Download Whiplash - Patrick Soto, DO

Whiplash and Its Associated Disorders
Patrick Soto, DO; ABPMR
Spokane Spine Center
124 E Rowan Ave
Spokane, WA 99207
509-487-8000
[email protected]
www.spokanespine.com
Physiatry
• We specialize in restoring optimal function to
people with injuries to the muscles, bones,
tissues and nervous system.
• Understanding the prognosis, recovery process
and functional impact of an illness.
• Primarily a nonsurgical conservative approach
when possible.
Physiatrist
Overview of Topics
• Injury mechanics, phases of healing, and stages
of treatment.
• Real world statistics of permanent injury.
• Medicolegal:
– Maximum Medical Improvement (MMI)
– Settling the MVC claim.
History
• First case series on Whiplash Associated
Disorder (WAD) : Gay J, Abbot K. Common
Whiplash injuries of the neck. JAMA 1953;152:
1698–704.
• In the 1950s and 1960s motor cars had no
supporting headrests.
• Ian Macnab, MD: extension-flexion injuries
recognized in WWI after observations of sudden
neck extension in pilots during catapult-assisted
takeoffs.
Ralph Nader 1965. Accused car manufacturers of resistance to
the introduction of safety features, like seat belts, and their general
reluctance to spend money on improving safety.
Prevalence
• Whiplash appears to be increasing in frequency
despite the addition of headrests to automobiles.
• In 1982 (UK), seat-belt legislation was
introduced and the next year the prevalence of
WAD rose 268% and continued to rise ~ 152%
yearly for the next 15 years
No-fault vs. Tort
• No-fault: entitled to benefits, regardless of fault,
but they are not allowed to sue for pain and
suffering.
• Tort: entitled to limited benefits (such as health
care and income replacement); they may also
sue the driver at fault for the collision for
additional expenses and for pain and suffering.
Annual incidence of reported WAD
Western world
(tort and no-fault)
300 per 100,000
inhabitants (0.3%)
Quebec, Canada
(no-fault)
70 per 100,000
(<0.1%)
UK
300,000 per
59,000,000 (0.5%)
Australia
(no-fault)
106 per
100,000 (0.1%)
Costs of US MVCs in 1994
•
•
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Total costs: $150.5 billion
Property damage: $52.1 billion
Lost market productivity: $42.4 billion
Medical expenses: $17 billion
Direct costs to taxpayers: $13.8 billion = $144 in
added taxes to each household.
PIP Coverage in Washington
• Basic provides the following minimum benefits:
• Up to $10,000 for reasonable and necessary medical
expenses for each individual injured in an auto accident.
This is available for up to three years from the date of
the accident.
• Up to $200 per week for income replacement coverage.
This is limited to one year after a person has been
disabled for 14 days after the accident.
• Up to $2,000 for funeral expenses.
• Up to $5,000 for loss of services (payment to others for
work you can't do).
Injury mechanics
• Whiplash Associated Disorder (WAD)
• Strains and sprains
• Post-traumatic core muscle fatty infiltration noted
on MRI
• Central hypersensitivity
Injury Mechanics
• The usual whiplash injury is a sprained neck
occurring as a result of a MVA that produces
stretching or occasionally tearing of soft tissues
such as muscle, fascia, ligaments, joint capsule,
blood vessels and nerve fibers. The upper and
lower back may also be sprained. Occasional
injuries to the intervertebral disc, bone or
neurological system may occur in complicated
cases but not in a common whiplash injury.
Signs and Symptoms
• Pain, stiffness and impaired mobility of the
cervical, thoracic and lumbar regions.
• Radiating pain and paresthesias in the
extremities
• Headache and cognitive problems.
• Nausea, dizziness, vision disturbances
• Impaired sleep
• Anxiety/PTSD/depression
Signs and Symptoms
• Examination can be nonfocal and nonanatomic
• X-rays, CT and MRI are seldom conclusive
Signs and Symptoms
• Experimental studies have shown that the
craniovertebral region as well as the mid- and
lower cervical spine can be exposed to harmful
translations and hyperflexion and extension
forces by a whiplash trauma.
1995 Quebec Task Force (QTF)
• WAD defined as the various clinical
manifestations of, or the disability caused by,
‘whiplash injury’
• An acceleration-deceleration mechanism of
energy transfer to the neck…which might result
in bony or soft tissue injuries
Quebec Task Force on WAD
• Grade 0: “no complaint about the neck, no
physical sign(s)”
• Grade 1: “neck pain, stiffness, or tenderness,
with no physical sign(s)”
• Grade 2: “neck pain, stiffness, or tenderness
with musculoskeletal sign(s)”
• Grade 3: “neck pain, stiffness, or tenderness
with neurological signs”
• Grade 4: “neck fracture or dislocation, SCI.”
Quebec Task Force on WAD
• Rear-end collisions resulted in higher rates of
relapse or recurrences of symptoms.
• Seatbelts may increase risk for injury
• Whiplash claims notably higher for women.
• 21% of occupants reported 12 hr delays in
symptoms
• Permanent injury should not occur.
• The cervical facet joints
have been proposed as a
source of chronic pain.
Cervical Facet Joints
• Several elegantly designed studies have
demonstrated the cervical facet joints to be the
source of persisting symptoms
• One group of authors have reported a
prevalence of ~ 50% facet derangement in a
selected group of patients with late whiplash
symptoms
Cervical Facet Joints
• Cadaver study of 18 specimens exposed to
2.6G-4.6G of right side impact acceleration.
Found with right lateral impact, left sided injuries
noted to the disc and rupture of facet joint
capsule at one of the C4-T1 joints. In some
cases noted fracture to the right articular
process.
Cervical Facet Joints
• Simulated in vitro low speed rear end collisions
of cadavers demonstrated cervical facet joint
spearing, significant stretch injury to the ALL and
facet joint capsules
Undetectable Injuries
• Seminal research by Taylor and Twomey:
serious spinal injuries detected on post-mortem
examination that were otherwise hidden to
conventional imaging.
• Found otherwise undetectable injuries including
bleeding into the dorsal root ganglia, small
fractures of the facet joints, bleeding into the
facet joints, and rim lesions to intervertebral
discs.
Post-Trauma Core Muscle Fatty
Infiltration
Post-Trauma Core Muscle Fatty
Infiltration
• Atrophy is associated with LBP and “appears to
help perpetuate an inhibitory feedback loop that
begins with pain in the spine, possibly stemming
from the IV disks or zygapophyseal joints,
followed by reflex inhibition of the multifidus and
then atrophy and fatty replacement of the
muscle
Post-Trauma Core Muscle Fatty
Infiltration
• Study of 113 females (79 WAD) with rest as
controls. Significantly higher fatty infiltration seen
in deep extensor muscles than controls.
Central Hypersensitivity
• The authors used live anesthetized rats and
stretched the C6-C7 cervical facet joint capsule.
“The increase in neuronal firing across a range
of stimulus magnitudes observed at day 7 postinjury provides the first direct evidence of
neuronal modulation in the spinal cord following
facet joint loading, and suggests that facetmediated chronic pain following whiplash injury
is driven, at least in part, by central
sensitization.”
Phases of healing
Phases of healing
• Hippocrates emphasized the importance of a
prognosis 2400 years ago.
• A physician should avoid giving a prognosis
immediately after the injury
• After 2 weeks if they are still symptomatic, it
helps patients to have some idea of the
prognosis.
Stages of treatment
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Acute, Subacute, Chronic treatment
Over treatment vs. lack of treatment
Passive treatment vs. active treatment
Practioners can prolong the disability by
continuing ineffective therapy and not realizing
that time is critical in deciding on appropriate
therapy and in preventing illness behaviors.
To Image or Not?
Canadian C-Spine Rule
• GCS 15
• Medically stable
• Dangerous mechanism =
fall >3 ft or 5 stairs, axial
load to the head,
MVC@> 62mph, rollover
or ejection.
• Motorized recreational
vehicle
• Bicycle collision
Imaging
• “There is no evidence that the degree of cervical
lordosis or kyphosis can accurately identify
“cervical muscle spasm” or distinguish patients
with WAD from those without WAD.”
• “There is no evidence that MRI accurately
detects specific trauma-related findings in the
cervical spine in the absence of fracture or major
ligamentous disruption.”
Bone & Joint Decade
2000–2010 Task Force on Neck Pain and Its
Associated Disorders
• Scott Haldeman, DC, MD, PhD.
• Gathering of international expertise covering all
relevant aspects related to neck pain and its
associated disorders.
• Initiative of the United Nations and the World
Health Organization
Bone & Joint Decade
2000–2010 Task Force on Neck Pain and Its
Associated Disorders
• ~32,000 research citations considered
• Critical appraisals of > 1,000 research studies
that were relevant to its mandate.
• Systematic review and a best evidence
synthesis, which resulted in a 21 chapter
supplement in the 2008 Spine journal.
• Focused on Grades I-III in regards to WAD
Bone & Joint Decade
2000–2010 Task Force on Neck Pain and Its
Associated Disorders
• 50% of those with WAD will report neck pain
symptoms 1 year after their injuries.
• Greater initial pain, more symptoms, and greater
initial disability predicted slower recovery.
• Few factors related to the collision itself were
prognostic.
Bone & Joint Decade
2000–2010 Task Force on Neck Pain and Its
Associated Disorders
• Post-injury psychological factors such as
passive coping style, depressed mood, and fear
of movement were prognostic for slower or less
complete recovery.
• Preliminary evidence that the prevailing
compensation system is prognostic for recovery
in WAD.
Medical Causation
• There must be a biologically plausible link
between injury event and the outcome (injurysymptoms)
• There must be a temporal relationship between
injury event and the outcome (injury-symptoms).
• There must not be any likely alternative
explanation for the injury or symptoms.
Causation
• There were no significant differences in the
presence and severity of WAD between men
and women at ΔV (change in velocity) 2.5 mph
and 5 mph or in the duration of WAD at 5 mph.
• There appears to be no connection between ΔV
and long term injury risk.
Causation
• 57 WAD cases evaluated for QTF grading and ΔV, with
56% reporting no symptoms. Of those reporting
symptoms (25 cases or 44%) c/o neck pain.
• QTF 1: 8 cases. QTF 2: 6 cases. QTF 4: 11 cases.
• There was no ΔV threshold associated with acceptable
sensitivity and specificity for the prognosis of a cervical
spine injury.
• Of the 57 cases, 21 involved rear impacts having a ΔV
range 5.6 - 23 mph.
Real world statistics of permanent
injury
• Bone and Joint Decade 2000-2010 Task Force
on Neck Pain and its Associated Disorders
concluded in review of 226 papers with 47
specifically on WAD prognosis, that about 50%
of WAD cases will continue to have symptoms at
one year.
Real world statistics of permanent
injury
• Approximately 25% of acute whiplash injuries
will become chronic. Áine Carroll. Clinical Rehabilitation
2008; 22: 513–519.
• Chronic pain after whiplash injuries may occur in
12–42% of cases. Long-term disability and
emotional distress is also frequent after whiplash
injuries. Ruben Nieto. Disability and Rehabilitation. 2011; 33(5):
389–398
Real world statistics of permanent
injury
• In subjects who did not have any complaints before the
collision, 77% still reported physical complaints four
years after the actual incident (headache, neck or
shoulder pain).
• 42% reported to suffer from neuropsychological
problems: impairments in attention and concentration,
memory and cognitive flexibility. Sleep disturbances and
depression.
• Symptom exaggeration, especially in patients involved in
medicolegal procedures, possibly resulting in
somatization behavior.
Neuropsych
• WAD patients often complain of concentration
problems and memory disturbances a long time
after the trauma (Schnurr and MacDonald 1995,
Provinciali et al. 1996).
• Temporarily impaired cognitive performance has
been verified by neuropsychological testing in
WAD patients: ‘impaired divided attention and
working memory’ (Kessel 2000: Bosnia et al.
2002)
Medicolegal
• Prolonged litigation is also likely to cause a
prolonged disability behavior. Litigation may
aggravate or cause psychological stress, may
lead to somatization, and such symptoms do not
appear to be cured by the verdict or settlement.
Medicolegal
• Primary goal of course is for the best possible outcome
of the patient. Regardless of the outcome there is a time
when the patient runs out of options.
• Has the patient been through conservative treatments?
• Has the patient seen the appropriate specialists?
• Can surgery correct the issue?
• Are there any new stated goals and progress towards
making those goals?
• Maintenance treatments = MMI.
Medicolegal
• If in your medical opinion the patient has
reached MMI, it is important for you to relay that
to the patient. (Key: expectations at the first
visit.)
• There is no benefit to the patient to keep a case
open beyond MMI since all it does is rack up
medical bills and lead to more patient anxiety
and a persistent state of unknown and
unrealistic expectations.
• Avoid redundant services.
Medicolegal Documentation
• Document and f/u at reasonable intervals. This
is different for each treating clinician.
• Stats from the Health Care Financing
Administration:
–
–
–
–
–
46.76% insuff/no documentation
36.78% lack of medical necessity
8.53% incorrect coding
5.26% unallowable services
2.67% other
MMI
• Lapse in care = >30 days
• Insurance companies argue that curative
treatment is within 60-90 days, beyond that its
therapeutic
• Maintenance/therapeutic care can be
recommended and continued after the case is
closed.
Summary
• There is extensive literature supportive of WAD
symptoms following a MVC.
• The most effective treatment regimen for WAD IIII classifications has not been established.
• 12-77% patients can be left with persistent
symptoms after exhausting available treatment
options.
• If this patient population is not your cup of tea,
then send them to us at Spokane Spine Center.
Thank you!
Bibliography
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Carroll, Áine. A prospective randomized controlled study of the role of botulinum toxin in whiplashassociated disorder. Clinical Rehabilitation 2008; 22: 513–519.
Carroll LJ et al. Course and Prognostic Factors for Neck Pain in WAD, pp S97-101. Spine,
2008;33(4S):1S-219S.
Centeno C. J., MD et al. The Case For and Against the MIST (Minor Impact Soft Tissue). Premise
Journal of Whiplash & Related Disorders, Vol. 4(2) 2005.
Elbel M, et al. Deceleration during “Real Life’ Motor Vehicle Collisions: A Sensitive Predictor for
the Risk of Sustaining a Cervical Spine Injury. Patient Saf Surg, 2009;3(1):5.
Elliiott J et al. Fatty Infiltration in the Cervical Extensor Muscles in Persistent Whiplash Associated
Disorders: A Magnetic Resonance Imaging Analysis. Spine. 2006;31(22)
Freeman MD, et al. The Role of the Lumbar Multifidus in Chronic Low Back Pain: A Review.
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Galasko, Charles S. B. Prevalence and Long-Term Disability Following Whiplash-Associated
Disorder. Journal of Musculoskeletal Pain, Vol. 8(1/2) 2000.
Grauer, J.N., et al., Whiplash produces an S-shaped curvature of the neck with hyperextension at
lower levels. Spine, 1997. 22(21): pp. 2489-94.
Guzman J et al. Clinical Practice Implications of the Bone and Joint Decade 2000-2010 Task
Force on Neck Pain and its Associated Disorders, Spine, 2008;33(4S):199-213.
Haldeman, S, et al. Findings From The Bone and Joint Decade 2000 to 2010 Task Force on Neck
Pain and Its Associated Disorders. JOEM, Vol 52, Number 4, April 2010: 424-427.
Bibliography
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