Whiplash Injury 10.5.12

Whiplash Injury.

Dr. Christopher A. Jenner MB BS, FRCA, FFPMRCADr. Jonathan Stewart MBChB, FRCA, MFPM

Consultants in Pain MedicineImperial Healthcare NHS Trust and London Pain Clinic

10th May 2012

Agenda

• Definition

• Clinical findings

• Management

• Prognosis

www.londonpainclinic.com

Definition


Definition

• Sudden hyperextension and hyperflexion injury to neck

• An acceleration/ deceleration mechanism of Energy transfer to the neck

• Whip-like movement

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.[

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

Soft Tissue Damage


Soft Tissue Damage

• Ligaments (ALL)

• Tendons

• Muscles

• Intervertebral discs

• Facet Joints

• Nerve roots

Serious

• Spine injuries

• Spinal Cord injury

• Brain injury

• (coup-contra-coup)

Pathophysiology

• Interaction sequence for a collision lasting approximately 300 milliseconds.

0 ms

• Rear car structure is impacted and begins to move forward and/or crushes

• Occupant remains stationary

• No occupant forces

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

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

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

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

Causes


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.

Causes

• RTA commonly- front/ back/ side

• Contact sport injuries

• Accidental/ intentional blows to head

• Child abuse- shaking, hitting

• Cervical acceleration-deceleration injury

Incidence


Incidence

• US National Highway Traffic Safety Administration (1995)

• 53% of 5.5 million RTA victims suffered whiplash injury


Prevalence of whiplash-associated disorder symptoms

Widespread pain seen after whiplash in car-crash victims, but not in survivors without whiplash [Rheumawire > News; Sep 30,

2005]

Ferrari R, et al. Ann Rheum Dis 2005; 64:1337-1342.

Symptom Males (%)

Females (%)

Neck/shoulder pain 100 100

Headache 78.4 86.1

Numbness/tingling or pain in arms/hands

37.8 46.4

Numbness/tingling or pain in legs/feet

23.5 28.3

Dizziness/unsteadiness 41.4 48.3

Nausea 21.6 33.9

Ringing in the ears 21.4 20.5

Concentration problems 24.1 27.8

Low back pain 61.9 64.6

Clinical

Symptoms and Signs

• Pain

• Stiffness

• ↓ ROM

Symptoms and Signs

• Local Neurological

- abnormal sensations arms (burning/ paraesthesia)


Symptoms and Signs

• General neurological

• dizziness • headache • blurred vision • pain on swallowing • ringing in ears • irritability • tinnitus

Symptoms and Signs

• Psychological-

• memory loss

• cognitive impairment

• sleep disturbance

• fatigue

• depression

• PTSD

Symptoms and Signs

• Secondary Myofacial Pain Syndrome (Fibromyalgia)

• Lower Back Pain


Symptoms and Signs

• Whiplash syndrome-

• continual headache

• pain

• reduced movement

• tingling

• lumbar pains

• fatigue

• sleep disturbance

Chronic Whiplash

Complex interaction between many factors:

Biological

Psychosocial Legal

Economics Beliefs / Attitudes

Psychological factors are also hypothesized to influence the existence of whiplash-related cognitive impairments.

Investigations

Investigations

• X-rays- exclude #

• CT

• MRI

Treatment


Overall Aim of Treatment

• Pain-free window

• Rehabilitation


Treatment

• Education

• Medication

• Physical Therapy/ Rehabilitation

• Minimally Invasive Pain Management Procedures


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

Education

• Ergonomics at home and work

• Home program of heat and cold & exercises

• Self Monitor stress, sleep and mood

• Headaches

• Avoid excessive investigation

Medication

Medication

• Pharmacological

• WHO ladder (amended from cancer)

Step 1 paracetamol/ NSAID/ COX 2

Step 2 + weak opioids

Step 3 + strong opioids


Medication

• Adequate medication- regularly, prevent breakthrough pain

• Muscle relaxant- Diazepam/ Baclofen


Physical Therapy/ Rehabilitation


• Clear red flags – C-spine instability/ #

• Adequate medication- regularly, prevent breakthrough pain



• Keep neck moving as normally as possible!

• Collars not recommended

• Gentle mobilisation


• Avoid ‘stiffening-up’

• Studies- quicker recovery with gentle exercise



• Pacing activities

• Fear avoidance

• Catastrophising- not torn muscle/ severe

Other Physical Treatments

• Physical- heat/ cold/ TENS/ hydro/ supports/ US/ IR/ firm supportive pillow/ good posture

• Manipulation- PxTx/ chiropracter/ osteopathy/ deep tissue massage

Minimally Invasive Pain Management


Cervical and Thoracic facet joint injections


Cervical and Thoracic facet joint radiofrequency

denervation


Trigger Point Injections


1. Dry Needling

2. Local Anaesthetic and Steroid preparations

3. Botulinum Toxin A

Prevention


Prevention

• Head restraints

• 3 in 4 not properly adjusted!


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, The Effect of Socio-Demographic and Crash-Related Factors on the Prognosis of Whiplash. J Clin Epidemiol Vol. 51, No. 5, pp. 377–384,

19981998

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•

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)

•

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)

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

Any Questions


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Whiplash Injury 10.5.12