Transcript Event dated June 2014

Neck pain and Whiplash
From the roadside to the pain clinic (via primary care)
Richard Griffiths FRCA FFPMRCA
Consultant in Anaesthesia and Pain Medicine
Agenda
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Resources
Definitions
Case histories
Evidence
Guidance
• Questions on the way…
Neck pain, whiplash and WAD
NICE Clinical knowledge summaries 2013
Neck pain
Clinical Evidence 2007
Whiplash injury
B J Bone and Joint 2008
Whiplash associated disorders Parts 1&2
Pain Research and Management 2010
The diagnosis and treatment of nonspecific neck
pain and whiplash Euramedicophys 2007
Percuteneous radiofrequency neurotomy NEJM 1996
Cochrane Summaries
Dr Wikipedia
Carotid artery dissection
Acute coronary syndrome
Head and neck cancer
Retropharyngeal abscess
Epiglottitis
Cervical disc herniation
Cervical stenosis
Spondylosis
Stress
Referred pain
Overuse
Muscular pain
Whiplash
Neck pain
• Pain in the cervical area
• Referred into occiput,
shoulders and upper
limbs
• Stiffness predominates
“2/3 of the population will experience neck pain. 10% becomes chronic”
Cervical spondylosis
9/10 of patients above 65 years have this
Medicalising “normal”
Radiographic changes correlate poorly to symptoms
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Brachialgia
Cervical radiculopathy
Pain in upper limb from entrapment of cervical nerve root(s)
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28 year old female
RTA 18 months – rear impact, ongoing litigation
Neck pain
Low back pain, fatigue and headaches
Unhelpful physical therapy
No red flags
Trauma
Systemic symptoms
Progressive pain
Night pain
Motor signs
Prior spinal disease (surgery, osteoporosis)
Age extremes
Differential diagnosis
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Soft tissue injury
Mechanical lesions – eg. disc injury
Inflammatory - arthropathies
Metabolic – Paget’s, osteoporosis
Infective – including TB
Malignancy - 1°, 2° and myeloma
Fibromyalgia
Whiplash
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Whiplash and WAD
“an acceleration-deceleration mechanism of energy
transfer in the neck”
WAD – Whiplash associated disorder
Neck pain (>88%)
Headache
Spinal pain
Fatigue, dizziness, parasthesia
Anxiety and depression
Whiplash
“an acceleration-deceleration mechanism of energy transfer in the neck”
Question 1
• Whiplash accounts for what proportion of
motor insurance claims?
• 35%
• 58%
• 76%
Pathophysiology
• Source of pain unclear
Cervical facet joints
Anterior longitudinal ligament
Trapezius muscle
Supraspinatus muscle
Brain injury (contra-coup)
• Peripheral and central spinal cord sensitisation
Whiplash - classification
“an acceleration-deceleration mechanism of energy transfer in the neck”
Quebec Taskforce grading
Acute whiplash
0 - 12 weeks
Chronic whiplash
> 12 weeks
I
No neck complaint
II
Pain/stiffness osigns
III
Pain + ROM + Tenderness
IV
as above with neuro signs
V
as above with fracture/
dislocation
Question 2
Which of the following would now be described
as whiplash?
• Railway spine
• Spinal concussion
• Cervical sprain
Radiology and whiplash
When should I image the neck?
Not routinely
Any red flags
Concerned re. serious pathology (radiculopathy / myelopathy)
To reassure? To reinforce illness behaviour?
Cervical MRI
Consider nerve conduction studies
Prognosis
Great variation
Factors that lead to poor prognosis are:
high initial disability
high initial pain scores
low self efficacy
catastrophising educational level
1 month
12 months
2 years
5 years
%recovered
44%
65%
75%
VAS (0-10)
3.8
2.5
2.2
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South Australasia Centre for trauma 2008
Question 3
What proportion of headrests are incorrectly
positioned?
• 20%
• 50%
• 70%
WHO Analgesic ladder
Step 1
Step 2
Step 2 3
Step 3
Paracetamol
NSAIDS / COX II inhibitors
Codeine
Dihydrocodeine
Co-analgesics
Tramadol
Tapenthadol
Zomorph
Oxycontin
Acute whiplash – guidance
NICE clinical knowledge summaries
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Diagnosis and exclude sinister causes
Reassurance
Encourage return to normal activity
Discourage rest and immobilisation
Simple analgesia
Physiotherapy
• Treat anxiety and low mood
Late whiplash > 3 months
• Bio-psychosocial model of pain
• Whiplash associated disorder
Neck pain (>88%)
Headache Spinal pain Fatigue
dizziness parathesia
• Symptom amplification
• Anxiety, PTSD, depression
• Litigation
The effect of litigation
How society views whiplash may determine its
clinical presentation and prognosis
Greece & Lithuania have little WAD
Quebec – 12% not recovered at 1 year
Litigation delays recovery
Evidence
Exercise for chronic neck pain
• Active, ultrasound
assisted, passive
techniques,
stabilisation,
• Safe
• Benign side effects
“there appears to be a role for exercises in the treatment of chronic
neck pain and cervicogenic headache if stretching and strengthening
exercises are focused on the neck and shoulder blade region”
Acupuncture for chronic neck pain
• 10 trials investigated
• 668 patients ACU
compared to sham or
waiting list
“Individuals with chronic neck pain who received acupuncture reported,
better pain relief immediately after treatment and in the short-term than
those who received sham treatments and waiting list controls”.
Traction for chronic neck pain
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7 RCTs investigated
1 had LOW risk of bias
100 patients
Intermittent or
continuous traction
“In summary, our review found no evidence from RCTs with a low
potential for bias that clearly supports or refutes the use of either
continuous or intermittent traction for individuals with chronic neck
disorders”.
Pillows
“No evidence in a cross over study that “special neck pillows”
outperformed a normal pillow” Cochrane Review 2011
Recommendations chronic whiplash
NICE clinical knowledge summaries
• Encourage return to normal activity
• Discourage rest and immobilisation
• Simple analgesia
• Trial of anti-neuropathic medications
“Anti-neuropathics are “reasonable” for chronic neck pain / WAD” McQuay 2011
• Treat anxiety and depression
Not recommended
• Surgery
• Cervical epidurals
• Botox injections
Cervical rhizotomy may be useful…
Cervical intervention
Lord, Bogduk et al NEJM 1996
• 24 patients
• Proven cervical facet
joint pain after
whiplash
• Multi-level cervical
facet rhizotomy (80°C)
• Telephone follow up
Following whiplash injury, patients with proven chronic cervical facet joint pain can
gain lasting relief (9 months) from radiofrequency neurotomy”
Common questions
What effect do immobilisation collars have?
Not good - prolonged use promotes loss of function
Do pillows make a difference?
Not really – but you’re welcome to try
Is physio helpful?
Yes – active treatments outperform passive therapy
Does age matter?
Probably - old age is associated with poor prognosis
Could exercise help?
Yes – Cochrane recommends stretching and strengthening exercises
Summary
• Neck pain is common
• Whiplash is common (*especially after an RTC)
• Reassure, movement and analgesia for all
• Image only when worried
• Consider pain clinic referral when symptoms persists