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PHTY3260 EOS > L26-27: Whiplash Associated Disorders > Flashcards

L26-27: Whiplash Associated Disorders Flashcards

1
Q

What are 3 characteristics of Musculoskeletal Pain & Injury?

A
  1. Second to cancer as a cause of disease burden
  2. Personal and economic costs
    1. Whiplash incurs greater costs than SCI and TBI from RTC
    2. Poor mental health outcomes
  3. Propensity to chronicity
    1. Whiplash injury -up to 50% will not recover; 30% moderate/severe pain/disability
    2. LBP –60% still have pain after 12 months
      4.
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2
Q

What are 7 characteristics of WAD?

A
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3
Q

What is the recovery pathways of WAD?

A

Predicted disability trajectories & predicted probability of membership (%).

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4
Q

What is the post-traumatic stress symptom of WAD?

A
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5
Q

What are 5 characteristics of the prognosis after whiplash injury?

A
  1. Initial pain
  2. Initial disability
  3. Cold hyperalgesia
  4. Neck movement
  5. Psychological factors
    1. PTSD symptoms
    2. Recovery expectations (How well do you think you will recovery?)
    3. Depression
    4. Pain catastrophising (Worried)
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6
Q

What are 10 psychological factors in WAD?

A
  1. PTSD symptoms –not necessarily a PTSD diagnosis
  2. Minority have a PTSD diagnosis ~ 20%
  3. Psychological distress
  4. Depression
  5. Anxiety
  6. Fear of movement
  7. Perceived injustice
  8. Pain catastrophizing
  9. Self efficacy
  10. Patient expectations/ beliefs

Diagnosis of PTSD can only be diagnosed by psychologist

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7
Q

What are 5 characteristics of mental health of WAD?

A
  1. One in five (20%) Australians (aged 16-85) experience mental health conditions in any year
  2. The most common mental health conditions are anxiety, depression and substance use disorders
  3. Almost half (45%) Australians will experience a mental health condition in their lifetime
  4. Rates higher following an injury/accident and in those with chronic health conditions
  5. Is LIKELY you will encounter patients with mental health issues
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8
Q

What are the 4 predictors of poor recovery (acute stage) of what does the patient who doesn’t recover look like?

A
  1. Higher levels of pain > 5/10
  2. Higher levels of disability
  3. Psychological Distress
    1. Posttraumatic stress symptoms
    2. Poor expectations of recovery
    3. Depressed mood
    4. Pain catastrophizing
  4. Cold Hyperalgesia
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9
Q

Can we predict those who will recover?

A
  • Not well investigated
  • Important
    • Patient assurance
    • Too much treatment may be detrimental –treatment iatrogenesis
    • May need minimal (less intense) treatment
    • Avoid ‘medicalisation
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10
Q

What are 8 variables of the Clinical Prediction Rule?

A
  1. Disability: NDI
  2. Pain: VAS
  3. Neck ROM
  4. Hyper-arousal symptoms (PDS)
  5. Cold pain threshold
  6. age
  7. gender
  8. presence of headaches
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11
Q

What are 4 characteristics of Clincal Prediction Rule?

A
  1. Simple
  2. Efficient
  3. Quick
  4. Use by GPs, Physios, Primary care
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12
Q

What is the WhipPredict to “RISK Stratify” of Acute WAD (0-12 weeks)?

A
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13
Q

What the CPR is and what it isn’t (5)?

A
  1. It is a screening tool only
  2. It should be used to ‘risk stratify’ patients only.
  3. It is nota replacement for clinical assessment
  4. It provides some information about the type of treatment required but it does not direct treatment
  5. It is nota replacement for clinical reasoning
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14
Q

How to convey prediction to the patient (3)?

A

PDS: Do not need to do multiple questionnaires –> just listen and ask informally (same outcome)

3 subscales:

  1. Intrusive thoughts
  2. Avoidance
  3. hyper-arousal
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15
Q

What is the 3 treatment of different levels of risk?

A
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16
Q

Overall, most studies reported small effect sizes suggesting that a small clinical effect can be expected with the use of_______ in WAD.

A

exercise alone

3 interventions combined = best outcomes

MT + exercise = best for idiopathic neck pain

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17
Q

We _____ (did/did not ) find evidence for or against the use of psychological interventions for neck pain or WAD

A

did not

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18
Q

What is evidence for chronic WAD?

A
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19
Q

What are the different mechanisms that seem to underlie different MSK condition?

20
Q

‘At risk’ patients need early _____ or _____ treatment ?

A

multiD; interD

Complex:

  • MDT in acute stage
21
Q

What is the management of acute whiplash: A randomized controlled trial of multidisciplinary stratified treatments?

22
Q

What is the evidence results of the RCT of the multidiscilinary stratified treatment in management of acute whiplash?

A
  1. Patients didn’t want to see a psychologist
  2. Patients didn’t like medication side effects
  3. Patients were more compliant with physio
  4. Burden to see 3 practitioners (for some) was high
  5. Some evidence that more treatment can be iatrogenic
23
Q

What are we missing in WAD (6)?

A
  1. Assuming that somehow addressing physical impairments will miraculously cure pain?
    1. Exercise in all its various forms
    2. Manual Therapy
    3. What is the relationship between physical impairments and pain/disability?
    4. What is the relationship between ‘pathology’ and pain/disability?
  2. Are we stuck in a biomedical model?Although we pay ‘lip-service’ to the biopsychosocial model
  3. Are we listening to the patients?
  4. What do they say?
  5. Why are we afraid to address psychological distress? –not talking psychopathology
  6. With current evidence for chronic pain development –we will have to step up!
24
Q

What do the patients say (5) in WAD?

A
  1. “The degree to which EVERY additional stress interferes with the recovery process & exacerbates both psychological & physical injuries” (Patient 3)
  2. “I was and still am very anxious when driving or being a passenger”
  3. “Doctor’s Practice does not take the injury seriously” (Patient 4)
  4. “Feel let down by lawyers and GPs” (Patient 20)
  5. “Medical Practitioner’s lack of care” (Patient 5)

Pathology does not necessarily related to pain/disability

25
What are 5 characteristics of PTSD symptoms predict poor recovery in Stress Related Responses?
1. 34% high levels of stress understanding claim 2. 30.4% with claim delays 3. 27% with number medico-legal assessment 4. 26% with amount of compensation 5. Predicted disability: 1. WHODAS (+6.94 pts); HADS (+2.61) 2. Lower QOL –WHODAS (-0.73 pts)
26
What is the recall of traumatic event?
27
What are 2 characteristics of the cervical spine in pressure pain thresholds?
1. PTSD group lower across time. 2. Further decrease in PTSD group after trauma-cue.
28
What are 2 characteristics of the remote sites in pressure pain thresholds?
1. PTSD group lower across time 2. Minimal changes after trauma-cue
29
\_\_\_\_\_\_ characteristics are poor predictors of outcome
Collision
30
Can molecular differences in blood, in the very first hours after MVC, predict outcomes? Can they provide insights into what causes post-MVC pain?
31
What are 2 characteristics of neurobiological stress systems in stress related responses?
1. Genetic variants which affect noradrenergic system function ( COMT) predict vulnerability to acute pain and persistent neck pain 6 mthsfollowing MVC 2. Genetic variants that affect glucocorticoid system function (FKBP5)predict chronic pain 6 mthsafter MVC
32
What if we try to modulate stress? Will this influence pain & disability? What can physios do?
1. Whiplash Grade II 2. No psychopathology –PHQ-9, ASDS, past history 3. **Medium/high risk based on Whiplash Clinical Prediction Rule (WhipPredict)** 4. 6 week intervention & 6wk, 6 and 12 month follow-up
33
What are 4 cases for using physiotherapists in WAD?
1. Patients not keen on seeing a psychologist * "GP and/or insurance company sent me to a psychologist –that was worthless-I have whiplash.“ 2. Not feasible to see a psychologist * Psychological debriefing non recommended post trauma (AustPTSD Guidelines) 3. Physiotherapists are commonly involved * “He was absolutely wonderful and knowing that people were seriously looking at what was going on took the stress out of the situation for me and just gave me other options of how to move and sit and that sort of thing” 4. Using current primary care resources * Funding/compensation implications
34
What are the interventions for 6 weeks in WAD?
35
What are 5 characteristics of exercise program of WAD?
Specific Exercise –Muscle control, sensorimotor control 1. Retraining cranio-cervical flexion pattern 2. Retraining scapular control 3. Progression to higher load activities 4. Progression to functional activities 5. Aerobic exercise
36
What are the 3 phases (2/3/4) in stress inoculation training?
1. Identifying and understanding stress 1. Education about the influence of stress on nociception/pain 2. What thoughts, feeling, actions have you noticed increase or decrease your whiplash pain? 2. Developing skills 1. Relaxation 2. Problem solving 3. Helpful coping self statements 3. Applying skills in various stressful situations 1. Identify specific stressor 2. Prepare for stress 3. Plan into action and review 4. Cannot move all anxiety, just keep it manageable
37
What is SIT + Physiotherapy Exercise?
38
What are the baseline characteristics of WAD?
* No serious adverse effects * Mild adverse effects: symptom exacerbation -1 participants in each group
39
What are the 2 characteristics of treatment credibility?
1. Credibility/Expectancy Questionnaire 2. Following first session with physiotherapist
40
What is the primary outcome of clinically relevant effects on disability?
41
What is the difference between multidisclinary team and usual care in the managemnet of acute whiplash?
42
What is the difference between physio package VS advice (emergency department treatment and physiotherapy for acute WAD) in the management of acute whiplash?
43
What are the clinically relevant effects on perceived recovery of WAD?
44
What do the physios think of the SIT/Exercise intervention (3)?
1. The physios could successfully deliver the SIT/exercise 1. Audit of audio files by clinical psychologist –39 sessions audited -\>90% compliance 2. 2 days training + follow-up refresher session 3. 19 physios across 12 clinics –Brisbane, Gold Coast, Toowoomba, Mackay 2. Physios found it valuable 3. Physios were confident in delivering the combined intervention
45
What are 5 characteristics of the use of opoids in WAVD (as a concerned)?
1. Misuse of prescription opioids in US and Canada is a public health crisis 2. A similar problem is developing in Australia 3. 39% of prescribed medications for WAD in general practice were opioids (Nikles et al, 2017) 4. Opioids used in \>60% of patients in ED, and \>90% of those receiving ED discharge scripts received either codeine‐containing medication or oxycodone 5. Early use of opioids in ED for RTC injury associated with continued use 6weeks later
46
What is ED and later management of WAD?
47
What are 8 implications of WAD?
1. Risk stratification in acute injury stage (Whip-Predict (better med-high risk) VS Orebro VS Startback) 2. Treatment matched to risk and presenting features 3. Holistic consideration of patients with injury –can’t separate the mind and body 4. Take care with your language (Accidentally catastrophise (eg. weak) --\> make patient hesitate to move) 5. Targeting of stress symptoms shows effect 6. Physiotherapists can successfully do this 7. Integration of these treatments into practice 8. Don’t contribute to the opioid problem –there are alternatives (e.g. physiotherapy). Be proactive.

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