Management Strategies for Whiplash Disorders

Hi everybody welcome to this workshop or lecture on integrated model of management for whiplash associated disorders. So what we're going to cover in this lecture is revisit some of the work you've already covered in 3401 AHS which is your musc physio 2 course where you already had an introduction to whiplash associated disorders. So we'll look review the pathophysiology look at the clinical presentations and the range of presentations in people presenting following a whiplash injury. Consider the prognostic indicators, especially with respect to the establishment of some really good quality clinical guidelines now, and then create a stratified management plan that's individualised to the patient. And we are also then specifically going to look at a treatment approach which is called stress inoculation training, and it's an evidence-based approach that's been used particularly for people following a whiplash injury. So as we know whiplash is a mechanism of injury to the neck and it involves an acceleration deceleration force and transfer of energy to the cervical spine. Now whiplash is most commonly associated with car accidents but it can happen in other industries or other sports and activities as well. So can you think of other other type of activities where people might sustain a whiplash type injury based on this definition some of the things you might come up with? football motor racing motor racing is a really classic one because of the acceleration deceleration forces of the car to the point where they've they've constructed special um helmets that lock into a brace at the back of the of the seat or on the back of their body and to stop that uh force from occurring or taking place at the neck high high velocity sports so snow skiing um snowboarding um things like roller coaster rides bumper cars, a whole range of things, even other type of sports. So falling off a bike, so cycling injuries is another common one. What do you think though is the difference between a car accident related whiplash and a whiplash sustained playing sport or doing something enjoyable like skiing? Can you think of what the other factors, the surrounding factors that are situationally related, I guess? and how they might change somebody's response to that whiplash type injury. Because typically, the mechanism may be very similar, but the prognosis is often very different between people sustaining a whiplash injury driving a car and people who sustain a whiplash injury playing sport, you know, something that's fun and interactive. They are common, of course, and not only do they result in neck pain, but they also result in a cascade of other types of symptoms including headache that's probably the most common radiating back pain arm pain so so more widely distributed pain pain involving the jaw neurological symptoms dizziness is another common feature and then you can see there there's some other more vague type of symptoms such as visual or auditory disturbances fatigue thinking or cognitive difficulties post-traumatic stress is often a sequelae of a car accident related whiplash and as is anxiety and depression. So it can become with a quite a complex presentation. Now quite a while ago now, we're talking 1995, the Quebec Task Force came up with a classification for whiplash and you can see it there on the screen that the classification goes from grade one right through to grade four. Now grade one is basically you know fit and well, no physical signs of dysfunction, no complaints of pain. Grade four at the other end includes a fracture or dislocation, so significant trauma and that's based on radiographic studies, so imaging is important for grade four. And then you've got grades one, two and three and you can see in there there's varying degrees of signs of like symptoms that are local, musculoskeletal in nature or neurological signs and symptoms. So when you start getting neurological signs and symptoms in addition to pain, that may or may not be radiating down the arm and local neck related musculoskeletal signs and symptoms then that's a grade three obviously so this classification system even though it was developed in 1995 is still being used today there are challenges with it and the main challenge is that while this is grading based on presenting signs and symptoms and some biomedical classifications such as the fractures it doesn't adequately adequately help us predict prognosis so broadly speaking grade fours obviously are have higher trauma and potentially do worse or take longer to get better and grade zero you would expect they should make a full complete recovery with no you know no long-term side effects but the grades one to three um it's completely unpredictable based on this classification as to who will do well and who won't do well long term so there's more to this presentation we can't just use the presenting signs and symptoms in this classification system to really um understand prognosis and therefore direct our treatment. So what do we do to pick up those grade four wads? OK, because that's kind of our red flag, right, group, that we need to make sure we can identify those who do need imaging. Imaging for everyone is a waste of money. We know from the other work we've been doing in integrated case management that imaging itself can have some negative consequences for patients in terms of the reporting and what that does to the individual's, I guess, belief system and belief structure about how serious their injury is. So. We don't image everybody, but we do need to make sure we pick up those who do need imaging when it's indicated. So I think you've already covered the Canadian cervical spine rule before as well in 3401. But this is obviously to screen for cervical fractures and indicate those who need to go be referred for imaging. So it is for patients who are alert. OK, if they are unconscious, then this doesn't apply. We need to have an alert patient who can follow instructions. OK. So the first one is are they aged over 65 or has there been a dangerous mechanism of injury or are there paresthesia in extremities? So if there are any neurological signs in the extremities if they're aged over 65 they go for radiography all right or imaging. Dangerous mechanism if you look down the bottom it tells you that so fall from an elevation like five stairs, axial loading so diving a diving injury where you hit your head onto something. a car accident greater than 100 kilometers per hour or something that involves a rollover or being thrown out of the car other motorized recreational vehicles such as jet skis they're another one that or a motorbike accident right where you get um thrown because you're not restrained or bicycle crash same thing all right so if the yes to any of those dangerous mechanisms they should get an x-ray or imaging done so then if the answer is no go to the next one any low risk factors that allow for safe assessment of range of motion. So if it's a simple car accident, if they're able to sit up, if they are ambulatory, or if there was delayed onset of neck pain or absence of pain or tenderness right centrally over the cervical spine. So if those don't apply, if there's none of those low risk factors, they should go for imaging. If they are, then look at neck range of motion, 45, minimum 45 degrees left and right. If they can't do that, they should go for imaging. If they can, they don't need imaging. Okay, so it's basically just a stepwise process. Oops, going back. All right, let's not forget, I'm going to put this in here, the neurological screening examination. You know how to do this. It's routine, but it is important to consider with people who present with a whiplash and, of course, any referral of pins and needles, numbness, anything like that, even referred pain below the level of the shoulder. So we're obviously considering sensory motor deficits, reduced reflexes. and then observing for anything else so antalgic postures are postures where they might be trying to hold their arm or or adjust their neck um to to reduce pain um and then there's some other tests that they that you can do with shoulder abduction and resting the arm and abduction relieves pain because it reduces the length over which those peripheral nerves are traveling down the arms or they have their arm in their pocket um these are here to remind us that oftentimes these patients present you'll be the first contact practitioner and and so you need to be sure of the classification so that you know you're safe to examine them and that there's nothing that might be a potential red flag but no need to refer directly or immediately to imaging just because they have radicular pain okay especially if it's in the absence of any neurological symptoms okay meaning pins and needles or numbers so this is a bit of a mind map on the complexity of contributing factors um and the pathophysiology related to whiplash associated disorders and you can see all the arrows are in multiple directions and they all are interconnected so there's a number of different factors there that we should be considering especially when it comes to our assessment of patients who've presented following a whiplash injury that that muscle tone and muscle reactivity may be present okay so they might be sore to touch they might be hypertonic so actively contracting and there's a whole area of dysfunctions that then follow on from that that can impair their their ability to feel their head position and neck position in space so they have poor control poor posture they lose their scapulothoracic control um then their neuromotor control of their head on their neck they then develop weakness in those deep stabilizing or supportive muscles that has a flow-on effect to the joint um the the joint sensory awareness um proprioception and you might end up with pain and dysfunction in the joints as well. pain processing mechanisms can change and they can have that neural tissue sensitivity as well. So we've got to think about all of those characteristics when someone presents, especially with that acute type presentation following an injury. Underneath in the pink are the other factors that are contributing to this person's presentation that we also need to take into consideration. Obviously the personal psychological factors and the environmental factors that we've talked about with a number of different case studies over this trimester. So this is another way to look at it and this comes this model comes straight from the Walton and Elliot paper which is one of the references that we've suggested that you read this week okay for this this particular topic. So it looks quite complex but if we break it down this is what they are essentially proposing that pain and injury associated with a whiplash is likely initiated by local tissue damage be it bony or soft tissue right so that there is some traumatic event that initiates um local nociceptive response okay um and that might result in inflammation local tissue injury but it also results in some level of psychological distress right that's associated with any injury but it's particularly prevalent in car accidents and especially where it's not someone's fault right somebody does this to them is often the way they feel right that they are a victim Now Walton and Elliot talk about some pre-existing states that might influence the results following an injury and they sort of put people into these two systems of vulnerabilities and then protective systems and that these vulnerabilities and protections relate to their pre-existing tissue health, their psychological state, some genetic factors and obviously the contextual factors as well. So if someone undergoes or experiences a car accident, local tissue damage, injury to the neck, but their pre-existing state is relatively in a protection mode so they're strong fit healthy psychologically well they don't have those genetic you know risk factors and that the context is not is not too traumatizing for them then they may well go down this right hand side of this pathway which is that they have transient pain and dysfunction but they adapt well psychologically and physiologically they they're resilient they don't have fear and they recover as per any acute injury like a sprained ankle. Then there's this other side of the equation. So people who are potentially more vulnerable prior to the accident, they may have comorbidities that mean that they've got a level of systemic inflammation or they might be weak, generally globally weak, not fit, not strong. They might be older, they might have some other health related issues. Psychologically they may not be particularly resilient, all those factors might come into play. and then following this injury which may or may not involve nerve damage as well so involvement of the nervous system peripheral or central then this whole cycle of of pain of the secondary consequences around sensory motor dysfunction and the psychosocial factors that then start to feed into this the psychological disturbances depression anxiety post-traumatic stress and they just end up in this this cycle of pain and then a maladaptive response to that pain. And then on the side there you can see disturbed sleep feeds into this even more because we know sleep is so important to recovery. So it's this stress response that is so common in people who experience a whiplash. This is the part that we need to really be able to pick up and identify in the early stages following an acute whiplash. so that we manage these people well because if we don't manage them effectively they are likely to end up with a really poor prognosis so here we've got an example of a case study and this is um a patient who is a 32 year old woman she is five weeks post motor vehicle accident so it's not quite in that acute phase it's in that sub-acute phase that she's presented here to us Now I'm not going to talk through all of this detail. What I want you to do is pause the recording and have a read through quickly that subjective history for this patient. Once you've had a look at that, I want you to think about how you would answer this question. Are there any indications of local tissue damage? Okay, in her presentation, what do you think? Any signs of mechanical or nociceptive type pain mechanisms? So what your answer should have been, oh, there we go, her name's Hetty. What you should have said was, yes, there are some signs. First, there was a mechanism of injury, so she was involved in a car accident. Secondly, her shoulder pain or that pain that radiates over the top of her shoulder there seems to be worse with prolonged use of the left arm. OK, so there is a mechanical pattern to it and it feels better when it's rested or unloaded. So, yeah, there may be some signs of local tissue pathology there. all right pause again have a quick read through the objective examination now answer this question what grade would you put what classification based on the quebec system what classification would you put um hetty at so what you should have said was grade two there is evidence of musculoskeletal dysfunction okay but there's no signs of neurological impairment no pins and needles or numbness no power loss and things like that pure all right so part of Hedy's presentation especially in that subjective history you would have seen some outcome measures there was an NDI on which she scored 52 percent there was another one called the IES that we'll look at where she scored 50 percent or 50 sorry if you score a 50. so the NDI is the neck disability index which you can see here on the screen so there are 10 questions and they each have a leichhardt scale that is scored zero to five and it gives a total score out of 100. by a percentage, 100%. So you convert the score to a percentage. Now this is a validated, reliable tool. This is something the neck disability index is an important tool to use if you do see patients with a whiplash type injury, because we can use this to help inform prognosis. So Hetty achieved a score of 52%. Now, what we do know about the NDI based on a volume of research is that an NDI score of 30% or higher is indicative of moderate to severe levels of pain related disability right it's about disability this one okay there is pain intensity is one factor but most of it is talking about disability so 30 or higher a score of 52 percent puts her obviously in that moderate to high um levels of disability a score an NDI score of 10 or less indicates full recovery the ies so hetty scored 50. now this is the ies it's an impact of events scale and so this is a scale it's a psychological questionnaire it was developed by um by psychologists and there are three sub scales to this questionnaire an intrusion an avoidance and a hyper arousal subscale and again on the bottom right hand side you can see which questions relate specifically to each domain so sorry i'll go back these ones that are highlighted here are directly related to the hyper arousal sub-scale and the reason why i'm pointing these out is because these are the types of questions that informed the development of a prediction tool that we can use for people presenting with whiplash okay so the hyper arousal score seems to be quite predictive of poor prognosis so it is used for the whip predict clinical prediction tool so with this hyper arousal oh sorry with this impact of events scale Again, it's a Leichhardt scale and each item is scored 0, 1, 2, 3, 4. So 0 to 4, there are 22 questions. So the maximum score is 88. The higher the score, the worse the impact is of these events. And so Hedy scored 50. And that basically is a high impact. The psychologist suggests that a score over 25 indicates significant impact and that the patient may need to be referred for counselling. to a psychologist so in the three scales we talked about intrusion is about intrusive thoughts so people having nightmares um intrusive feelings um reliving the experience over and over again this the avoidance subscale is um about avoiding a response to their feelings um feeling numb um avoiding situations and not thinking about ideas uh that are related to the event and then the hyper arousal subscale is about is more about a measurement of their anger or their irritability their hyper vigilance a heightened startle so that that kind of increased anxiety stress kind of response and as i said the hyper arousal is the score that's most closely linked to poor prognosis and it's been used to inform this whip predict clinical prediction rule so you can see the questions there so do you feel irritable or are you prone to getting angry easily do you have difficulty falling or staying asleep difficulty concentrating over are you overly alert and are you jumpy or easily startled so they're not exactly the same as the hyper arousal or the impact of events the girl but they came from there so the patient again scores zero to four um and then there's a a calculation that's done which you can see below and then this is how we apply it so we've got two scores we've got the whip predict we've um sorry we've got the hyper arousal score from the whip predict and we've got the neck disability index now immediately if someone is over the age of 35, they immediately fall into the medium or high risk group. If they're young, they fall into the low risk. Now if their neck disability index is over 40 percent, okay, then they start to fall down into that towards that high risk. Neck disability index between 33 and 39 percent, so remember if it's over 30 percent they're about, so if they're at risk of a poor prognosis, so neck disability index of 33 to 39, they go to medium risk. 40 percent over the age of 35, they then look at the hyper arousal score. If that is greater than six then they're in the high risk if it's less than six they go to medium risk okay so we can work through this with predict tool to try and help stratify patients um and and that helps inform our management because how we manage low risk versus medium and high risk are quite different all right so that's the whip predict tool now there is another tool called the erebro short form and this is also a validated tool it's widely used and you can use this to help inform prognosis and management as well. So with this Aribro tool, this one has again, you can see here we've got 10 questions this time and they're on a numerical rating scale from 0 to 10. So your score is what goes into the grey box on the right-hand side. There are three questions where the score is flipped and so you can see there it says 10 minus X. So you get your score, you subtract that score from 10 and that's the score you write. in the box. So this gives you a sum total, a maximum of 100 with this score. And with the Aribro, a score greater than 50 out of 100 can put someone in that high risk subgroup. So high risk of poor outcomes. When would you do WIP predict over the Aribro? Sometimes it's a matter of choice. It might be the clinic where you're working and which one they use. They're both considered equally valid. The Aribro is a little bit more generic and it might be better used in people who have multiple areas of pain. The WIP predict tends to focus more on neck related symptoms, whereas the Aribro talks generally about pain, not location. So you might find Aribro better if you've got someone who's got multiple areas of pain. Here's something to think about. How do you communicate the outcome of these prognostic risk tools to your patient? How do we sit down and have this conversation? We apply these tools to somebody who presents to us in clinic. What are you going to say to them? Oh, you're at low risk. You're at really high risk of a poor prognosis. That doesn't sound good, does it? What are you going to say to your patients? How do we manage patients based on this risk stratification? Because that's what it's about, that we use that tool to help inform our clinical pathway, our clinical management. Now, there is a website called My Whiplash Navigator. There are links there for clinicians and links for patients as well. And it's really, really helpful. So there are things on there that will help you with that communication style and what you could or couldn't say to patients. or should or shouldn't say to patients. All right, so I'm going to leave that there and we're going to come back now to Hetty, our 32 year old. So based on her history, her scores, her age and some of those other factors you can see in a physical exam, what do you think now are the good prognostic factors and what do you think are maybe some not so good or some poorer prognostic factors that are relevant to Hetty? pause and have a think about that some of the things you might have come up with Hedy seems to have some good social support around her she's motivated to get back to work maybe she wasn't quite so severe at baseline she can't really recall she did sort of say at some point of pain six out of ten but she's five weeks post injury so that's that's a bit of an unknown there she doesn't seem to have any sensory impairments such as cold hyperalgesia or anything like that On the not so good side, she's got a high NDI, higher than 30% puts her in that high risk subgroup. Her expectation of recovery. So when she was asked, do you expect to recover? She basically on a scale from zero to 10 went five out of 10. So to me, that says it's a bit of a coin toss, 50-50. Maybe I will, maybe I won't. That's not necessarily that good. And her impact of event scale was quite high. Now we don't know what subscale was particularly high, but her overall level. impact event scale suggests that she might need some psychological support. And she certainly does seem to have some psychological distress. She's irritable, frustrated, angry. She expresses fear of driving and she's got night pain. And the other poor prognostic factor is that she's tipping into that chronic state, right? She's at five weeks and it doesn't seem to be getting any better. So what are we going to do? There is this. A draft, you can see the reference down the bottom, a draft Australian clinical guidelines for health professionals managing people with whiplash associated disorders. Now, this is an updated version. The third edition was published in 2014, and this is now the most recent updated version. It has changed a bit from the 2014 version. It's currently in draft form because it's out for consultation and they are looking for feedback, but it's not likely to change a great deal from the draft to the final version. But you'll see the final version come out probably in not. you know before the end of this year The nice thing about these guidelines, they are really comprehensive. They use an expert panel, but they also synthesise all of the evidence from the literature. So the recommendations are really robust. And they don't just say, yes, this is great, no, that's bad. There is some middle ground as well, where they say, well, we can't really recommend for or against because the evidence is not strong enough. So it doesn't mean you throw that out. It just means that, you know, we're not too sure. And it may be that it's not for everybody, right? Now this is broadly speaking treatment recommendations regardless of stratification. So we've talked about people being subgrouped into mild, moderate, severe, right? Broadly speaking, one of the key take-home messages is that if people are subgrouped into that mild group, less is more. Meaning, don't put your hands on those patients. Less treatment, the sooner they get out and they are reassured and they have the confidence that they will recover, the better they will do what they're seeing. is that physios and other professionals start treating these patients, start treating everybody who presents with a whiplash. And as soon as we start putting our hands on people, these ones in particular, they tend to do worse. So if you see a patient and they fall into that low risk subgroup, the recommended treatment is minimal, minimal hands on. Reassure them to stay active. Give them education about what's happened, what the pathology is, but what that predicted healing pathway should look like. encourage them to return to usual activities. Now you can give them some exercises, you know, to improve range of motion, low load exercises that might involve isometric control, postural endurance, and maybe some strengthening exercises. But you don't need to do any of the other stuff, right, that's listed on that table. Maybe some simple analgesics if they're indicated, if they're required to help them sleep or something like that. But reassurance and education and getting them back to normal life is paramount. the if they fall into the medium or the high-risk subgroup then the other um the other treatment recommendations there come into play so if your patients have reporting dizziness related symptoms then you might give them specific exercises to help with their just their dizziness psychologically informed exercise and trauma-based cognitive behavioral therapy and multi-disciplinary care become important for those medium and high risk subgroups but more so that the CBT and the multidisciplinary care, the evidence around them is really for those people who are already presenting with chronic pain. So over that six weeks to three months type pain scenario. But the exercise and the simple analgesics and possibly non-steroidals if basic paracetamol isn't enough, there is evidence that they help in that acute phase. Under the not routinely recommended section, this is not. these are not to say you don't do these ones these are more to say for certain patients for certain subgroups you might choose to do these none of these should be given to people who fall into that low risk subgroup that's really important to know all right but you might for the medium and high risk include some manual therapy and and that kind of falls under this multimodal type of treatment approach most of the evidence there is for the chronic whiplash not the acute don't stick hands on the acute ones maybe a soft collar if it's indicated, especially if they're in that higher risk, medium or high risk, and they've got significant trauma. Antidepressants and pregabalin. Okay, so they're kind of more around that neuropathic kind of pain medication for some people in that medium to high risk. Massage, again, they say neither here nor there for it. There's no evidence for or against. Again, not for everybody. Pick your patient. Thoracic manipulation is something that there is some evidence for, but not everybody. Same with acupuncture. and surgical treatment possibly if you've got somebody who's got myelopathy or radiculopathy sensory impairment neurological signs and symptoms that are unremitting and unchanging or worsening then obviously you know surgery might be an option then in the right hand side you can see treatments that are not recommended stay away from these cervical spine manipulation and meaning the classic high velocity low amplitude amplitude thrust do not manipulate the cervical spine acute or chronic opioids not indicated. Electrotherapy, trigger point needling or dry needling to trigger points, muscle relaxants, botulism toxin type A injections into muscles, corticosteroid injections either into the facet joints or intravenously, spinal manipulation for chronic, not at all, and radio frequency neurotomies, not indicated. They're often something that the surgeons or the pain specialists will recommend. The evidence does not support their use. We'll take a break here and then what we're going to talk about is some of the other treatment specific options around stress inoculation.

So as we know whiplash is a mechanism of injury to the neck and it involves an acceleration deceleration force and transfer of energy to the cervical spine. Now whiplash is most commonly associated with car accidents but it can happen in other industries or other sports and activities as well. So can you think of other other type of activities where people might sustain a whiplash type injury based on this definition some of the things you might come up with? football motor racing motor racing is a really classic one because of the acceleration deceleration forces of the car to the point where they've they've constructed special um helmets that lock into a brace at the back of the of the seat or on the back of their body and to stop that uh force from occurring or taking place at the neck high high velocity sports so snow skiing um snowboarding um things like roller coaster rides bumper cars, a whole range of things, even other type of sports.

So falling off a bike, so cycling injuries is another common one. What do you think though is the difference between a car accident related whiplash and a whiplash sustained playing sport or doing something enjoyable like skiing? Can you think of what the other factors, the surrounding factors that are situationally related, I guess? and how they might change somebody's response to that whiplash type injury. Because typically, the mechanism may be very similar, but the prognosis is often very different between people sustaining a whiplash injury driving a car and people who sustain a whiplash injury playing sport, you know, something that's fun and interactive.

They are common, of course, and not only do they result in neck pain, but they also result in a cascade of other types of symptoms including headache that's probably the most common radiating back pain arm pain so so more widely distributed pain pain involving the jaw neurological symptoms dizziness is another common feature and then you can see there there's some other more vague type of symptoms such as visual or auditory disturbances fatigue thinking or cognitive difficulties post-traumatic stress is often a sequelae of a car accident related whiplash and as is anxiety and depression. So it can become with a quite a complex presentation. Now quite a while ago now, we're talking 1995, the Quebec Task Force came up with a classification for whiplash and you can see it there on the screen that the classification goes from grade one right through to grade four. Now grade one is basically you know fit and well, no physical signs of dysfunction, no complaints of pain.

Grade four at the other end includes a fracture or dislocation, so significant trauma and that's based on radiographic studies, so imaging is important for grade four. And then you've got grades one, two and three and you can see in there there's varying degrees of signs of like symptoms that are local, musculoskeletal in nature or neurological signs and symptoms. So when you start getting neurological signs and symptoms in addition to pain, that may or may not be radiating down the arm and local neck related musculoskeletal signs and symptoms then that's a grade three obviously so this classification system even though it was developed in 1995 is still being used today there are challenges with it and the main challenge is that while this is grading based on presenting signs and symptoms and some biomedical classifications such as the fractures it doesn't adequately adequately help us predict prognosis so broadly speaking grade fours obviously are have higher trauma and potentially do worse or take longer to get better and grade zero you would expect they should make a full complete recovery with no you know no long-term side effects but the grades one to three um it's completely unpredictable based on this classification as to who will do well and who won't do well long term so there's more to this presentation we can't just use the presenting signs and symptoms in this classification system to really um understand prognosis and therefore direct our treatment. So what do we do to pick up those grade four wads?

OK, because that's kind of our red flag, right, group, that we need to make sure we can identify those who do need imaging. Imaging for everyone is a waste of money. We know from the other work we've been doing in integrated case management that imaging itself can have some negative consequences for patients in terms of the reporting and what that does to the individual's, I guess, belief system and belief structure about how serious their injury is. So.

We don't image everybody, but we do need to make sure we pick up those who do need imaging when it's indicated. So I think you've already covered the Canadian cervical spine rule before as well in 3401. But this is obviously to screen for cervical fractures and indicate those who need to go be referred for imaging. So it is for patients who are alert.

OK, if they are unconscious, then this doesn't apply. We need to have an alert patient who can follow instructions. OK.

So the first one is are they aged over 65 or has there been a dangerous mechanism of injury or are there paresthesia in extremities? So if there are any neurological signs in the extremities if they're aged over 65 they go for radiography all right or imaging. Dangerous mechanism if you look down the bottom it tells you that so fall from an elevation like five stairs, axial loading so diving a diving injury where you hit your head onto something.

a car accident greater than 100 kilometers per hour or something that involves a rollover or being thrown out of the car other motorized recreational vehicles such as jet skis they're another one that or a motorbike accident right where you get um thrown because you're not restrained or bicycle crash same thing all right so if the yes to any of those dangerous mechanisms they should get an x-ray or imaging done so then if the answer is no go to the next one any low risk factors that allow for safe assessment of range of motion. So if it's a simple car accident, if they're able to sit up, if they are ambulatory, or if there was delayed onset of neck pain or absence of pain or tenderness right centrally over the cervical spine. So if those don't apply, if there's none of those low risk factors, they should go for imaging.

If they are, then look at neck range of motion, 45, minimum 45 degrees left and right. If they can't do that, they should go for imaging. If they can, they don't need imaging. Okay, so it's basically just a stepwise process.

Oops, going back. All right, let's not forget, I'm going to put this in here, the neurological screening examination. You know how to do this.

It's routine, but it is important to consider with people who present with a whiplash and, of course, any referral of pins and needles, numbness, anything like that, even referred pain below the level of the shoulder. So we're obviously considering sensory motor deficits, reduced reflexes. and then observing for anything else so antalgic postures are postures where they might be trying to hold their arm or or adjust their neck um to to reduce pain um and then there's some other tests that they that you can do with shoulder abduction and resting the arm and abduction relieves pain because it reduces the length over which those peripheral nerves are traveling down the arms or they have their arm in their pocket um these are here to remind us that oftentimes these patients present you'll be the first contact practitioner and and so you need to be sure of the classification so that you know you're safe to examine them and that there's nothing that might be a potential red flag but no need to refer directly or immediately to imaging just because they have radicular pain okay especially if it's in the absence of any neurological symptoms okay meaning pins and needles or numbers so this is a bit of a mind map on the complexity of contributing factors um and the pathophysiology related to whiplash associated disorders and you can see all the arrows are in multiple directions and they all are interconnected so there's a number of different factors there that we should be considering especially when it comes to our assessment of patients who've presented following a whiplash injury that that muscle tone and muscle reactivity may be present okay so they might be sore to touch they might be hypertonic so actively contracting and there's a whole area of dysfunctions that then follow on from that that can impair their their ability to feel their head position and neck position in space so they have poor control poor posture they lose their scapulothoracic control um then their neuromotor control of their head on their neck they then develop weakness in those deep stabilizing or supportive muscles that has a flow-on effect to the joint um the the joint sensory awareness um proprioception and you might end up with pain and dysfunction in the joints as well. pain processing mechanisms can change and they can have that neural tissue sensitivity as well.

So we've got to think about all of those characteristics when someone presents, especially with that acute type presentation following an injury. Underneath in the pink are the other factors that are contributing to this person's presentation that we also need to take into consideration. Obviously the personal psychological factors and the environmental factors that we've talked about with a number of different case studies over this trimester.

So this is another way to look at it and this comes this model comes straight from the Walton and Elliot paper which is one of the references that we've suggested that you read this week okay for this this particular topic. So it looks quite complex but if we break it down this is what they are essentially proposing that pain and injury associated with a whiplash is likely initiated by local tissue damage be it bony or soft tissue right so that there is some traumatic event that initiates um local nociceptive response okay um and that might result in inflammation local tissue injury but it also results in some level of psychological distress right that's associated with any injury but it's particularly prevalent in car accidents and especially where it's not someone's fault right somebody does this to them is often the way they feel right that they are a victim Now Walton and Elliot talk about some pre-existing states that might influence the results following an injury and they sort of put people into these two systems of vulnerabilities and then protective systems and that these vulnerabilities and protections relate to their pre-existing tissue health, their psychological state, some genetic factors and obviously the contextual factors as well. So if someone undergoes or experiences a car accident, local tissue damage, injury to the neck, but their pre-existing state is relatively in a protection mode so they're strong fit healthy psychologically well they don't have those genetic you know risk factors and that the context is not is not too traumatizing for them then they may well go down this right hand side of this pathway which is that they have transient pain and dysfunction but they adapt well psychologically and physiologically they they're resilient they don't have fear and they recover as per any acute injury like a sprained ankle.

Then there's this other side of the equation. So people who are potentially more vulnerable prior to the accident, they may have comorbidities that mean that they've got a level of systemic inflammation or they might be weak, generally globally weak, not fit, not strong. They might be older, they might have some other health related issues.

Psychologically they may not be particularly resilient, all those factors might come into play. and then following this injury which may or may not involve nerve damage as well so involvement of the nervous system peripheral or central then this whole cycle of of pain of the secondary consequences around sensory motor dysfunction and the psychosocial factors that then start to feed into this the psychological disturbances depression anxiety post-traumatic stress and they just end up in this this cycle of pain and then a maladaptive response to that pain. And then on the side there you can see disturbed sleep feeds into this even more because we know sleep is so important to recovery. So it's this stress response that is so common in people who experience a whiplash.

This is the part that we need to really be able to pick up and identify in the early stages following an acute whiplash. so that we manage these people well because if we don't manage them effectively they are likely to end up with a really poor prognosis so here we've got an example of a case study and this is um a patient who is a 32 year old woman she is five weeks post motor vehicle accident so it's not quite in that acute phase it's in that sub-acute phase that she's presented here to us Now I'm not going to talk through all of this detail. What I want you to do is pause the recording and have a read through quickly that subjective history for this patient. Once you've had a look at that, I want you to think about how you would answer this question. Are there any indications of local tissue damage?

Okay, in her presentation, what do you think? Any signs of mechanical or nociceptive type pain mechanisms? So what your answer should have been, oh, there we go, her name's Hetty.

What you should have said was, yes, there are some signs. First, there was a mechanism of injury, so she was involved in a car accident. Secondly, her shoulder pain or that pain that radiates over the top of her shoulder there seems to be worse with prolonged use of the left arm.

OK, so there is a mechanical pattern to it and it feels better when it's rested or unloaded. So, yeah, there may be some signs of local tissue pathology there. all right pause again have a quick read through the objective examination now answer this question what grade would you put what classification based on the quebec system what classification would you put um hetty at so what you should have said was grade two there is evidence of musculoskeletal dysfunction okay but there's no signs of neurological impairment no pins and needles or numbness no power loss and things like that pure all right so part of Hedy's presentation especially in that subjective history you would have seen some outcome measures there was an NDI on which she scored 52 percent there was another one called the IES that we'll look at where she scored 50 percent or 50 sorry if you score a 50. so the NDI is the neck disability index which you can see here on the screen so there are 10 questions and they each have a leichhardt scale that is scored zero to five and it gives a total score out of 100. by a percentage, 100%.

So you convert the score to a percentage. Now this is a validated, reliable tool. This is something the neck disability index is an important tool to use if you do see patients with a whiplash type injury, because we can use this to help inform prognosis. So Hetty achieved a score of 52%.

Now, what we do know about the NDI based on a volume of research is that an NDI score of 30% or higher is indicative of moderate to severe levels of pain related disability right it's about disability this one okay there is pain intensity is one factor but most of it is talking about disability so 30 or higher a score of 52 percent puts her obviously in that moderate to high um levels of disability a score an NDI score of 10 or less indicates full recovery the ies so hetty scored 50. now this is the ies it's an impact of events scale and so this is a scale it's a psychological questionnaire it was developed by um by psychologists and there are three sub scales to this questionnaire an intrusion an avoidance and a hyper arousal subscale and again on the bottom right hand side you can see which questions relate specifically to each domain so sorry i'll go back these ones that are highlighted here are directly related to the hyper arousal sub-scale and the reason why i'm pointing these out is because these are the types of questions that informed the development of a prediction tool that we can use for people presenting with whiplash okay so the hyper arousal score seems to be quite predictive of poor prognosis so it is used for the whip predict clinical prediction tool so with this hyper arousal oh sorry with this impact of events scale Again, it's a Leichhardt scale and each item is scored 0, 1, 2, 3, 4. So 0 to 4, there are 22 questions. So the maximum score is 88. The higher the score, the worse the impact is of these events. And so Hedy scored 50. And that basically is a high impact. The psychologist suggests that a score over 25 indicates significant impact and that the patient may need to be referred for counselling. to a psychologist so in the three scales we talked about intrusion is about intrusive thoughts so people having nightmares um intrusive feelings um reliving the experience over and over again this the avoidance subscale is um about avoiding a response to their feelings um feeling numb um avoiding situations and not thinking about ideas uh that are related to the event and then the hyper arousal subscale is about is more about a measurement of their anger or their irritability their hyper vigilance a heightened startle so that that kind of increased anxiety stress kind of response and as i said the hyper arousal is the score that's most closely linked to poor prognosis and it's been used to inform this whip predict clinical prediction rule so you can see the questions there so do you feel irritable or are you prone to getting angry easily do you have difficulty falling or staying asleep difficulty concentrating over are you overly alert and are you jumpy or easily startled so they're not exactly the same as the hyper arousal or the impact of events the girl but they came from there so the patient again scores zero to four um and then there's a a calculation that's done which you can see below and then this is how we apply it so we've got two scores we've got the whip predict we've um sorry we've got the hyper arousal score from the whip predict and we've got the neck disability index now immediately if someone is over the age of 35, they immediately fall into the medium or high risk group.

If they're young, they fall into the low risk. Now if their neck disability index is over 40 percent, okay, then they start to fall down into that towards that high risk. Neck disability index between 33 and 39 percent, so remember if it's over 30 percent they're about, so if they're at risk of a poor prognosis, so neck disability index of 33 to 39, they go to medium risk.

40 percent over the age of 35, they then look at the hyper arousal score. If that is greater than six then they're in the high risk if it's less than six they go to medium risk okay so we can work through this with predict tool to try and help stratify patients um and and that helps inform our management because how we manage low risk versus medium and high risk are quite different all right so that's the whip predict tool now there is another tool called the erebro short form and this is also a validated tool it's widely used and you can use this to help inform prognosis and management as well. So with this Aribro tool, this one has again, you can see here we've got 10 questions this time and they're on a numerical rating scale from 0 to 10. So your score is what goes into the grey box on the right-hand side. There are three questions where the score is flipped and so you can see there it says 10 minus X. So you get your score, you subtract that score from 10 and that's the score you write.

in the box. So this gives you a sum total, a maximum of 100 with this score. And with the Aribro, a score greater than 50 out of 100 can put someone in that high risk subgroup. So high risk of poor outcomes. When would you do WIP predict over the Aribro?

Sometimes it's a matter of choice. It might be the clinic where you're working and which one they use. They're both considered equally valid.

The Aribro is a little bit more generic and it might be better used in people who have multiple areas of pain. The WIP predict tends to focus more on neck related symptoms, whereas the Aribro talks generally about pain, not location. So you might find Aribro better if you've got someone who's got multiple areas of pain. Here's something to think about. How do you communicate the outcome of these prognostic risk tools to your patient?

How do we sit down and have this conversation? We apply these tools to somebody who presents to us in clinic. What are you going to say to them?

Oh, you're at low risk. You're at really high risk of a poor prognosis. That doesn't sound good, does it? What are you going to say to your patients?

How do we manage patients based on this risk stratification? Because that's what it's about, that we use that tool to help inform our clinical pathway, our clinical management. Now, there is a website called My Whiplash Navigator. There are links there for clinicians and links for patients as well.

And it's really, really helpful. So there are things on there that will help you with that communication style and what you could or couldn't say to patients. or should or shouldn't say to patients.

All right, so I'm going to leave that there and we're going to come back now to Hetty, our 32 year old. So based on her history, her scores, her age and some of those other factors you can see in a physical exam, what do you think now are the good prognostic factors and what do you think are maybe some not so good or some poorer prognostic factors that are relevant to Hetty? pause and have a think about that some of the things you might have come up with Hedy seems to have some good social support around her she's motivated to get back to work maybe she wasn't quite so severe at baseline she can't really recall she did sort of say at some point of pain six out of ten but she's five weeks post injury so that's that's a bit of an unknown there she doesn't seem to have any sensory impairments such as cold hyperalgesia or anything like that On the not so good side, she's got a high NDI, higher than 30% puts her in that high risk subgroup.

Her expectation of recovery. So when she was asked, do you expect to recover? She basically on a scale from zero to 10 went five out of 10. So to me, that says it's a bit of a coin toss, 50-50. Maybe I will, maybe I won't. That's not necessarily that good.

And her impact of event scale was quite high. Now we don't know what subscale was particularly high, but her overall level. impact event scale suggests that she might need some psychological support. And she certainly does seem to have some psychological distress.

She's irritable, frustrated, angry. She expresses fear of driving and she's got night pain. And the other poor prognostic factor is that she's tipping into that chronic state, right? She's at five weeks and it doesn't seem to be getting any better. So what are we going to do?

There is this. A draft, you can see the reference down the bottom, a draft Australian clinical guidelines for health professionals managing people with whiplash associated disorders. Now, this is an updated version. The third edition was published in 2014, and this is now the most recent updated version.

It has changed a bit from the 2014 version. It's currently in draft form because it's out for consultation and they are looking for feedback, but it's not likely to change a great deal from the draft to the final version. But you'll see the final version come out probably in not.

you know before the end of this year The nice thing about these guidelines, they are really comprehensive. They use an expert panel, but they also synthesise all of the evidence from the literature. So the recommendations are really robust. And they don't just say, yes, this is great, no, that's bad. There is some middle ground as well, where they say, well, we can't really recommend for or against because the evidence is not strong enough.

So it doesn't mean you throw that out. It just means that, you know, we're not too sure. And it may be that it's not for everybody, right? Now this is broadly speaking treatment recommendations regardless of stratification. So we've talked about people being subgrouped into mild, moderate, severe, right?

Broadly speaking, one of the key take-home messages is that if people are subgrouped into that mild group, less is more. Meaning, don't put your hands on those patients. Less treatment, the sooner they get out and they are reassured and they have the confidence that they will recover, the better they will do what they're seeing. is that physios and other professionals start treating these patients, start treating everybody who presents with a whiplash. And as soon as we start putting our hands on people, these ones in particular, they tend to do worse.

So if you see a patient and they fall into that low risk subgroup, the recommended treatment is minimal, minimal hands on. Reassure them to stay active. Give them education about what's happened, what the pathology is, but what that predicted healing pathway should look like.

encourage them to return to usual activities. Now you can give them some exercises, you know, to improve range of motion, low load exercises that might involve isometric control, postural endurance, and maybe some strengthening exercises. But you don't need to do any of the other stuff, right, that's listed on that table. Maybe some simple analgesics if they're indicated, if they're required to help them sleep or something like that.

But reassurance and education and getting them back to normal life is paramount. the if they fall into the medium or the high-risk subgroup then the other um the other treatment recommendations there come into play so if your patients have reporting dizziness related symptoms then you might give them specific exercises to help with their just their dizziness psychologically informed exercise and trauma-based cognitive behavioral therapy and multi-disciplinary care become important for those medium and high risk subgroups but more so that the CBT and the multidisciplinary care, the evidence around them is really for those people who are already presenting with chronic pain. So over that six weeks to three months type pain scenario.

But the exercise and the simple analgesics and possibly non-steroidals if basic paracetamol isn't enough, there is evidence that they help in that acute phase. Under the not routinely recommended section, this is not. these are not to say you don't do these ones these are more to say for certain patients for certain subgroups you might choose to do these none of these should be given to people who fall into that low risk subgroup that's really important to know all right but you might for the medium and high risk include some manual therapy and and that kind of falls under this multimodal type of treatment approach most of the evidence there is for the chronic whiplash not the acute don't stick hands on the acute ones maybe a soft collar if it's indicated, especially if they're in that higher risk, medium or high risk, and they've got significant trauma. Antidepressants and pregabalin.

Okay, so they're kind of more around that neuropathic kind of pain medication for some people in that medium to high risk. Massage, again, they say neither here nor there for it. There's no evidence for or against.

Again, not for everybody. Pick your patient. Thoracic manipulation is something that there is some evidence for, but not everybody.

Same with acupuncture. and surgical treatment possibly if you've got somebody who's got myelopathy or radiculopathy sensory impairment neurological signs and symptoms that are unremitting and unchanging or worsening then obviously you know surgery might be an option then in the right hand side you can see treatments that are not recommended stay away from these cervical spine manipulation and meaning the classic high velocity low amplitude amplitude thrust do not manipulate the cervical spine acute or chronic opioids not indicated. Electrotherapy, trigger point needling or dry needling to trigger points, muscle relaxants, botulism toxin type A injections into muscles, corticosteroid injections either into the facet joints or intravenously, spinal manipulation for chronic, not at all, and radio frequency neurotomies, not indicated. They're often something that the surgeons or the pain specialists will recommend. The evidence does not support their use.

We'll take a break here and then what we're going to talk about is some of the other treatment specific options around stress inoculation.

Transcript for:Management Strategies for Whiplash Disorders

Transcript for:
Management Strategies for Whiplash Disorders