Whiplash: The Problem Whiplash latest evidence for rehabilitation and recovery

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1 Whiplash: The Problem Whiplash latest evidence for rehabilitation and recovery Michele Sterling BPhty, MPhty, Grad Dip Manip Physio, FACP, PhD Director NHMRC CRE in Road Traffic Injury Associate Director, CONROD, Griffith University NHMRC Senior Research Fellow Adjunct Professor, CAI, UQ Most common minor RTC injury Up to 50% will not recover; 30% moderate/severe pain/disability (Carroll et al, 2008) Poor mental health outcomes: PTSD, Depression, Generalised Anxiety Disorder (Heron Delaney et al 2012) Greater costs than SCI and TBI from RTC (MAIC, Queensland 2009) Usually within a compensable environment Precipitated by a traumatic event I found your info while I was looking for answers, as you can see I can not sleep even after taking diazepam. I was working at Greenslopes Hospital in the dispensary and March 2014 slipped on wet stairs, hit my elbow but as I was trying to keep my head from hitting the concrete stairs, strained to keep it up I returned to the dispensary and two hours later my neck was stiff so I was sent down to Emergency where I was sent home with Ibuprofen and Panadeine, four days later I could not move my neck, over the course of the next 6 months I suffered, vertigo, tinnitus, nausea & headaches ( still have) and very tight neck pain ( feels like an elastic band requires cutting & still have it), also feels heavy and struggled to do my job as looking down at charts seemed to aggravate it, needless to say I was terminated but I still have no answers even after changing GP's as he told me that I am sensitive and imagining it all. Whiplash likely there is a lesion but usually can t be seen with clinical imaging (Curatolo et al 2011, Spine) Karen, July Michele Sterling CONROD, Griffith University 1

2 Whiplash: Where to Start? What is the recovery pathway like? What processes underlie WAD? Can we predict those who will not recover? Does current treatment work? Can we develop better treatments? CAN we improve health outcomes and. reduce costs? Recovery Pathways Predicted disability trajectories & predicted probability of membership (%). Mild/recovered N=155 Group based trajectory modeling 2 3 months important Sterling, Hendrikz, Kenardy 2010 Pain 150:22-28 Trajectories: PTSD symptoms Trajectories: Dual Analyses Severe Mod/severe 68% are in sync Moderate Resilient Sterling, Hendrikz, Kenardy 2010 Pain 150:22 28 Sterling, Hendrikz, Kenardy 2011, Pain 152(6): Michele Sterling CONROD, Griffith University 2

3 Processes underlying WAD Aetological Processes of WAD Why bother looking? Isn t it just neck pain? Its just a minor injury Movement/motor dysfunction Augmented nociceptive processing Stress related factors Psychosocial Sociocultural Environmental Physical and psychological Nociceptive (pain) processing PTSD symptoms and stress responses Motor/movement deficits Psychological factors Recovery expectations Perceived injustice Pain catastrophising Motor/muscle function Similar patterns of motor dysfunction occur in various neck pain conditions Altered muscle recruitment (Jull et al 2004; Johnston et al 2008) Altered muscle activity with functional tasks (Falla et al 2004, Johnston et al 2008) Kinaesthetic deficits (Field et al 2008, Treleaven et al 2003) Not a consistent predictor of poor recovery Control Chronic Whiplash Altered muscle recruitment patterns, kinaesthetic deficits, eye movement control not predictive of outcome (Sterling 2005,2006; Nederhand et al 2002; Kongsted et al 2008) Deceased range of movement inconsistent predictor (Sterling et al 2005) Fat Elliott et al Michele Sterling CONROD, Griffith University 3

4 N = 44 27% WHIPLASH Elliott, et al., 2011 Different mechanisms seem to underlie different neck pain conditions Sensory features predict poor functional recovery following whiplash injury PPT Cold pain Threshold Change NPQ Chronic WAD; NDI 44(12)% Chronic Idiopathic; NDI 29(16)% Controls Scott, Jull, Sterling 2005 Clin J Pain (21): Elliott et al Clinical Radiology 2008 Chien, Eliav, Sterling 2009 Manual Therapy C5/6, C2/3, Upper limb nerve trunks Tibialis Anterior Control Recovered NDI <8% Milder Treatment pain NDI group 9 29% baselines Moderate to severe pain NDI 30>% Sterling et al (2003) Pain 104: Michele Sterling CONROD, Griffith University 4

5 Stress Related Responses PTSD symptoms predict poor recovery Van Oosterwijck J et al, Europ J Pain % high levels of stress understanding claim 30.4% with claim delays 27% with number medico-legal assessment 26% with amount of compensation Predicted disability: WHODAS (+6.94 pts); HADS (+2.61) Lower QOL WHODAS (-0.73 pts) Stress Related Responses Neurobiological Stress Systems Genetic variants which affect noradrenergic system function ( COMT) predict vulnerability to acute pain and persistent neck pain following MVC Genetic variants that affect glucocorticoid system function (FKBP5) predict chronic pain after MVC How does all this fit together? Borstov et al Neuromolecular Med Mar;16(1):83-93 Mclean et al Journal of Pain 2011; 12 (1): Borstov et al Pain Aug;154(8): Michele Sterling CONROD, Griffith University 5

6 Recall of traumatic event 2x2 Mixed Experimental design Baseline PTSD (n = 33) PTSD higher baseline arousal and negative affect and lower pain threshold. Trauma cue exposure Post exposure Arousal and negative affect Pain threshold Pressure Pain Thresholds Cervical Spine PTSD group lower across time. Further decrease in PTSD group after trauma cue. C2 No PTSD (n = 39) Minimal changes in arousal, affect and pain. Between groups = PTSD, No PTSD Repeated Measures = Baseline and Post Exposure Remote Sites PTSD group lower across time Minimal changes after trauma cue. Thermal Pain Thresholds PTSD group had lower thresholds to cold and heat across time. Significant decrease in cold threshold for PTSD after trauma cue. Minimal change in heat thresholds after trauma cue. Michele Sterling CONROD, Griffith University 6

7 Time (n) PPT (kpa) (Cervical) Median PPT (kpa) (Median N) Median PPT (kpa) (Tib Ant) Median CPT ( C) Median HPT ( C) Median NFR (ma) Media n BPPT ( elb ext ROM) Median Smith, Jull, Schneider, Frizzell, Sterling 2014 Pre RFN (53) 215 [161,327] 270 [210,379] 398 [310,565] 19.6 [11.3,25.3] 42.6 [40.3, 45.0] 14 [10,24] 29 [18,39] Gender (F/M) WAD: Age (yrs +/ SD) WAD: Duration of symptoms Mths (median) [25,75] 43 VAS (+/ SD) (0 100mm) t(1): 58 (19) NDI (+/ SD) (%) t(1): 42 (15) Pre RFN (53) 1 Mnth (53) 240 [168,352] 236 [178,304] 285 [202,387] 307 [242,379] 416 [323,547] 428 [363,549] 20.8 [11.0,24.7] 12.6 [4.9,17.8] 43.5 [41.8, 45.9] 46.7 [43.7, 48.1] 14 [8,26] 18 [10,30] 31 [20,37] 12 [5,20] 36/ (10.9) [30,69] t(2): 55 (19) t(3): 25 (20) t(4): 27 (23) t(2): 43 (16) t(3): 29 (16) t(4): 27 (16) 3 Mnth s (50) 308 [219,380] 348 [270,426] 526 [408,681] 9.7 [3.6,17.0] 46.6 [44.0, 48.4] 17 [10,38] 10 [3,19] Time Period t(1) t(2) t(3) GHQ 28 % 23 64% 62% 40% Scor e 24 [19,3 2] 25 [17,3 7] 17 [12,3 1] PCS % >24 19% 23% 13% Score 15 [9,22] 17 [7,23] 10 [4,17] PDS % met criteria probable PTSD 30% 34% 26% Symptom Score 7 [2,13] 8 [2,14] 5 [0,14] PTSD symptoms Nociceptive processing Movement/motor deficits Other psychological factors WHIPLASH t(4) 34% 19 [12,2 6] 10% 8 [1,15] 16% 6 [2,11] Michele Sterling CONROD, Griffith University 7

8 Can we predict those who don t recover? Most consistent predictors: Initial pain intensity Initial disability levels most have been phase 1 (exploratory) studies Phase 1 study ( ) (Sterling et al, Pain, 2005, 2006) Phase 2 (validation study) (Sterling et al, Pain, 2012, 153: ) Initial disability levels Decreased neck movement Cold hyperalgesia PTSD symptoms Impact of Events Scale Initial pain Initial disability Cold hyperalgesia Neck movement Psychological factors PTSD symptoms Recovery expectations Depression Pain catastrophising Can we predict those who will recover? Clinical Prediction Rule Not well investigated Important Patient assurance Too much treatment may be detrimental treatment iatrogenesis (Cote et al 2007) May need minimal intervention Avoid medicalisation 2 Prospective, longitudinal studies, 12 month NDI values, n=262 Included variables NDI VAS ROM Hyper arousal symptoms (PDS) Cold pain threshold age gender presence of headaches 12 month Recovered 43% (n=110) Mild/Moderate disability 31% (n=83) Chronic disability 26% (n=69) 1. Univariate logistic regression 2. ROC curve analyses 3. Backwards stepwise multiple logistic regression 4. Accuracy statistics Michele Sterling CONROD, Griffith University 8

9 Posttraumatic Stress Diagnostic Scale (PDS) Similar to IES 3 subscales: Intrusive thoughts Avoidance hyper arousal Having trouble falling or staying asleep Feeling irritable or having fits of anger Having trouble concentrating Being overly alert Being jumpy or easily startled : Not at all or only one time 1: once a week or less/ once in a while 2: 2 to 4 times a week / half of the time 3: 5 or more times a week / almost always <35 NDI < Age Predicted: Recovery LOW RISK >35 Hyperarousal <6 Neither recovered nor chronic moderate/severe MEDIUM RISK Ritchie, Sterling et al. Pain (2013): 154: >6 >40 AGE <35 >35 Predicted: Chronic/Moderate severe HIGH RISK NDI NDI Accuracy Statistics >40 <30 Accuracy Statistics Hyperarousal >6 AGE >35 <35 Age Predicted: Recovery LOW RISK Presence of all 3 factors Predicted: Chronic/Moderate severe HIGH RISK Predicted Chronicity Sensitivity Specificity +LR PPV.435 (.31.55).938 (.89.96) 7.02 ( ) 71.4 (55 84) NDI <30 and age <35 Predicted Recovery Sensitivity Specificity +LR PPV.483 (.39.57).832 (.76.88) 2.87 ( ) 70.7 (59 80) Ritchie, Sterling et al. Pain (2013): 154: Michele Sterling CONROD, Griffith University 9

10 Implications Does current treatment work? Predicted: Recovery Medium Risk Predicted: Chronic/Severe?? Minimal treatment: Monitor and Reassess Further assessment: Nociceptive processing Psychological factors Movement/ Motor function Strongest evidence for activity/exercise ~ acute and chronic WAD ~ but effects are modest Ritchie, Hendrikz, Kenardy, Sterling. Pain (2013): 154: To be tested: NHMRC Pathway Grant (MAA, MAIC), GU, Usyd, UQ Insufficient evidence to support any treatment for sub acute WAD Chronic WAD Modest effects at best with rehabilitation (Jull et al 2007, Stewart et al 2007) RFN Acute WAD Interpretation: Provision of active management consultation did not show additional benefit. A package of physiotherapy gave a modest acceleration to early recovery of persisting symptoms but was not cost effective from a UK NHS perspective. Usual consultations in emergency departments and a single physiotherapy advice session for persistent symptoms are recommended. Michele Sterling CONROD, Griffith University 10

11 Management of acute whiplash: A randomized controlled trial of multidisciplinary stratified treatments (1) medication (11) Physiotherapy (111) Psychology Management of acute whiplash: A randomized controlled trial of multidisciplinary stratified treatments Jull, Sterling, Kenardy, Hendrikz, Cohen, 2013, Pain a) NDI <30 Simple Analgesia a) No hyperalgesia MT + Th Ex a) IES >26 CBT b) NDI >30 + Hyperalgesia Opioid Analgesia b) Reduced kinaesthesia Add proprioceptive retaining b) GHQ28 >30 CBT c) NDI >30 + Neuropathic pain Adjuvant agents c) NDI >30 + hyperalgesia Pain management Delayed MT + ThEx Chronic WAD Vs 1 PT session/information booklet 1 PT session and simple advice was equally as effective No significant treatment effect modifiers could be identified Michele Sterling CONROD, Griffith University 11

12 Where do we go from here? Predominantly physical rehabilitation approaches have only modest effects - is this so unexpected? May be effective in some -? who are they People need activity/exercise important!! May need to consider additional interventions that target those at high risk Pain modulation processes Psychological factors eg stress related factors & others Neuro-immune responses Environmental/system & social processes Where do we go from here? Target processes/risk factors: Pain modulation processes Psychological factors eg stress related factors & others Neuro-immune responses Environmental/system & social processes Who should be targeted? Avoid iatrogenesis How will this be done? primary care Do we really understand the condition? Mechanism studies still required How do all the processes fit together Need to further understand identified processes? New yet to be identified processes Will drive intervention research Michele Sterling CONROD, Griffith University 12

13 PTSD symptoms Other psychological factors Cold hyperalgesia PTSD symptoms Pain levels Disability levels Other factors Nociceptive processing WHIPLASH Movement/motor deficits Medications Physical Rehabilitation Psych intervention Whiplash Research Group Dr Carrie Ritchie Dr Leanne McGregor Dr Annick Maujean Dr Ash Pedler Dr Angelo Basteris Dr Dan Harvie Dr Ash Smith Letitia Campbell Joan Carlisle Tania Manning Viv Hughes Viviana Silva Joan Kelly Gail Durbridge Michele Sterling CONROD, Griffith University 13