Transcript Cognitive behaviour therapy for whiplash

CONROD, The University of Qld
,
 Traumatic event + Reaction
 Symptoms
 Reexperiencing
 Avoidance
 Hyperarousal



Duration > 1 mo. (< 1 mo Acute Stress
Disorder)
Functional impairment
Diagnosis vs symptoms (subclinical)

Higher rates of PTSD in Whiplash patients1,2,3.

Overlapping epidemiologic and clinical
features1

May involve stress system dysregulation4
› Cortisol abnormalities in both Whiplash4,5 and PTSD6
› Sensory hypersensitivity (lower pain thresholds)7
› impaired sensory nervous system functioning 7
1.
McLean, Clauw, Abelson & Liberzon, 2005
2.
Buitenhuis et al , 2006
3.
Sullivan, et al., 2009
4.
Wessa, Rohleder, Kirschbaum & Flor, 2006
5.
Gaab, Baumann, Budnoik, Gmunder, Hottinger, Ehlert, 2005
6.
Liberzon, Abelson, Flagel, Raz & Young, 1999
7.
Sterling and Kenardy, 2006
PTSD
(n=33)
No PTSD
(n=39)
Cohen’s
d
Neck Disability (NDI)
41.09 (15.88)
34.31 (13.43)
0.46
Neuropathic pain (s-lanss)
11.91 (5.85)
9.67 (6.17)
0.37
Headaches
75.8%
84.6%
Dizziness
51.5%
53.8%
2.55 (0.90)
2.10 (0.68)
-Neck
100%
100%
- *Back
51.5%
28.2%
- *Shoulders
81.8%
53.8%
-Arms
24.2%
28.2%
-Legs
6.1%
2.6%
Number of pain locations
* = p < .05; ** = p < .01.
0.56
*= p < .01; ** = p < .05.

Higher initial pain and disability1, 2

Posttraumatic stress reaction1, 3, 4, 5

Cold hyperalgesia1, 3

Older age1,2
1.
2.
3.
4.
5.
Sterling, Jull, Vicenzio, Kenardy & Darnell, 2005
Buitenhuis, Spanjer, Fidler, 2003
Sterling, Kenardy, Jull & Vicenzio, 2003
Buitenhuis et al, 2006
Jaspers, 1998
 Aim
› Investigate the effect of co-morbid PTSD on
physiological arousal and sensitivity to
induced pain in patients with chronic
Whiplash.
 Participants (N = 72)
› 17-65yrs (M = 35), 65% female
› Chronic Whiplash to Grade 3 (3mths – 5yrs, M
= 2.5yrs)
› Exclusions: fractures, head injury, history of
neck pain.


Neck Pain and Disability (NDI)
Neuropathic pain (S-LANSS)
Assessment of PTSD


Posttraumatic Stress Diagnostic Scale (PDS)
Structured Clinical Interview for DSM (SCID)
› Allows screening out of symptoms attributable to
injury/environment.
“Challenge” assessment

Derive individual recall of trauma events

Assess pre- and post-trauma cue

Physiological arousal, pain sensitivity, affect.
Baseline
Trauma cue
exposure
↑ Arousal and negative
affect
PTSD
(n = 33)
PTSD – higher baseline arousal and
negative affect and lower pain threshold.
No PTSD
(n = 39)
Post-exposure
↓ Pain threshold
Minimal changes in
arousal, affect and pain.
Between groups = PTSD, No PTSD
Repeated Measures = Baseline and Post-Exposure
Heart rate
Blood pressure
Respiratory Rate
Skin Conductance
Skin Temperature
Pressure
- Local - cervical spine
- Remote - Median nerve
& tibialis anterior

Heat and Cold
- cervical spine
-PTSD group reported more negative affect across time.
-Increase in negative affect for both groups after trauma-cue
-Stronger increases in PTSD group compared to the No PTSD group.
-Similar results for self-reported Pain on NRS.
Heart Rate
Blood Pressure
- PTSD group higher arousal (HR and BP) across time.
- Increased arousal in both groups after trauma-cue.
- Significantly greater increases in PTSD group compared to No
PTSD.
C2
Cervical Spine
- PTSD group lower
across time.
- Further decrease in
PTSD group after
trauma-cue.
240
PTSD
No PTSD
220
200
180
160
140
120
100
Remote Sites
Baseline
- PTSD group lower across time
- Minimal changes after trauma-cue.
Post trauma cue
-PTSD group had lower thresholds to cold and heat across time.
- Significant decrease in cold threshold for PTSD after trauma cue.
- Minimal change in heat thresholds after trauma-cue.

PTSD in WAD patients is associated with:
› greater negative affect and
physiological arousal.
› Lower sensory pain thresholds
› Further decreases in cold and
cervical pressure thresholds after
trauma-cues.

Can we treat PTSD in patients with WAD?
Trauma focused CBT has been shown to
have moderate effectiveness in treating
PTSD within chronic pain samples.1,2,3
 A case study has shown CBT aimed at
PTSD within Whiplash resulted in
improved chronic pain management
and coping.4

1.
2.
3.
4.
Back, Coffey, Foy, Keane & Blanchard, 2009
Shipherd , Back, Hamblen, Lackner & Freeman., 2003
Taylor et al., 2001
Jaspers, 1998

CBT for PTSD will result in:
› reduced PTSD symptoms
› reduced negative affect and physiological
arousal to trauma-cues
› improved functional disability and quality of life

Previous research indicates minimal
impact of CBT for PTSD on pain measures.
Assessed as eligible from
Study 1 (PTSD and WAD) (n = 33)
Did not consent to
participate (n = 7)
Consented to participate –
Random allocation (n = 26)
4 due to time, 2 due to
transport and 1 was
already receiving psych
treatment
Allocated to TREAT condition
(n = 13)
Allocated to WL condition
(n = 13)
Analysed at post (n = 12)
Analysed at post (n = 11)
Discontinued treatment (n =1)
due to moving interstate
Lost to follow up (n =2)
1 declined to participate further and
1 unable to contact
Analysed at 6-mo follow-up (n = 11)
Discontinued participation (n = 1)
1 participant completed questionnaire data but not
physical measures
10 weekly sessions with clinical psychologist
 CBT for PTSD based on Bryant program
 Treatment components included:

› Relaxation training (e.g. deep breathing, PMR)
› Cognitive restructuring
› Imaginal Exposure (recalling accident with
thoughts, physical sensations and emotions)
› Invivo Exposure (fear hierachy of avoided
accident related activities, people and
places)
› Relapse prevention

Participants in Treatment (n=13) and WL
(n=13) were comparable on:
› demographic and accident variable
› initial and current WAD symptoms.
› trauma symptoms (SCID, PDS and IES-R)
› depression, anxiety and stress (DASS)
› Fear of re-injury (TSK)
› Neck pain intensity (NRS) and disability (NDI)
› Medication use
90
80
70
60
50
40
30
20
10
0
76.9
61.5
WL
TREAT
15.4
Post
6month
- Sig more people in TREAT group (8/13) no longer met
PTSD criteria at post-assessment, compared WL (1/13).
- Treatment effects were maintained at 6mo FU with 9/13 no
longer meeting criteria for PTSD.
45
40
35
WL
TREAT
30
Pre
Post
6mo
-TREAT group showed significantly greater improvement
in neck disability post-treatment, compared to WL group .
- Improvements were maintained at 6month follow-up.
- Overall trend (p=.08)
for greater
reductions in
baseline arousal
measures (BP and
HR) in TREAT group
compared to WL.
HR
78
76
74
WL
TREAT
72
70
68
Pre
Post
- Reduced physiological reactivity to the
6mo
trauma cue (comparison of difference scores
pre-post cue) in TREAT group compared to WL
group for all 3 arousal measures.

Minimal changes between groups or over time
for PPTs (remote or local) or HPT.
16
Trend (p=.07) for
greater reductions in Cold
14
Thresholds for TREAT
compared to WL.
12
 Also trend (p=.08) for
reduced Cold thresholds in10
TREAT Group from pre-6mo.
Cold

WL
TREAT
Pre
Post
6mo

The trauma cue was found to have less
impact in TREAT group compared to WL
for Cold pain at post-treatment and this
was maintained at 6mo.
CBT was found to be effective in treating
PTSD within chronic WAD.
 Need to replicate in acute WAD.
 CBT for PTSD had impact on pain thresholds.
 Future research on treatment for this
comorbidity should look at using CBT first to
reduce PTSD symptoms and then focus on
physical therapy for WAD symptoms.

1.
2.
3.
4.
Identify high risk of PTSD using a screen.
Provide information-based intervention
Confirm with clinical assessment.
If ASD/PTSD comorbid with WAD pretreat with Trauma-Focussed CBT +1 mo.,
then intervene with WAD.