Physical and psychological aspects of whiplash: Important considerations for primary care assessment, Part 2 e Case studies

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1 Available online at Manual Therapy 14 (2009) e8ee12 Masterclass Physical and psychological aspects of whiplash: Important considerations for primary care assessment, Part 2 e Case studies Michele Sterling a,b, * a Centre of National Research on Disability and Rehabilitation Medicine (CONROD), The University of Queensland, Mayne Medical School, Herston Road, Herston, QLD 4066, Australia b Division of Physiotherapy, The University of Queensland, QLD 4072, Australia Received 20 March 2008; accepted 20 March Abstract Whiplash is a heterogenous and in many, a complex condition involving both physical and psychological factors. Primary care practitioners are often the first health care contact for individuals with a whiplash injury and as such play an important role in gauging prognosis as well as providing appropriate management for whiplash injured patients. It is imperative that factors associated with poor outcome are recognized and managed in the primary care environment at the crucial early acute stage post-injury. This paper presents 2 case studies of individuals with acute whiplash pain. The case studies illustrate the heterogeneity of the whiplash condition and the importance of clinical assessment that includes consideration of both physical and psychological manifestations. They also demonstrate the important role physiotherapists play in the management of people with whiplash, particularly in the early post-injury stage. Crown Copyright Ó 2008 Published by Elsevier Ltd. All rights reserved. Keywords: Whiplash associated disorders; Central hyperexcitability; Posttraumatic stress; Assessment 1. Introduction Whiplash is a common and costly consequence following a motor vehicle crash, with up to 60% of those injured reporting persistent neck pain and disability (Rebbeck et al., 2006; Sterling et al., 2006). In recent times, there has been an accumulation of research data demonstrating whiplash to be a heterogeneous and complex condition involving varying degrees of both physical and psychological manifestations. Importantly some of these features, for example, hyperalgesia, movement loss, posttraumatic stress symptoms, moderate/ * Centre of National Research on Disability and Rehabilitation Medicine (CONROD), The University of Queensland, Mayne Medical School, Herston Road, Herston, QLD 4066, Australia. Tel.: þ ; fax: þ address: severe levels of pain and disability are predictive of poor functional recovery (Scholten-Peeters et al., 2003; Rebbeck et al., 2006; Sterling et al., 2006). Musculoskeletal clinicians play an important role in the early management of whiplash injury, particularly in the primary care environment where many injured people will seek treatment for their condition. In the accompanying paper to this one, the heterogeneous clinical presentation of acute and chronic whiplash was outlined and suggestions made for the assessment of this condition. It was argued that some patients will present with a less complex clinical presentation and these patients should respond well to shortterm physiotherapy interventions. In contrast and at the other end of the spectrum, there are the group of patients whose clinical presentation is complicated by the additional presence of widespread sensory hypersensitivity and symptoms of posttraumatic stress (Fig. 1). This X/$ - see front matter Crown Copyright Ó 2008 Published by Elsevier Ltd. All rights reserved. doi: /j.math

2 M. Sterling / Manual Therapy 14 (2009) e8ee12 e9 Fig. 1. An outline of factors that is indicative of 2 different clinical presentations of whiplash. It is argued that the more complex presentation will require a more intensive and interdisciplinary approach to management. group will likely require a more concerted approach to their management based on early identification of these factors and others associated with poor outcome. In order to illustrate the varied clinical presentation of whiplash and the assessment required, 2 case studies will be presented. Acute whiplash injury has been selected for the outline of these case studies, in order to emphasize the importance of this stage of the whiplash process and that effective assessment and management may help to prevent the development of chronicity in those at risk. In order to illustrate the overall management of acute whiplash, in depth discussion of specific physical interventions is not provided, instead readers are provided with appropriate references with more detailed discussion of specific techniques. 2. Case studies 2.1. Case 1: less complex whiplash presentation Patient interview and history Jane, 30-year-old female; married; 1 child (3 years old). Work: Personal assistant to CEO of advertising company. History: Jane was on her way home from work 10 days ago when her car was rear-ended whilst stopped at a red traffic light. Jane felt slight pain in her neck at the time of the accident and after organising the car to be towed away she went home. That night she could feel her neck getting stiff. She went to bed early but when she awoke the next morning, she could barely turn her neck. Jane managed to rest that day and her partner cared for their child. Jane took the following 2 days off work (sick leave). She then returned to work and reports that she struggles through her day before collecting her child from childcare and returning home to rest as much as she can. Jane is usually very active and goes to gym classes 3 times a week as well as playing hockey on the weekends but has not been able to do so since the car accident due to neck pain. However, she has been able to ride a stationary bike at home for about 15 min at a time. Jane presents to the physiotherapist 10 days after the accident as she feels that her neck should be better by now and she is worried since her friend experienced a similar injury and was unable to play any sports for 12 months. Jane has not had any radiological investigations. She has taken Panadol as necessary with some reported relief. Jane s sleep is not disturbed by pain and her pain is no worse with cold. Pain: left sided neck pain (VAS: 5/10); left sided frontal headache (VAS: 4/10). Patient Specific Functional Scale (PSFS) (Westaway et al., 1998): Picking up child: 4/10. Working at office desk (longer than 30 min): 6/10. Reading (longer than 30 min): 6/10. Neck Disability Index (NDI) (Vernon and Mior, 1991): 32/100. Impact of Events Scale (IES) (Horowitz et al., 1979): 7 (Note: the IES is preferred to the IES-R for clinical

3 e10 M. Sterling / Manual Therapy 14 (2009) e8ee12 use as cut-off scores for levels of posttraumatic stress symptoms have been reported). General Health Questionnaire-28 (GHQ-28): 19 (just below threshold of 23/24) (Goldberg, 1978). Self-reported Leeds Assessment of Neuropathic Signs and Symptoms scale (S-LANSS) (Bennett et al., 2005): Physical examination Posture: can actively correct posture to good position when facilitated. Neck range of movement (measured using gravity dependent goniometer): left rotation: 50 ; extension: 30. Right rotation and flexion: full. Cervical muscle control: tested using the craniocervical flexion test (Jull et al., 2007). Could achieve 24 mm Hg before loss of correct movement pattern and marked superficial muscle activity. Shoulder girdle muscle control: good control in prone lying, sitting and with arm movement (Jull et al., 2007). Postural control (Treleaven, 2007): joint position error e less than 3 all directions. Manual examination (Maitland et al., 2001): decreased movement and pain (VAS: 4/10) at C2/3 segment on the left side with localised hyperalgesia only. Clinical neurological examination (muscle power, reflexes, sensation): nothing abnormal detected. Brachial plexus provocation test (BPPT) (Elvey, 1997; Sterling et al., 2002): elbow extension 15 from 180 (bilaterally) at pain threshold (VAS: 1/10) Key findings from the examination Moderate levels of pain and disability. Some psychological distress (GHQ-28 approaching threshold); anxiety about not being able to return to sport. No symptoms of posttraumatic stress: low scores on the IES. No evidence of central hyperexcitability (hyperalgesia is localised to the cervical spine and is not widespread; S-LANSS score is <12; no hypersensitivity with the BPPT; no sleep disturbance due to pain; condition is not irritable). Indications of a localised condition of the cervical spine associated with movement loss and impaired muscle control of the neck Prognosis The presence of moderate levels of pain and disability is a prognostic indicator for poor recovery (Kamper et al., in press). However, Jane s levels of psychological distress are low (below threshold); she reports no symptoms of posttraumatic stress; there is no evidence of central hyperexcitability and neck ROM is not markedly restricted. Therefore it would be expected that Jane should recover well Management plan At this stage, the physiotherapist should be able to undertake the management of this patient. There is little to indicate that referral to other heath care providers is indicated. Cognitive management should include: assurance about prognosis and that full recovery is expected; provide awareness of mechanisms underlying the condition; provide an explanation to Jane of the proposed management plan (see below) and its expected effects. Physical management should be a multimodal approach. This would primarily involve improvement of cervical movement, retraining of motor control commencing in an unloaded supine position but progressing rapidly to functional and weight bearing activities (for further detail see: Sterling et al., 2001; Jull et al., 2007; Stewart et al., 2007). Gentle manual therapy to C2/3 could also be included for its hypoalgesic effect on the cervical spine (Sterling et al., 2001). As pain and disability decreases, a graduated cardiovascular fitness program could be introduced with the aim of restoring full sporting activities. In this case, this is little to indicate a prolonged recovery. Therefore it would be expected that improvements would be seen quickly (as determined by clinically relevant changes on pain and functional outcomes) and that physiotherapy treatment would not be of a long-term nature Case 2: more complex whiplash presentation Patient interview and history Patricia, 38-year-old female, married; 2 children (15 and 10 years). Work: Administration assistant. History: 6 weeks ago, Patricia was involved in a motor vehicle crash where her car was hit on the rear passenger driver s side, by a car that ran a red light. She felt immediate sharp pain in her neck and head. The car was extensively damaged and she was taken to hospital where X-rays revealed no fracture or dislocation and she was sent home with analgesics. Patricia went to her General Practitioner (GP) the next day as her pain which had spread into her right arm was reaching an intolerable level. He prescribed Voltaren and Panadeine Forte and advised her to take a week off work. After this time, Patricia then attempted to return to work

4 M. Sterling / Manual Therapy 14 (2009) e8ee12 e11 but this exacerbated her pain; she couldn t concentrate and was experiencing some light-headedness. She has not since returned to work. She is not sleeping well due to neck pain and reports that she can t get to sleep due to thoughts about the accident. Patricia returned to her GP who has referred her to physiotherapy. Usually, Patricia has a busy life with full-time work and caring for her children. She finds time to walk approximately 5 km, 3 times a week but has been unable to do this since the accident. Pain: Constant neck (8/10) and right arm (6/10) pain. Intermittent paraesthesia (3/10) in the right hand. PSFS (Westaway et al., 1998): Sitting longer than 10 min: 2/10. Turning head to look over right shoulder: 1/10. Washing-up: 1/10. NDI (Vernon and Mior, 1991): 52/100. IES (Horowitz et al., 1979): 30 (moderate symptoms of posttraumatic stress). GHQ-28 (Goldberg, 1978): 30 (above threshold of 23/ 24). S-LANSS (Bennett et al., 2005): 24(>12, likely neuropathic component to the pain). In both case studies it could be argued that additional questionnaires that aim to measure other psychological substrates could be included (for example, fear avoidance beliefs or catastrophisation). The above questionnaires have been included in view of their use in the investigation of whiplash Physical examination Posture: right shoulder elevated, cradling right arm. Arm pain increases with shoulder depression. Neck range of movement (measured using gravity dependent goniometer): left and right rotations: 20 ; extension: 10 ; flexion: 10. Cervical muscle control: poor pattern of craniocervical flexion; marked activity in superficial flexors (Jull et al., 2007). Unable to formally test with biofeedback unit due to the presence of allodynia. Shoulder girdle muscle control: not tested due to pain provocation with shoulder depression. Postural control (Treleaven, 2007): joint position error e unable to test due to lack of neck ROM. Balance e unsteadiness in tandem stance. Manual examination (Maitland et al., 2001): unable to effectively perform as neck is allodynic. Clinical neurological examination (muscle power, reflexes, sensation): generalized decrease in light touch sensation over right arm but not specific to a particular dermatome. BPPT (Elvey, 1997; Sterling et al., 2002): right, elbow extension 60 from 180 at pain threshold (VAS: 8/ 10); left, elbow extension 20 from 180 ) at pain threshold (VAS: 2/10). Allodynia of right arm Key findings from the examination Moderate levels of pain and disability. Moderate psychological distress (GHQ-28 above threshold). Moderate levels of posttraumatic stress symptoms; IES score of 30. Evidence of central hyperexcitability and/or neuropathic pain condition (constant pain; irritable condition; S-LANSS score of >12; allodynia; marked hypersensitivity to the BPPT on the right side and protective posture may indicate mechanosensitivity of peripheral nerve tissue although nerve conduction appears normal, Hall and Elvey, 1999). Indications of a complex presentation involving central hyperexcitability; possible peripheral nerve tissue involvement (mechanosensitivity) as well as moderate levels of distress, particularly posttraumatic stress Prognosis There are several adverse prognostic indicators associated with this clinical presentation. In addition to moderate/high levels of pain and disability, there is evidence of central hyperexcitability, marked neck movement loss and moderate levels of posttraumatic stress. Patricia is at risk of developing chronic pain and disability as a result of her injury. It is important that any treatment plans take this into account Management plan This is a critical time period for Patricia s condition. The complex nature of her condition indicates that an interdisciplinary approach to her management will be required. It is now 6 weeks post-injury and the patient is reporting moderate levels of posttraumatic stress symptoms. A psychological referral should be instigated such that further evaluation of the patient s psychological status is undertaken. Guidelines recommend that trauma-focussed cognitive behavioural therapy delivered by a psychologist should be commenced (Forbes et al., 2007). The physiotherapist also plays a role and it is important that clear information is provided to the patient without further adding to her distress or catastrophising the condition. It is unlikely that a psychological approach to treatment alone will be sufficient to reduce pain (Blanchard et al., 2003), so it is also important that some pain relief is achieved via other means. Liaison with the GP would be indicated with the view to improve pain control via medication (Curatolo et al., 2006). Physical interventions such as active movement/exercises within pain limits, gentle manual therapy and modalities such as

5 e12 M. Sterling / Manual Therapy 14 (2009) e8ee12 TENS may also assist in this regard (Skyba et al., 2003; Sluka et al., 2006). Whilst at this stage, treatment emphasis should be placed on the psychological and pain processing aspects of the condition, it is also important that treatment is directed to improving movement and function. This may take the form of advice and encouragement to commence gentle exercises of the neck as well as general activity as tolerated by pain (MAA, 2007), taking care not to overly provoke symptoms. The physiotherapist should also be aware that posttraumatic stress symptoms can influence activity levels of people with whiplash (Sterling and Chadwick, submitted for publication) and this should be taken into account. The physiotherapist may elect to defer more intensive rehabilitation (e.g., motor and postural control retraining) in order to decrease the burden on the patient until her posttraumatic stress symptoms improve. In this case, liaison with the treating psychologist would be essential such that the patient s progress be monitored and more intensive physical treatment commenced at an appropriate time. Due the complexity of this whiplash presentation, it is clear that a more concerted approach to management is required. It is likely that the length of treatment time and the number of treatments will be greater than those required for case study 1. In both cases, progress should be monitored with validated outcome measures and treatment adapted in view of the individual patient s progress. It can be seen that such an integrated approach to the management of this patient requires collaborative communication between the health care providers involved in her management. However, for this to occur the physiotherapist must consider the overall status of the patient and resist focusing on motor retraining only Summary These 2 distinct clinical presentations of acute whiplash injury highlight the importance of adequate and appropriate early assessment. Musculoskeletal clinicians play an important role in the assessment and management of both the physical and psychological aspects of this condition and are ideally placed to play a role in the co-ordination of care for patients such as this. References Bennett M, Smith B, Torrance N, Potter J. The S-LANSS score for identifying pain of predominantly neuropathic origin: validation for use in clinical and postal research. The Journal of Pain 2005; 6:149e58. Blanchard E, Hickling E, Devineni T, Veazey C, Galovski T, Mundy E, et al. A controlled evaluation of cognitive behaviour therapy for posttraumatic stress in motor vehicle accident survivors. Behaviour Research and Therapy 2003;41:79e96. Curatolo M, Arendt-Nielsen L, Petersen-Felix S. Central hypersensitivity in chronic pain: mechanisms and clinical implications. Physical Medicine Rehabilitation Clinics of North America 2006;17: 287e302. Elvey R. Physical evaluation of the peripheral nervous system in disorders of pain and dysfunction. Journal of Hand Therapy 1997;10: 122e9. Forbes D, Creamer M, Phelps A, Bryant R, McFarlane A, Devilly G, et al. Australian guidelines for the treatment of adults with acute stress disorder and posttraumatic stress disorder. Australian and New Zealand Journal of Psychiatry 2007;41:637e48. Goldberg D. Manual of the general health questionnaire. Windsor: NFER-Nelson; Hall T, Elvey R. Nerve trunk pain: physical diagnosis and treatment. Manual Therapy 1999;4:63e73. Horowitz M, Wilner N, Alvarez W. Impact of event scale: a measure of subjective stress. Psychosomatic Medicine 1979;41:209e18. Jull G, Sterling M, Falla D, Treleaven J, O Leary S. Whiplash, headache and neck pain: research based directions for physical therapies. Edinburgh: Elsevier; Kamper S, Rebbeck T, Maher C, McAuley J, Sterling M. Course and prognostic factors of whiplash: a systematic review and metaanalysis. Pain, in press. doi: /j.pain MAA. Guidelines for the management of whiplash associated disorders. Sydney: Motor Accidents Authority; p. 16. Maitland G, Banks K, English K, Hengeveld E, editors. Maitland s vertebral manipulation. Butterworth Heinemann; Rebbeck T, Sindhausen D, Cameron I. A prospective cohort study of health outcomes following whiplash associated disorders in an Australian population. Injury Prevention 2006;12:86e93. Scholten-Peeters G, Verhagen A, Bekkering G, van der Windt D, Barnsley L, Oostendorp R, et al. Prognostic factors of whiplash associated disorders: a systematic review of prospective cohort studies. Pain 2003;104:303e22. Skyba D, Radhakrishnan R, Rohlwing J. Joint manipulation reduces hyperalgesia by activation of monoamine receptors but not opioid or GABA receptors in the spinal cord. Pain 2003;106:159e68. Sluka K, Lisi T, Westlund K. Increased release of serotonin in the spinal cord during low, but not high, frequency transcutaneous electric nerve stimulation in rats with joint inflammation. Archives of Physical Medicine and Rehabilitation 2006;87:1137e40. Sterling M, Chadwick B. Psychological processes in daily life with chronic whiplash: relations of post-traumatic stress symptoms and fear-of-pain to hourly pain and uptime, submitted for publication. Sterling M, Jull G, Kenardy J. Physical and psychological predictors of outcome following whiplash injury maintain predictive capacity at long term follow-up. Pain 2006;122:102e8. Sterling M, Jull G, Wright A. Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity. Manual Therapy 2001;6:72e81. Sterling M, Treleaven J, Jull G. Responses to a clinical test of mechanical provocation of nerve tissue in whiplash associated disorders. Manual Therapy 2002;7:89e94. Stewart M, Maher C, Refshauge K, Herbert R, Bogduk N, Nicholas M. Randomised controlled trial of exercise for chronic whiplash associated disorders. Pain 2007;128:59e68. Treleaven J. Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control. Manual Therapy 2007;13(3):262e75. Vernon H, Mior S. The neck disability index: a study of reliability and validity. Journal of Manipulative and Physiological Therapeutics 1991;14:409e15. Westaway M, Stratford P, Binkley J. The patient-specific functional scale: validation of its use in persons with neck dysfunction. The Journal of Orthopaedic and Sports Physical Therapy 1998;27: 331e8.

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