Whiplash Associated Disorder: The pathway from acute to chronic pain (Hours 3-4) James J. Lehman, DC, FACO Associate Professor of Clinical Sciences Director of Community Health Clinical Education University of Bridgeport Learning Objectives
Able to evaluate and perform a differential diagnosis of a whiplash type injury patient. Acute whiplash injury (G89.11) (Acute pain due to trauma) Post-traumatic chronic pain syndrome (G89.21) Post-traumatic, high-impact chronic pain (G89.21) 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
Diagnosis is the key to successful treatment! Richard C. Ackerman, DC, FACO Is the Whiplash Type Injury in a Chronic or Acute State? How Do You Grade this Injury? How Do You Determine if the Patient Will Develop a Chronic Pain
Condition? Patient Presentation 33 year-old female, self-employed lawyer with two associates She is properly insured with disability, health insurance and med-pay Rear-ended 7 days prior to initial encounter in your office Denies prior neck injuries or neck pain Chief concern of neck stiffness and aching in the lower cervical and upper thoracic spine. My neck is stiff and it hurts. Able to work but distracted because of aching discomfort later in the work day
Differential Diagnosis Process Intake form with pertinent data regarding injury Medical records from ER or other providers Neck Disability Index (NDI) Patient interview or history taking Create list of potential diagnoses Physical examination Rule-in and rule-out diagnoses
Working diagnosis (es) Pathoanatomical Lesions in the Whiplash Injury 1. 2. 3. 4. 5. 6.
temporomandibular joint dysfunction, photophobia, dysphonia, dysphagia, fatigue, cognitive difficulties such as concentration and memory loss, anxiety, insomnia, and depression (3) Diagnosis and prognosis are the
keys to successful treatment of whiplash associated disorder. Subjective Data Elicit a patient history and record the subjective findings in order to list potential diagnoses and use objective testing to rule-in and rule-out potential
conditions. Post-Whiplash Type Injury Interview Intake form to cover all injury data (MVI, Slip and fall, lifting, etc.), past medical history, NDI, etc. Medical records including ER Focused L-T acronym Chief concern Open-end questions
Closed-end questions Focused Interview or History Taking Process Using a Mnemonic Location of pain/injury Mechanism of injury New injury/condition Old injury/condition Palliative/Provocative
Quality of pain Radiations/Referred pain Severity Timing and Treatment Subjective Data Identify the Pain Generating Tissue Location of pain Use finger point test Palpate to confirm the pain generating tissue and specific
location Example: Pain with palpation at right C1-3 posterior cervical muscles, facet capsules and the ligamentum nuchae Subjective Data Be Specific Location of pain Right posterior upper cervical
spine C1-3 Ligamentum nuchae C1-3 Potential tissues injured and painful Cervical muscles (Strain) Capsular ligaments and ligamentum nuchae (Sprain) Osseous tissues (Fracture) List of Potential Diagnoses Based on Subjective Data Cervical strain
Cervical sprain Cervical dislocation Cervical fracture 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. List of Potential Diagnoses Based on Subjective Data
Are these potential diagnoses acute or chronic? Cervical strain Cervical sprain Cervical dislocation Cervical fracture Grading of Spinal Injury Is this whiplash type injury an acute, mild, moderate, or severe
soft or hard tissue injury to the cervical spine? Can you describe the injuries? Description of Tissue Injuries Odontoid process fracture. The small fragment is rotated anteriorly and superiorly. Portions of the ruptured cruciate ligament and of the rectorial membrane are entrapped in the wide fracture gap.
The apical ligament is avulsed. Only the dura is intact. In addition in this specimen, uncovertebral and facet joint injuries as well as several disc avulsions (cartilaginous endplate separations) were found. Soft Tissue Injury Grading Grade 1 sprain of ligament/joint (Mild) Overstretch or tear up to 5%
Grade 2 sprain of ligament/joint (Moderate) Tear up to 50% Grade 3 sprain of ligament/joint (Severe) Rupture or complete 100% tear Grade 4 sprain of ligament/joint/bone (Avulsion) Complete tear with avulsion of bone
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 Case One = WAD I Patient presents with neck complaints including stiffness or tenderness in the neck regions and no physical signs of injury.
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;20:1S73S. Most likely diagnosis is acute, mild cervical strain Prognosis is good Spontaneous recovery within 2-3
weeks is common. Case Two: WAD II Patient presents with neck complaints including stiffness or tenderness, and some physical signs of injury, such as point tenderness or trouble turning the head. Acute, moderate cervical sprain/
strain is most likely DX Prognosis is difficult to predict Current management does not appear to lessen transition from acute to chronic pain status Physical and psychological impairment poorly addressed by treatments predictive of poor recovery Case Three: WAD III
Patient presents with neck complaints including stiffness or tenderness and neurological signs of injury such as deep tendon reflex or motor deficits. Acute, moderate sprain/strain with resultant cervical radiculopathy Current management does not appear to lessen transition from
acute to chronic pain status Physical and psychological impairment poorly addressed by treatments predictive of poor recovery Case Four: WAD IV Patient presents with neck complaints with a fracture or dislocation of the cervical spine.
List of Potential Diagnoses Based on Subjective Data Are these potential diagnoses mild, moderate or severe? Cervical strain Cervical sprain Cervical dislocation Cervical fracture
Objective Data Ruling-in and Ruling-out Diagnoses Observation Palpation Range of motion Orthopedic testing Neurological testing Laboratory Objective Data Observation
Appearance Stated age Well-nourished Well-developed Distinguishing findings
Posture Antalgic Erect Scoliosis (functional or structural) Gait Smooth or limping Objective Data Observation of Posture What do you see with this young
patient? Does she have scoliosis? If yes, is it structural or functional? What could be the cause (s) of this postural deviation? Objective Data Postural Evaluation Adams positon Increased dorsal rib hump or
increased curvature indicates a structural scoliosis Reduction of spinal curvature indicates a functional scoliosis What could be a cause (s) of functional scoliosis? Objective Data Long Sit Testing Objective Data
Palpation (Flat/Pinching/Static) Signs of inflammation Dolar Rubor Calor Tumor Provocative or pain
Occipital neuralgias Greater Occipital (2nd Cervical) Third Occipital Cervicogenic Headaches Neurogenic Differentiate Cranial and Occipital neuralgias Objective Data
Range of Motion (ROM) Active First ROM General findings of pain and restriction or full ROM without pain Passive Pain and restriction indicates ligament and/or joint injury (Sprain) Resistive
Pain and restriction indicates muscle and/or tendon injury (Strain) LHermittes Sign Spinal Cord Compression Pain Stabbing or lightning-like pain shooting down the spine and any combination of the extremities Active or passive flexion or extension of the cervical spine
Objective Data Orthopedic Testing An orthopedic test is most often a provocative maneuver that reproduces the chief concern pain in order to identify the painful/injured tissue. An orthopedic test may be positive when palliative. Describe your findings
Do not list + or indicators alone Do not state a diagnosis based upon an orthopedic test alone Objective Data Orthopedic Testing Passive compression of the cervical spine in lateral flexion, rotation, and extension produced localized pain at C 5-6 left with radiating pain down the
left upper extremity to the thumb and index finger. Objective Data Cervical Spine Orthopedic Testing Cervical compression and distraction Neutral, flexion and extension cervical compression Active and passive maximum cervical compression with lateral
flexion, rotation and extension Objective Data Orthopedic Testing Chart the specific findings in order to determine the injured tissue Cervical compression + does not tell the story or demonstrate objective findings.
Upper Cervical Transverse Ligament Sprain Injuries Sharp Purser Test Stand to the side of the patient and stabilize the C2 spinous process using pincer grasp. Gently apply a posterior translation force from the palm of the hand into the patient's forehead Assess symptoms for degree of linear translation and/or symptom provocation Positive test would be reproduction of
myelopathic symptoms during forward flexion or displacement during AP movement Neurological Examination Mental status CNS examination Cranial nerve examination Three-part peripheral nerve examination Deep tendon reflexes Motor function
Sensory perception Differentiate Upper Motor vs Lower Motor Neuron Lesions UMNL Spastic paralysis Clonus present Increased deep tendon reflexes Pathological reflexes present Weakness with atrophy absent
Central Nervous System examination https://www.youtube.com/watch?v=kZOcz0czWs4 Peripheral Nervous System examination https:// www.youtube.com/watch?v=I7YF4vCBisQ Spine and paraspinal examination https:// www.youtube.com/watch?v=HegByhhb8sI Diagnosis and prognosis are the keys to successful treatment of
whiplash associated disorder. Prognosis Post Whiplash Type Injury End of Healing Stage Sprained ligaments heal with a cheaper grade of mesenchymal tissue = cicatrix or scar. A scar left by the formation of new connective tissue over a healing sore or wound.
Scar tissue is avascular, pale, contracted, and firm after the earlier phase of soft tissue healing. Prognosis Post Whiplash Type Injury Post-traumatic chronic pain syndrome Chronic myofascial pain syndrome Degenerative joint and disc
disease or Cervical Spondylosis Cervical Spine Video Fluoroscopy Laxity of Cervical Ligaments https://www.bing.com/videos/s earch?q=dmx+cervical+joint+mo tion+study&&view=detail&mid= 893FE46450F84E6A1994893FE4 6450F84E6A1994&&FORM=VRD GAR
Post Whiplash Cervical Spine Fracture https://www.bing.com/videos/s earch?q=dmx+cervical+joint+mo tion+study&&view=detail&mid= D1F938F5AA32C79EB8A5D1F93 8F5AA32C79EB8A5&& FORM=VDRVRV Post Whiplash Injury to the Cervical Spine with Arm Pain
How you advise your patient of the diagnosis, prognosis and treatment may affect the patient response. Placebo versus Nocebo Effects The placebo effect is related to the perceptions and expectations of the patient If the intervention is viewed as helpful, it can heal, but, if it is
viewed as harmful, it can cause negative effects, which is known as the nocebo effect. 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 (Neck Disability Index [NDI])
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 Patient Presentation 33 year-old female, self-employed lawyer with two associates She is properly insured with disability, health insurance and med-pay Rear-ended 7 days prior to initial encounter in your office Denies prior neck injuries or neck pain Chief concern of neck stiffness and aching in the lower cervical and
upper thoracic spine Able to work but distracted because of aching discomfort later in the work day Engaged Learning Task (30 minutes) Form groups of 3-4 Select a spokesperson who will provide a brief presentation Determine appropriate evaluation including history and physical examination
Perform differential diagnosis Recommend treatment plan Give prognosis Chart with SOAP process Spokesperson Will Present and Defend Your Work 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;58:283307.
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;20:1S73S. 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): 930935. 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 MRIverified 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;22:466475.
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.
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 self-reports 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--43.43. 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: 4959. 21. Walton DM, & Elliott JM. An Integrated Model of Chronic Whiplash-Associated Disorder. Journal of Orthopedic and Sports Physical Therapy. July 2017, Volume 47, Number 7.
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