Whiplash Injury 10.5.12

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Overview of the assesment and treatment of Whiplash and Whiplash associated Disorder

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Whiplash Injury 10.5.12

  1. 1. Whiplash Injury. Dr. Christopher A. Jenner MB BS, FRCA, FFPMRCA Dr. Jonathan Stewart MBChB, FRCA, MFPM Consultants in Pain MedicineImperial Healthcare NHS Trust and London Pain Clinic 10th May 2012
  2. 2. Agenda• Definition• Clinical findings• Management• Prognosis www.londonpainclinic.com
  3. 3. Definition www.londonpainclinic.com
  4. 4. Definition• Sudden hyperextension and hyperflexion injury to neck• An acceleration/ deceleration mechanism of Energy transfer to the neck• Whip-like movement
  5. 5. Whiplash-Associated Disorders (WAD)• Given the wide variety of symptoms that are associated with whiplash injuries the Quebec Task Force on Whiplash- Associated Disorders, coined the phrase, Whiplash-Associated Disorders.[
  6. 6. Whiplash Associated Disorders (WAD)• Classed by severity of signs and symptoms- Québec Task Force (QTF)• WAD 0 No complaints or physical signs• WAD 1 Neck complaints but no physical signs• WAD 2 Neck complaints and musculoskeletal signs• WAD 3 Neck complaints and neurological signs• WAD 4 Neck complaints and fracture / dislocation• Most whiplash injury results from low impact collisions
  7. 7. Soft Tissue Damage www.londonpainclinic.com
  8. 8. Soft Tissue Damage• Ligaments (ALL)• Tendons• Muscles• Intervertebral discs• Facet Joints• Nerve roots
  9. 9. Serious• Spine injuries• Spinal Cord injury• Brain injury• (coup-contra-coup)
  10. 10. Pathophysiology• Interaction sequence for a collision lasting approximately 300 milliseconds.
  11. 11. 0 ms• Rear car structure is impacted and begins to move forward and/or crushes• Occupant remains stationary• No occupant forces
  12. 12. 100 ms• Vehicle seat accelerates and pushes into occupant’s torso (i.e. central portion of the body in contact with seat)• The torso loads the seat and is accelerated forward (seat will deflect rearward)• Head remains stationary due to inertia
  13. 13. 150 ms• Torso is accelerated by the vehicle seat and may start to ramp up the seat• Lower neck is pulled forward by the accelerated torso/seat• The head rotates and extends rapidly rearward hyper-extending the neck
  14. 14. 175 ms• Head is still moving backwards• Vehicle seat begins to spring forward• The torso continues to be accelerated forward• The head rotation rearward is increased and is fully extended
  15. 15. 300 ms• Head and torso are accelerated forward• Neck is “whipped” forward rotating and hyper-flexing the neck forward• The head accelerates due to neck motion and moves ahead of the seat back
  16. 16. Causes www.londonpainclinic.com
  17. 17. Causes• “Railroad spine” first coined in 1919 following train collisions.• Following invention of cars, number of whiplash-related injuries risen sharply due to an increase in rear-end motor vehicle collisions.
  18. 18. Causes• RTA commonly- front/ back/ side• Contact sport injuries• Accidental/ intentional blows to head• Child abuse- shaking, hitting• Cervical acceleration-deceleration injury
  19. 19. Incidence www.londonpainclinic.com
  20. 20. Incidence• US National Highway Traffic Safety Administration (1995)• 53% of 5.5 million RTA victims suffered whiplash injury www.londonpainclinic.com
  21. 21. Prevalence of whiplash-associated disorder symptomsSymptom Males Females (%) (%)Neck/shoulder pain 100 100Headache 78.4 86.1Numbness/tingling or pain in 37.8 46.4arms/handsNumbness/tingling or pain in 23.5 28.3legs/feetDizziness/unsteadiness 41.4 48.3Nausea 21.6 33.9Ringing in the ears 21.4 20.5Concentration problems 24.1 27.8Low back pain 61.9 64.6 Ferrari R, et al. Ann Rheum Dis 2005; 64:1337-1342. Widespread pain seen after whiplash in car-crash victims, but not in survivors without whiplash [Rheumawire > News; Sep 30, 2005]
  22. 22. Clinical
  23. 23. Symptoms and Signs• Pain• Stiffness• ↓ ROM
  24. 24. Symptoms and Signs• Local Neurological- abnormal sensations arms (burning/ paraesthesia) www.londonpainclinic.com
  25. 25. Symptoms and Signs• General neurological • dizziness • headache • blurred vision • pain on swallowing • ringing in ears • irritability • tinnitus
  26. 26. Symptoms and Signs• Psychological- • memory loss • cognitive impairment • sleep disturbance • fatigue • depression • PTSD
  27. 27. Symptoms and Signs• Secondary Myofacial Pain Syndrome (Fibromyalgia)• Lower Back Pain www.londonpainclinic.com
  28. 28. Symptoms and Signs• Whiplash syndrome- • continual headache • pain • reduced movement • tingling • lumbar pains • fatigue • sleep disturbance
  29. 29. Chronic WhiplashComplex interaction between many factors: Biological Psychosocial Legal Economics Beliefs / Attitudes Psychological factors are also hypothesized to influence the existence of whiplash-related cognitive impairments.
  30. 30. Investigations
  31. 31. Investigations• X-rays- exclude #• CT• MRI
  32. 32. Treatment www.londonpainclinic.com
  33. 33. Overall Aim of Treatment• Pain-free window• Rehabilitation www.londonpainclinic.com
  34. 34. Treatment• Education• Medication• Physical Therapy/ Rehabilitation• Minimally Invasive Pain Management Procedures www.londonpainclinic.com
  35. 35. Education• Explain benign nature of WAD• Avoid confusing and conflicting info• Watch for factors leading to pain chronicity• Home / work programmes as effective as physiotherapy• Teach relaxation and stress management• Educate posture and neck care
  36. 36. Education• Ergonomics at home and work• Home program of heat and cold & exercises• Self Monitor stress, sleep and mood• Headaches• Avoid excessive investigation
  37. 37. Medication
  38. 38. Medication• Pharmacological • WHO ladder (amended from cancer) Step 1 paracetamol/ NSAID/ COX 2 Step 2 + weak opioids Step 3 + strong opioids www.londonpainclinic.com
  39. 39. Medication• Adequate medication- regularly, prevent breakthrough pain• Muscle relaxant- Diazepam/ Baclofen www.londonpainclinic.com
  40. 40. Physical Therapy/ Rehabilitation
  41. 41. Physical Therapy/ Rehabilitation• Clear red flags – C-spine instability/ #• Adequate medication- regularly, prevent breakthrough pain www.londonpainclinic.com
  42. 42. Physical Therapy/ Rehabilitation• Keep neck moving as normally as possible!• Collars not recommended• Gentle mobilisation
  43. 43. Physical Therapy/ Rehabilitation• Avoid ‘stiffening-up’• Studies- quicker recovery with gentle exercise www.londonpainclinic.com
  44. 44. Physical Therapy/ Rehabilitation• Pacing activities• Fear avoidance• Catastrophising- not torn muscle/ severe
  45. 45. Other Physical Treatments • Physical- heat/ cold/ TENS/ hydro/supports/ US/ IR/ firm supportive pillow/ goodposture • Manipulation- PxTx/ chiropracter/osteopathy/ deep tissue massage
  46. 46. Minimally Invasive Pain Management www.londonpainclinic.com
  47. 47. Cervical and Thoracic facet joint injections www.londonpainclinic.com
  48. 48. Cervical and Thoracic facet joint radiofrequency denervation www.londonpainclinic.com
  49. 49. Trigger Point Injections www.londonpainclinic.com
  50. 50. 1. Dry Needling
  51. 51. 2. Local Anaesthetic and Steroid preparations
  52. 52. 3. Botulinum Toxin A
  53. 53. Prevention www.londonpainclinic.com
  54. 54. Prevention• Head restraints• 3 in 4 not properly adjusted! www.londonpainclinic.com
  55. 55. Prognosis• 25% better within one week• Most better within 1 month• Only 2% not recover at 1 yr• With other injuries:• 19% better within 1 wk• 30% within 1 month• 4% not recover at 1 yr N=2810 (all waiting for compensation) The Effect of Socio-Demographic and Crash-Related Factors on the Prognosis of Whiplash. J Clin Epidemiol Vol. 51, No. 5, pp. 377–384, 1998
  56. 56. Prognosis• Lower rate of recovery:• Multiple injuries• Female• Older age, every decade increase in age, likelihood of recovery decreases by 14%• Larger number of dependents,• Married status,• Not being employed full time, low income• Low education•
  57. 57. Prognosis• Being in a truck time.or bus (less in cars)• Being a passenger, 15% lower for passengers than drivers• Collision with a moving object,• Colliding head-on or sideways (rear collision better)•
  58. 58. Prognosis• Wearing a seatbelt! (Head restraints better outcome)• Neck rotated or side bent• Previous neck pain (females) and cervical deg. changes• Lawyer involvement! (proof they are a pain in the neck)
  59. 59. Rule of thumb• Those with continuing symptoms three months after the accident are likely to remain symptomatic for at least two years, possibly much longer
  60. 60. AnyQuestions www.londonpainclinic.com

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