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Neck pain and Whiplash From the roadside to the pain clinic (via primary care)

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. Resources Definitions Case histories Evidence Guidance Questions on the way…. Neck pain, whiplash and WAD

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Neck pain and Whiplash From the roadside to the pain clinic (via primary care)

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  1. Neck pain and WhiplashFrom the roadside to the pain clinic (via primary care) Richard Griffiths FRCA FFPMRCA Consultant in Anaesthesia and Pain Medicine

  2. Agenda • Resources • Definitions • Case histories • Evidence • Guidance • Questions on the way…

  3. 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

  4. 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

  5. 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”

  6. 9/10 of patients above 65 years have this Medicalising “normal” Radiographic changes correlate poorly to symptoms Cervical spondylosis ######## ########

  7. BrachialgiaCervical radiculopathy Pain in upper limb from entrapment of cervical nerve root(s) ##### ##### ####### ######

  8. 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

  9. Differential diagnosis • Soft tissue injury • Mechanical lesions – eg. disc injury • Inflammatory - arthropathies • Metabolic – Paget’s, osteoporosis • Infective – including TB • Malignancy - 1°, 2° and myeloma • Fibromyalgia • Whiplash

  10. ####################

  11. 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

  12. Whiplash “an acceleration-deceleration mechanism of energy transfer in the neck”

  13. Question 1 • Whiplash accounts for what proportion of motor insurance claims? • 35% • 58% • 76%

  14. 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

  15. Whiplash - classification “an acceleration-deceleration mechanism of energy transfer in the neck” Acute whiplash 0 - 12 weeks Chronic whiplash > 12 weeks Quebec Taskforce grading I No neck complaint II Pain/stiffness osigns III Pain + ROM + Tenderness IV as above with neuro signs V as above with fracture/ dislocation

  16. Question 2 Which of the following would now be described as whiplash? • Railway spine • Spinal concussion • Cervical sprain

  17. 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

  18. Prognosis Great variation Factors that lead to poor prognosis are: high initial disability high initial pain scores low self efficacy catastrophising educational level %recovered VAS (0-10) 1 month 44% 3.8 12 months 65% 2.5 2 years - 2.2 5 years 75% - South Australasia Centre for trauma 2008

  19. Question 3 What proportion of headrests are incorrectly positioned? • 20% • 50% • 70%

  20. WHO Analgesic ladder Step 1 Paracetamol NSAIDS / COX II inhibitors Step 2 Codeine Dihydrocodeine Co-analgesics Step 2 3 Tramadol Tapenthadol Step 3 Zomorph Oxycontin

  21. Acute whiplash – guidanceNICE clinical knowledge summaries • Diagnosis and exclude sinister causes • Reassurance • Encourage return to normal activity • Discourage rest and immobilisation • Simple analgesia • Physiotherapy • Treat anxiety and low mood

  22. 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

  23. 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

  24. Evidence

  25. 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”

  26. 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”.

  27. Traction for chronic neck pain • 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”.

  28. Pillows “No evidence in a cross over study that “special neck pillows” outperformed a normal pillow” Cochrane Review 2011

  29. Recommendations chronic whiplashNICE 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

  30. Not recommended • Surgery • Cervical epidurals • Botox injections Cervical rhizotomy may be useful…

  31. 24 patients Proven cervical facet joint pain after whiplash Multi-level cervical facet rhizotomy (80°C) Telephone follow up Cervical interventionLord, Bogduk et al NEJM 1996 Following whiplash injury, patients with proven chronic cervical facet joint pain can gain lasting relief (9 months) from radiofrequency neurotomy”

  32. Common questions

  33. 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

  34. 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

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