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whiplash associated disorder
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whiplash associated disorder - June 15, 2006 7:07:00 AM
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ptadams
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The longer length of healing for WAD is a puzzle. Most of my patients with injuries to the the spine(neck, upper back, and lower back) from a rear end collision take about three months to heal. This starts from the time they begin physical therapy and ends when symptoms are resolved or mimimal. Some patients take several months more before reaching their goals, and sadly a few an unaccetable plateau of pain and decreased function.
My question is why does it take longer for WAD patients to heal then it does for patients with similar injuries. I have had several patients with similar spinal injuries but not WAD that have resolved in a shorter time span. What is unique about WAD?
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Re: whiplash associated disorder - June 15, 2006 7:18:00 AM
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Alex Brenner PT MPT OCS
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David,
It may be the fact that we are calling it WAD and labeling their pain like they have some sort of disease. I personally would stay away from any type of "labeling" or "diagnosis" which can introduce a psychosocial component to their pain possibly causing some fear avoidance behaviors. As we all know, once you get this involved it just adds a barrier to rehab.
You have to also think about the litigation that typically accompanies motor vehicle accidents. Any time there is litigation involved you can be assured that their pain will not get better until their legal problems are resolved.
I think there are actually some studies to support this but I can not recall the authors or the journals that they were reported in.
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Alex Brenner, PT, MPT, OCS
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Re: whiplash associated disorder - June 15, 2006 7:33:00 AM
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drbuddy
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I think WAD injuires are generally more severe than most other types of neck injuries that we see (postural syndromes, 'stiff necks', etc). Plus, the c-spine is fairly unstable, making it difficult to rehab completely in a short amount of time. Lots of neuro and vascular structures in the area too, along with being an important "organ" for equilibrium.
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Re: whiplash associated disorder - June 15, 2006 8:58:00 AM
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PTupdate.com
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I think the majority is due to litigation, and articles in Spine have discussed how there are signifcantly fewer issues in those areas where this cannot be pursued by the patient. Did you ever notice how we do not get people in with limited tort? Or even the ones that were at fault? Interesting.
John Duffy, PT OCS
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Re: whiplash associated disorder - June 15, 2006 1:04:00 PM
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steve
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I was thinking about this problem very recently and did a little lit search on prognosis. Interestingly, the avg. injury time varies greatly from study to study and more informatively, from place to place (Suggesting some element of culture or litigation do have a significant effect). Part of the reason for this variation is that different outcomes (Ie. time off work, claim settlement, pain) are used to measure resolution of symptoms. A couple of names to look up on prognosis include Sterling, Cassidy and Hendriks.
Most of the evidenc that I have read suggests that the problem is multifactorial ie. sociodemographics, psychological and physical and often linked to the patients status in these areas prior to injury. I certainly agree with some of the previous comments on litigation as previously posted.
Steve
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Re: whiplash associated disorder - June 15, 2006 4:57:00 PM
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SJBird55
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What is it like in Australia? Is there a high probability that in a motor vehicle accident situation that there would be litigation involved? Just curious. I listened to I can't remember what Australian at the conference last year or the year before discuss whiplash associated disorders.
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Re: whiplash associated disorder - June 15, 2006 5:09:00 PM
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nari
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As Steve suggests, there is wide variation.
Litigation here is not as widespread as in the USA, but there are significant compensation claims for pain that often goes away with settlement. I don't have figures at hand.
It was useful in the 90s to recognise whiplash effects as 'real' pain (?!) but there are always car travellers and lawyers who are looking for milking the system. At one stage there were entire families arranging rear-end collisions in order to claim; but that has been exposed now.
Notwithstanding that, some 'whiplash' injuries can be very long lasting and a severe problem for the owner of the neck.
Nari
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Re: whiplash associated disorder - June 15, 2006 5:21:00 PM
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certMDT
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The effect of litigation is real, but it's important to recognize real physiological changes that have been found. Sterling, as mentioned above, has lead research describing differences in hypersensitivity between those with whiplash and other types of neck pain:
"Sensory hypersensitivity of WAD has been shown to
occur independently of psychological distress (Sterling et al., 2003) and whilst demonstrating a relationship with posttraumatic stress, this relationship is mediated by pain and disability levels (Sterling and Kenardy, 2006) suggesting that psychological factors alone cannot explain the sensory disturbance. A more likely explanation is that it reflects biological phenomena involving
augmented central pain processing. It has been shown that widespread sensory hypersensitivity does not occur in idiopathic (non-traumatic) neck pain indicating different underlying mechanisms to these two conditions (Scott et al., 2005)."
Sterling M. Balancing the 'bio' with the psychosocial in whiplash associated disorders. Man Ther. 2006 Mar 28; [Epub ahead of print]
Charlie
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Charles Sheets PT OCS Dip MDT
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Re: whiplash associated disorder - June 15, 2006 5:31:00 PM
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PTdirector
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I think that you all have hit on the things that I would think cause these cases to take longer. Of course the litigation is a major factor (especially if they have a disability policy that is paying their salary in the mean time). I was at an Ola Grimsby course on evaluation of the cervical spine and I seem to remember that there were some significant studies performed on cervical pain after motor vehicle accidents and the findings were quite shocking in my opinion. There were undiagnosed dens fractures, annular ligament tears, pars fractures, stress fractures, etc...that were undiagnosed prior to the studies. I would be willing to bet that many of these patients were in physical therapy and may have been with therapists that assumed they were malingering due to the litigation. Pretty scary stuff. In fact, the speaker at the class told a story regarding a patient seen at one of his competitor's clinics that had a dens fracture. The neurosurgeon who followed up with the patient for headaches was a good friend of his and stated that another physician saw the xrays and asked him why he was looking at post-mortem xrays and he told him that the guy was in room 3. The physician told him that the only reason why the patient was still alive was because his neck muscles were stronger than the therapists hands.
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Re: whiplash associated disorder - June 15, 2006 7:08:00 PM
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ptadams
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I have some studies from other countries where compensation for pain is not considered and the prognosis is about the same. Depending upon the study, the chronicity rate is from 10 to 30%. So I am not much of a believer of the pain equals money argument. In my 30 years I have only seen just a few fakers.
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Re: whiplash associated disorder - June 16, 2006 12:06:00 AM
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Alex Brenner PT MPT OCS
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I don't necessarily think that people with psychosocial compenents to their pain are fakers. I believe they truely have pain but that the pain they feel is amplified due to these other factors. There also seems to be a higher fear avoidance behavior in patients with these disorders. How many times have you had patients that just don't want to give up the white cervical collar due to fear of movement? I personally do not automatically throw these type of patients into the faker category but what I was trying to provide was a possible explanation to David's orignal question. Certainly we must all rule out the more serious physiological pathology first.
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Alex Brenner, PT, MPT, OCS
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Re: whiplash associated disorder - June 16, 2006 7:05:00 AM
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steve
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Alex,
I think it is an excellent point to note that these people are NOT "fakers" but rather have multimodal components to there pain. Too often this is what is thought by the medical community as we have a pathoanatomical bias.
Charles, I've read the Sterling study and would note that hypersensitivity seems to occur with any type of chronic pain syndrome and whiplash simply seems to fall into the same category.
Steve
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Re: whiplash associated disorder - June 17, 2006 3:04:00 PM
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nari
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Steve
You're right - WAD is chronic pain (or hypersensitivity whichever way one looks at it).
It is not a condition out on its own. Every chronic condition has a 'psychological' component, some more than others, and the management follows what is presenting. It does seem to attract litigation, but 'faking it' is not something we can prove or disprove.
The head and neck, however, is where we 'live' and its dysfunction tends to have more of an impact on emotional welfare than other conditions of a similar nature, where pain is involved.
Nari
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Re: whiplash associated disorder - June 18, 2006 10:32:00 PM
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goodlooks58
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Alex..I think you have the answer. Most MVAs have quick reflex action of bracing movements. There is also a loud noise during the time of the accident and the pt does beleive that the accident has caused some major physical damage. All the action and reaction occurs instantaneously. I think fear and shock factor plays a tremendous role. Many years ago I was in an MVA and the screeching sound of the brakes applied by the driver behind me ending in a loud noise and a whiplash action is very scary. Stangely I had under the rib cage lingering pain for a few weeks. I believed that I might have pushed on my diaphragm as I was watching the driver behind me in my rearview mirror as I not worn my seat belt. I think it was more of a psychological traumatic experinece rather than physical.
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Re: whiplash associated disorder - June 19, 2006 1:53:00 AM
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SJBird55
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Physical and psychological factors maintain long-term predictive capacity post-whiplash injury.
Pain. 2006 May;122(1-2):102-8
Authors: Sterling M, Jull G, Kenardy J
Higher initial levels of pain and disability, older age, cold hyperalgesia, impaired sympathetic vasoconstriction and moderate post-traumatic stress symptoms have been shown to be associated with poor outcome 6 months following whiplash injury. This study prospectively investigated the predictive capacity of these variables at a long-term follow-up. Sixty-five of an initial cohort of 76 acutely injured whiplash participants were followed to 2-3 years post-accident. Motor function (ROM; kinaesthetic sense; activity of the superficial neck flexors (EMG) during cranio-cervical flexion), quantitative sensory testing (pressure, thermal pain thresholds and brachial plexus provocation test), sympathetic vasoconstrictor responses and psychological distress (GHQ-28, TSK and IES) were measured. The outcome measure was Neck Disability Index (NDI) scores. Participants with ongoing moderate/severe symptoms at 2-3 years continued to manifest decreased ROM, increased EMG during cranio-cervical flexion, sensory hypersensitivity and elevated levels of psychological distress when compared to recovered participants and those with milder symptoms. The latter two groups showed only persistent deficits in cervical muscle recruitment patterns. Higher initial NDI scores (OR 1.00-1.1), older age (OR 1.00-1.13), cold hyperalgesia (OR 1.1-1.13) and post-traumatic stress symptoms (OR 1.03-1.2) remained significant predictors of poor outcome at long-term follow-up (r2=0.56). The robustness of these physical and psychological factors suggests that their assessment in the acute stage following whiplash injury will be important.
PMID: 16527397 [PubMed - indexed for MEDLINE]
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