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1 WHIPLASH and WHIPLASH-ASSOCIATED DISORDERS AN EVIDENCE-BASED APPROACH Nikolai Bogduk Emeritus Professor of Pain Medicine University of Newcastle Australia NO CONFLICTS OF INTEREST
2 WHIPLASH and WHIPLASH-ASSOCIATED DISORDERS EVIDENCE DIAGNOSIS BIOENGINEERING PHYSIOLOGY TREATMENT
3 WHIPLASH There is no injury There is no lesion There is nothing wrong You re making it up more politely It s psychosocial
4 Yoganandan N, Pintar FA, Larson SJ, Sances A (eds). Frontiers in Head and Neck Trauma. Amsterdam: IOS Press, 1998 Yoganandan N, Pintar FA (eds). Frontiers in Whiplash Trauma. Amsterdam: IOS Press. 2000
5 McConnell, WE, Howard, RP, Guzman, HM, Bomar, JB, Raddin, JH, Benedict, JV, Smith, HL, and Hatsell, CP. Analysis of human test subject kinematic responses to low velocity rear end impacts. Proceedings of the 37th Stapp Car Crash Conference, San Antonio, TX, 1993, pp
6 Kaneoka K, Ono K, Inami S, Hayashi K. Motion analysis of cervical vertebrae during whiplash loading. Spine 1999; 24:
7 S-shape compression from below 0 ms 110 ms
8 distraction impaction S-shape
9 iar A B
10 iar A B
11 iar iar A B
12 lesion lesion
13
14 MECHANISM OF INJURY In Cadavers Increased strains Pearson AM, Ivancic PC, Ito S, Panjabi MM. Facet joint kinematics and injury mechanisms during simulated whiplash. Spine 2004; 29: Panjabi MM, Cholewicki J, Nibu K, Grauer J, Vahldiek M. Capsular ligament stretches during in vitro whiplash simulations. J Spinal Dis 1998; 11: Panjabi MM, Pearson AM, Ito S, Ivancic PC, Wang JL. Cervical spine curvature during simulated whiplash. Clin Biomech 2004; 19:1-9. Panjabi MM, Ito S, Pearson AM, Ivancic PC. Injury mechanisms of the cervical intervertebral disc during simulated whiplash. Spine 2004; 29: I
15 MECHANISM OF INJURY In Laboratory Animals Rats whiplash submaximal chronic spinal Goats strain nociception cord and changes hyperalgesia Winkelstein BA. How can animal models inforam on the transition to chronic symptoms in whiplash? Spine 2011; 36:S218-S225.
16 Quinn KP, Winkelstein BA. Cervical facet capsular ligament yield defines the threshold for injury and persistent jointmediated neck pain. J Biomech 2007; 40: Lu Y, Chen C, Kallakuri S, et al. Neural response of cervical facet joint capsule to stretch: a study of whiplash pain mechanism. Stapp Car Crash J 2005; 49: Lu Y, Chen C, Kallakuri S, et al. Development of an in vivo method to investigate biomechanical and neurophysiological properties of spine facet joint capsules. Eur Spine J 2005; 14: Quinn KP, Dong L, Golder FJ, et al. Neuronal hyperexcitability in the dorsal horn after painful facet joint injury. Pain 2010; 151: Kallakuri S, Singh A, Lu Y, et al. Tensile stretching of cervical facet joint capsule and related axonal changes. Eur Spine J 2008; 17: Lee KE, Davis MB, Winkelstein BA. Capsular ligament involvement in the development of mechanical hyperalgesia after facet joint loading: behavioral and inflammatory outcomes in a rodent model of pain. J Neurotrauma 2008; 25: Lee KE and Winkelstein BA. Joint distraction magnitude is associated with different behavioral outcomes and substance P levels for cervical facet joint loading in the rat. J Pain 2009; 10: Dong L, Odeleye AO, Jordan-Sciutto KL, et al. Painful facet joint injury induces neuronal stress activation in the DRG: implications for cellular mechanisms of pain. Neurosci Lett 2008; 443: Dong L and Winkelstein BA. Simulated whiplash modulates expression of the glutamatergic system in the spinal cord suggesting spinal plasticity is associated with painful dynamic cervical facet loading. J Neurotrauma 2010; 27: Winkelstein BA and Santos DG. An intact facet capsular ligament modulates behavioral sensitivity and spinal glial activation produced by cervical facet joint tension. Spine 2008; 33: Lee KE, Davis MB, Mejilla RM, et al. In vivo cervical facet capsule distraction: mechanical implications for whiplash and neck pain. Stapp Car Crash J 2004; 48: Lee KE, Thinnes JH, Gokhin DS, et al. A novel rodent neck pain model of facetmediated behavioral hypersensitivity: implications for persistent pain and whiplash injury. J Neurosci Methods 2004; 137:
17 WHIPLASH Aetiology Pathology
18 WHIPLASH: EVIDENCE ON DIAGNOSIS
19 WHIPLASH MVA Neck Pain Associated Movement Hyperalgesia Fear ψ distress
20 WHIPLASH MVA Neck Pain Associated =Ψ Movement Hyperalgesia Fear ψ distress
21 WHIPLASH MVA Neck Pain Associated Movement Hyperalgesia Fear ψ distress
22 WHIPLASH: EVIDENCE ON TREATMENT
23 Teasell RW, McClure JA, Walton D, Pretty J, Salter K, Meyer M, Sequeira K, Death B. A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): Part 2 interventions for acute WAD. Pain Res Manag 2010; 15: A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): Part 3 interventions for subacute WAD. Pain Res Manag 2010 Sep-Oct; 15(5): A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): Part 4 noninvasive interventions for chronic WAD. Pain Res Manag 2010 Sep-Oct; 15(5): A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): Part 5 surgical and injection-based interventions for chronic WAD. Pain Res Manag 2010 Sep-Oct; 15(5):
24 ACUTE SUBACUTE CHRONIC Drugs Education conflicting Exercise reduced pain counterproductive short relief no change recovery Interdisciplinary conflicting Mobilisation? = act as usual Manipulation?0 (short FU) 0 Laser acupuncture = placebo Botox = placebo conflicting Intra-articular steroids = LA
25 Radanov BP, Sturzenegger M, Di Stefano G (1995). Long-term outcome after whiplash injury: a 2- year follow-up considering features of injury mechanism and somatic, radiologic, and psychosocial findings. Medicine 74: Whiplash recovery curve Patients disabled with pain Time
26 Whiplash recovery curve Patients disabled with pain Time
27 Whiplash recovery curve Patients disabled with pain 2-3 months Time
28 Whiplash recovery curve Patients disabled with pain recover essentially regardless of treatment reassurance activation exercises Time
29 Whiplash recovery curve Patients disabled with pain Time
30 distinguishing features? Time
31 greater pain disability cold hyperalgesia hyperalgesia remote distress distinguishing features? Time
32 Whiplash recovery curve Patients disabled with pain do not recover even after tailored conservative care Time Jull G, Kenardy J, Hendrikz J, Cohen M, Sterling M. Management of acute whiplash: a randomized controlled trial of multidisciplinary stratified treatments. Pain 2013; 154:
33 WHIPLASH MVA Neck Pain Associated =Ψ Movement Hyperalgesia Fear ψ distress
34
35 WHIPLASH: EVIDENCE ON DIAGNOSIS
36 ZYGAPOPHYSIAL JOINT PAIN AFTER WHIPLASH
37 Cervical Medial Branch Blocks
38 CERVICAL ZYGAPOPHYSIAL JOINT PAIN DISTRIBUTION Cooper G, Bailey B, Bogduk N. Cervical zygapophysial joint pain maps. Pain Medicine 2007; 8:
39 C2-3 C2-3 C C2-3 C4-5 1 C2-3 C2-3 C5-6 C3-4 C C2-3 C5-6 C6-7 C3-4 C3-4 C4-5 C3-4 C5-6 C6-7 C4-5 C4-5 C5-6 C5-6 C5-6 C6-7 C
40 C2-3 C2-3 C C2-3 C4-5 1 C2-3 C2-3 C5-6 C3-4 C C2-3 C5-6 C6-7 C3-4 C3-4 C4-5 C3-4 C5-6 C6-7 C4-5 C4-5 C5-6 C5-6 C5-6 C6-7 C
41 whiplash 1 whiplash 2 pain clinic 3 pain clinic 4 pain clinic PREVALENCE (%) 1. Barnsley L, Lord SM, Wallis BJ, Bogduk N. The prevalence of chronic cervical zygapophysial joint pain after whiplash. Spine 1995; 20: Lord S, Barnsley L, Wallis BJ, Bogduk N. Chronic cervical zygapophysial joint pain after whiplash: a placebo-controlled prevalence study. Spine 1996; 21: Speldewinde GC, Bashford GM, Davidson IR. Diagnostic cervical zygapophysial joint blocks for chronic cervical pain. Med J Aust 2001; 174: Manchikanti L, Singh V, Rivera J, Pampati V. Prevalence of cervical facet joint pain in chronic neck pain. Pain Physician 2002; 5: Yin W, Bogduk N. The nature of neck pain in a private pain clinic in the United States. Pain Med 2008; 9:
42 CERVICAL MEDIAL BRANCH RADIOFREQUENCY NEUROTOMY
43 PLACEBO CONTROLLED TRIAL OUTCOME CRITERIA: COMPLETE RELIEF OF PAIN, FULL RESTORATION OF ADLS, NO NEED FOR OTHER TREATMENT Lord SM, Barnsley L, Wallis B, McDonald GM, Bogduk N. Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal joint pain. N Eng J Med 1996;335:
44 Active RF Sham RF Days
45 Active RF Sham RF Days
46 Active RF Sham RF Days
47 LONG-TERM FOLLOW-UP OUTCOME CRITERIA: COMPLETE RELIEF OF PAIN, FULL RESTORATION OF ADLS, NO NEED FOR OTHER TREATMENT Lord SM, McDonald GJ, Bogduk N. Percutaneous radiofrequency neurotomy of the cervical medial branches: a validated treatment for cervical zygapophyseal joint pain. Neurosurgery Quarterly 1998;8: McDonald GJ, Lord SM, Bogduk N. Long term follow-up of patients treated with cervical radiofrequency neurotomy for chronic neck pain. Neurosurgery 1999;45:61-68.
48 Duration of complete relief years
49 Duration of complete relief years
50 LONG-TERM FOLLOW-UP Govind J, King W, Bailey B, Bogduk N. Radiofrequency neurotomy for the treatment of third occipital headache. J Neurol Neurosurg Psychiat 2003; 74: patients with Third Occipital Headache Complete relief: 88% median duration: 297 days ++
51 days
52 RECENT STUDIES Macivar J, Borowczyk J, MacVicar A, Loughnan B, Bogduk N. Cervical medial branch radiofrequency neurotomy in New Zealand. Pain Med 2012; 13: Practice A Practice B Treated Complete relief of pain (VAS = 0) Restoration of all ADLs 74% 61% No need for other health care Return To work
53 PRACTICE A Complete relief of pain (VAS = 0) Restoration of all ADLs No need for other health care Return to work From first RFN: Median = 15 m (IQR = m) From all RFNs: Median = 13 m (IQR = 9 26 m) Otherwise, Or 575 months, for a cost of 35 RFNs 16 months per RFN months
54 PRACTICE B Complete relief of pain (VAS = 0) Restoration of all ADLs No need for other health care Return to work From first RFN: Median = 15 m (IQR = m) From all RFNs: Median = 13 m (IQR = m) Otherwise, or 1,067 months, for a cost of 66 RFNs 16 months per RFN months
55 Associated features Ψ distress Eliminated by relief of pain by RFN Wallis BJ, Lord SM, Bogduk N. Resolution of psychological distress of whiplash patients following treatment by radiofrequency neurotomy: a randomised, double-blind, placebocontrolled trial. Pain 1997; 73: Smith AD, Jull G, Schneider G, Frizzell B, Hooper RA, Dunne-Proctor R, Sterling M. Cervical radiofrequency neurotomy reduces psychological features in individuals with chronic whiplash symptoms. Pain Physician 2014; 17:
56 Associated features Ψ distress Eliminated by relief of pain by RFN hyperalgesia Reduced or eliminated by RFN Smith AD, Jull G, Schneider G, Frizzell B, Hooper RA, Sterling M. Cervical radiofrequency neurotomy reduces central hyperexcitability and improves neck movement in individuals with chronic whiplash. Pain Med 2014; 15:
57 WHIPLASH MVA Neck Pain Associated =Ψ Movement Hyperalgesia Fear ψ distress
58 WHIPLASH MVA Neck Pain Associated =Ψ Movement Hyperalgesia Fear ψ distress
59 WHIPLASH MVA Neck Pain Associated Movement Hyperalgesia Fear ψ distress
60 WHIPLASH RELIEVE Neck Pain Associated Movement Hyperalgesia Fear ψ distress
61 WHIPLASH RELIEVE Neck Pain Associated RELIEVE Movement Hyperalgesia Fear ψ distress
62 CONVERGENT VALIDITY BASIC SCIENCES Occult injuries at post mortem CZJ Mechanism of injury demonstrated in normal volunteers, and in cadavers Pain in patients relieved by blocks. Prevalence = 50% + Relieved by RFN Long term The ONLY treatment able and proven to be able to provide COMPLETE relief of neck pain CLINICAL SCIENCES
63 No other cause of neck pain has been so comprehensively studied. For no other cause of chronic neck pain is the mechanism known has the pathophysiology been demonstrated has the prevalence been established is there a treatment that relieves pain completely restores function obviates other health care
64 Towards optimal management Patients disabled with pain recover essentially regardless of treatment reassurance activation exercises Time
65 Towards optimal management Early referral for cervical MBBs Patients disabled with pain Early treatment with MB RF neurotomy Performed according to ISIS standards * Time * Bogduk N (ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures, 2 nd edn. International Spine Intervention Society, San Francisco, 2013.
66 READING Bogduk N. On cervical zygapophysial joint pain after whiplash. Spine 2011; 36:S194-S199.
On Cervical Zygapophysial Joint Pain After Whiplash. Spine December 1, 2011; Volume 36, Number 25S, pp S194 S199
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