and implementation of the software tracking cervical and lumbar vertebrae in spinal fluoroscopy images. Future Sci OA. 2017 Nov; 3(4): FSO240. Published online 2017 Sep 11. https://www.bing.com/videos/search?q= spinal+fluoroscopy&&view=detail&mid=1 802D84042E937A87A801802D84042E937 A87A80&&FORM=VDRVRV Cervical Disc Injuries Present in 25% of subjects post whiplash injury and correlated with radicular symptoms (9, 10) 7
Cervical Disc Injuries C 5-6 segmental level was found to be the most common level of disc injury... greater risk of low-grade spinal cord injury with pre-existing spinal canal narrowing at C5-6 level Ito S, Panjabi MM, Ivancic PC, Pearson AM. Spinal canal narrowing during simulated whiplash. Spine. 2004;29:1330-1339. Cervical Spondylotic Myelopathy Common symptoms Clumsy or weak hands Leg weakness or stiffness Neck stiffness Pain in shoulders or arms Unsteady gait Common signs Atrophy of the hand musculature Hyperreflexia Lhermitte's sign (electric shock-like sensation down the center of the back following flexion of the neck) Sensory loss Muscles Strained Whiplash has been demonstrated to strain SCM, semispinalis, splenius capitis and upper trapezius with rear-end impacts. Brault JR, Siegmund GP, Wheeler JB. Cervical muscle response during whiplash: evidence of a lengthening muscle contraction. Clin Biomech (Bristol, Avon). 2000;15:426-435. 8
Soft Tissue Injury Grading Grade 1 strain of muscle/tendon (Mild) Overstretch or tear up to 5% Grade 2 strain of muscle/tendon (Moderate) Tear up to 50% Grade 3 strain of muscle/tendon (Severe) Rupture or complete 100% tear Grade 4 strain of muscle/tendon/bone (Avulsion) Complete tear with avulsion of bone Post-Traumatic Myofascial Pain Syndrome When should specific interventions take place and why? Medications Immobilization Spinal manipulation Soft tissue treatments Ice/Heat/Cryotherapy Electrotherapy Cold laser therapy Traction (intersegmental, long-axis, and non-surgical spinal decompression) Rehab exercises Behavioral health 9
Chiropractic Use of Cold Laser for Pain https://www.youtube.com/watc h?v=irb9flmdzmw&index=9&lis t=pluqjzapeoort- F0fAaLBmj9ZkwDLBt_9p Extentrac and Dr. David F. Cuccia 3 Dimensional non-surgical spinal decompression Dr. James M. Cox 10
Conclusions: The evaluation and management of whiplash injuries must attempt to accomplish the following before starting treatments: Discover mechanism of injury Reveal pain severity (acute and chronic) Determine the injured tissues and pain generators Understand biopsychosocial factors Perform a differential diagnosis Provide a reasonable prognosis Offer appropriate treatment Integrate a health care team of providers Patient Presentation 56 y/o male chiropractor, self-employed, multidisciplinary clinic with health and disability insurance Presenting with an acute, exacerbation of neck pain and unilateral upper extremity paresthesias in the C6 dermatome. Past history of side impact motor vehicle collision (MVC) with whiplash injury some 20 years earlier. Resulted in fractured teeth, spinal and hand strain/sprain injuries, confusion and short-term memory loss. He has experienced daily neck pain and stiffness since the MVC with episodic neck/arm pain with paresthesias. Radiographic and MRI studies demonstrated degenerative disc and joint disease at the levels of C5-6-7. Engaged Learning Task (25 minutes) Form groups of 3-4 Select a spokesperson who will provide a brief presentation of your SOAP notes Determine appropriate evaluation including history and physical examination and chart expected findings Perform differential diagnosis Recommend treatment plan Give prognosis Chart with SOAP process 11
Spokesperson Will Present and Defend Your Work (25 minutes) Another group will be selected to question the presentation. Do you agree with evaluation? Do you agree with list of potential diagnoses and working diagnosis? Do you agree with the prognosis and treatment recommendations? Recommendations prior to treating patients with whiplash injuries. Discover mechanism of injury Determine history of neck pain prior to whiplash injury Reveal pain severity with Numerical Pain Rating Scale (NPRS) Identify the injured tissues and pain generators Understand biopsychosocial factors Perform differential diagnosis Determine a reasonable prognosis Offer appropriate treatment with the use of a team of health care providers Avoid nocebo effect and promote placebo effect References 1. Barnsley L, Lord S, Bogduk N. Whiplash injury. Pain. 1994;58:283 307. 2. Spitzer WO, Skovron ML, Salmi LR, et al. Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: redefining whiplash and its management. Spine. 1995;20:1S 73S. 3. Elliot JM, et al. Characterization of Acute and Chronic Whiplash-Associated Disorders. Journal of Orthopaedic & Sports Physical Therapy, 2009, Volume: 39 Issue: 5 Pages: 312-323. 4. Jouko Kivioja, Irene Jensen, and Urban Lindgren. Neither the WAD-classification nor the Quebec Task Force follow-up regimen seems to be important for the outcome after a whiplash injury. A prospective study on 186 consecutive patients. Eur Spine J. 2008 Jul; 17(7): 930 935. 5. Hasue M. Pain and the nerve root. An interdisciplinary approach. Spine. 1993;18:2053-2058. 6. Jansen J, Bardosi A, Hildebrandt J, Lucke A. Cervicogenic, hemicranial attacks associated with vascular irritation or compression of the cervical nerve root C2. Clinical manifestations and morphological findings. Pain. 1989;39:203-212. 7. Kaale BR, Krakenes J, Albrektsen G, Wester K. Head position and impact direction in whiplash injuries: associations with MRI-verified lesions of ligaments and membranes in the upper cervical spine. J Neurotrauma. 2005;22:1294-1302. 8. Kaale BR, Krakenes J, Albrektsen G, Wester K. Whiplash-associated disorders impairment rating: neck disability index score according to severity of MRI findings of ligaments and membranes in the upper cervical spine. J Neurotrauma. 2005;22:466-475. 9. Jonsson H, Jr, Bring G, Rauschning W, Sahlstedt B. Hidden cervical spine injuries in traffic accident victims with skull fractures. J Spinal Disord. 1991;4:251. 10. Pettersson K, Hildingsson C, Toolanen G, Fagerlund M, Bjornebrink J. Disc pathology after whiplash injury. A prospective magnetic resonance imaging and clinical investigation. Spine. 1997;22:283-287; discussion 288.263. 12
References 11. Borchgrevink GE, Kaasa A, McDonagh D, Stiles TC, Haraldseth O, Lereim I. Acute treatment of whiplash neck sprain injuries. A randomized trial of treatment during the first 14 days after a car accident. Spine. 1998;23:25-31. 12. Kasch H, Qerama E, Bach FW, Jensen TS. Reduced cold pressor pain tolerance in non-recovered whiplash patients: a 1- year prospective study. Eur J Pain. 2005;9:561-569. 13. Tjell, C. and U. Rosenhall (1998). Smooth pursuit neck torsion test: a specific test for cervical dizziness. Otology & Neurotology 19(1): 76. 14. Treleaven, J., G. Jull, et al. (2003). Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error. Journal of Rehabilitation Medicine 35(1): 36-43. 15. Treleaven, J., G. Jull, et al. (2005). Smooth pursuit neck torsion test in whiplash-associated disorders: relationship to selfreports of neck pain and disability, dizziness and anxiety. Journal of Rehabilitation Medicine 37(4): 219-223. 16. Treleaven, J., G. Jull, et al. (2005). Standing balance in persistent whiplash: a comparison between subjects with and without dizziness. Journal of Rehabilitation Medicine 37(4): 224-229. 17. Jull, G., D. Falla, et al. (2007). Retraining cervical joint position sense: The effect of two exercise regimes. Journal of Orthopaedic Research 25(3): 404-412. 18. Treleaven J, Jull G, Sterling M. Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error. J Rehabil Med. 2003 Jan;35(1):36-- 43. 19. Sterling M, et al. Sensory hypersensitivity occurs soon after whiplash injury and is associated with poor recovery Pain 104 (2003) 509-517. 20. Adams JH, Doyle D, Ford I, Gennarelli TA, Graham DI, McLellan DR. Diffuse axonal injury in head injury: definition, diagnosis and grading. Histopathology. 1989; 15: 49 59. 13