Whiplash Associated Disorders

"Whiplash" is defined as an acceleration-deceleration mechanism of energy transfer to the neck that results from rear-end or or side impact motor vehicle collisions. It can also derive from diving accidents or other similarly occurring impacts that result in bony or soft tissue injuries. These injuries can in turn lead to a variety of clinical manifestations. The collection of clinical manifestations has been called "Whiplash Associated Disorders" or WAD.

The Quebec Task Force WAD classification according to clinical presentation is as follows:

Grade Clinical Presentation

0 No neck complaints and no physical sign(s)

I Neck pain, stiffness or tenderness and no physical sign(s)

II Neck complaint and musculoskeletal sign(s)

III Neck complaint and neurologic sign (s)

IV Neck complaint and fracture or dislocation

The Gargan and Bannister classification of symptom severity is as follows:

Group Symptons

A Asymptomatic

B Mild Symptons not affecting work or leisure activities

C Intrussive symptons interfering with work or leisure. Frequent use of analgesics, orthosis, or physiotherapy.

D Severe problems: lost job, continual reliance on analgesics, orthosis. Repeated medical consultations.

The epidemiology of Whiplash Associated Disorders varies from country to country. The incidence has been reported as highest, 188/100,000 in the Netherlands to lowest, 39/100,000 in Australia.

Early ideal treatment involves the general rules of assessment for major trauma at the initial site and time of the accident. These involve preservation of life and prevention of further damage to the spine and cord and preservation of spinal function. This has been laid out in the US National Acute Spinal Cord Injury Study. The key is to assume spinal instability until proven otherwise.

In the Emergency Department Acute Traumatic Central Cord Syndrome (ATCCS) must be excluded. This is a complex spinal cord syndrome which presents with incomplete neurological deficits such as the ability to walk but not move hands, and sensory changes such as burning hands or urinary retention. MRI generally shows white matter involvement but no hemorrhage. The prognosis is generally good.

Fractures are ruled out by xrays.However if the xrays are normal but the patients persists in having severe pain special x ray views are indicated. If persisting severe pain without any abnormality being found then a hard collar is applied and an MRI is done within24-48 hours showing flexion/extension views to rule out ligamentous injury.These xrays and imaging are all however open to a variety of pitfalls requiring expert interpretation.

Once major injuries are ruled out the normal approach to WAD (Whiplash Associated Disorder) is reassurance and education, no soft collar, Non steroidal anti inflammatory medication such as ibuprofen or naproxens, and early mobilization. Rest and cervical collars can have a detrimental effect on the outcome.

This said nearly 75% of injured patients report immediate symptons such as cervical pain, painful neck movement, painful back, shoulder pain, disturbance of consciousness and dizziness. Examination may show paresthesias, ie unusual sensations, and weakness. Later patients may have visual disturbance, problems with concentration, fatigue, sleep impairment, as well as irritability and anxiety and depression. Interestingly studies show that the anxiety and depression are most directly related to the presence of symptons such as pain and disability. Anxiety and depression do not appear in contrast in those who are early asymptomatic.

While it is important to remember that approximately 10 to 30 % of the general population who have not had an injury report chronic neck symptons, studies show that 15 to 40 % of the WAD patients have chronic neck pain with 10% reporting this as severe. Studies have showed that there can be little alteration of in symptons by three months and stabilizing at 2 years. Authors in prospective study showed little alteration in sympton severity for the majority of patients (64%) between 3 months and 7.5 years . Between 3 months and 2 years the symptons fluctuated significantly and prognosis based on this were unreliable. Therapeutically the greatest benefit for influencing outcome was in those first three months. One interesting study showed that high dose methylprednisone resulted in earliest return to work.

There have been many issues raised relative to the prognosis or eventual outcome of the injury. This has been difficult because there is no clear definition of what is recovery. At best crude measures of symptons or disability have been used along with such matters as 'return to work', 'discontinuation of treatment', or 'conclusion of litigation' .

That said, a systematic review of prospective cohort studies done in Pain 2003 concluded that "strong evidence was found for high initial pain intensity, and strong evidence for no prognostic value for older age, female gender, high acute psychological response, angular deformity of the neck, rear-end collision and compensation". Limitted evidence was found for some physical, psychosocial, neuropsychological, crash related and treatment related factors in terms of prognosis.

References:

Initial assessment of whiplash patients, Dr. R Gunzburg, M. Szpalski, J. Van Goethem,Pain Res Manage Vol 8 No 1 Spring 2003

Fluctuation in recovery following whiplash injury, 7.5 year prospective review, P.J. Tomlinson, M.F. Gargan, G.C. Bannister, Injury, Int. J. Care Injured (2005) 36, 758-761

Sensory hypersensitivity occurs soon after whiplash injury and is associated with poor recovery, Michele Sterling, Gwendolen Jull, Bill Vicenzino, Justin Kenardy, Pain 104 (2003) 5009-517

Prognostic factors of whiplash-associated disorders: a systematic review of prospective cohort studies, Gwendolijne G.M. Scholten-Peeters, Arianne P. Verhagen, Geertruida E. Bekkering, Danielle A.W.M. van der Windt, Les Barnsley, Rob A.B. Oostendorp, Erik J.M. Hendriks, Pain (104 (2003)303-322

Psychosomatic and Complex Pain

Pain disorders have been called the new "hysteria". When I began in psychiatry I saw a lot more 'waxy catatonics' and 'hebephrenics'. There was a lot of 'drama' in psychiatry a few decades back. Multiple personality disorders let loose with alien possessions and demon states. More and more though 'lethargy' and "pain" became front and centre. Part of it is an aging population. There's just so much drama the old can stand. "Martha, don't get your depends in a twist." That's the new toughlove statement of the new aging boomers..

When I began in psychiatry everyone was hearing the devil speaking to them. Today the only ones who care about Satan are the one's who have that name on their record labels. Hallucinations are not from religion but from the CIA. Big Brother is watching, not God. Paranoia is as common if not more so, just the themes have changed.

Pain is subjective. With hysteria there was 'mutism' and 'mannerisms' and generally some 'objective' criteria. Today pain is seen in a 'limp' or a 'grimace' but everyone has pain. Your pain is greater than my pain. I can work. You can't work. I can't work. You can work. Secondary gain is the same. Is there an advantage to having the pain. Of course I 'll argue till the cows come home and indeed my arguing in that way will only mean 'the lady protestest too much' but my lawyer will make it even clear. I've got pain. Get it. If it's associated with a compensation claim or insurance the pain just has to be worse. But then there is pain. Chronic pain is the worst. Once you've had pain you appreciate pain. Experience brings empathy

"It's not all in my head, doc." He says when I say "You've a pain disorder." Of course it's all in his head. Cut off the head and the pain would go for sure. But I know what he means. "You're not making it up and you're not imagining it but all chronic pain is 'psychosomatic." Indeed all medicine is psychosomatic. Only the surgeons would have us believe anything is just physical. In collusion with the anesthetist they do their work with the patient in a dream state and because their 'fix' is 'mechanical and 'visible' and 'objective' then it's 'real'.

But their post surgical survival rates are 'psychosomatic'. It's all a combination of mind and matter and nothing is just physical because the mind is the communication hub. Without the mind or 'psycho' there would be no complaint that lead to the surgery and no inhabitant of the housing to appreciate the sutures post surgery. Infection, well, that's a whole lot worse in people with depression or a variety of contributing mental illnesses.

Psychiatry separates pain disorder with a physical medical condition and pain disorder with out an accompanying physical condition. In the former case the pain is the subject of treatment as well as the physical condition where as in the latter there is as yet and may never be a treatable physical condition. In the formal case, treating the physical condition often alleviates the pain as much as just treating the psychological state. Treating the physical pain in the latter can create addiction and generally those conditions respond better to antidepressants or anti anxiety medications. Not surprisingly most of the 'chronic pain' conditions were treated with psychiatric medications like amitriptylline.

I began treating the pain of cancer patients. We used a cocktail of antidepressants, anti anxiety medication and traditional anti pain medication. If narcotics only treated pain there would simply be no addiction to narcotics. Either that or life is pain. The Buddha said Desire is the root of all suffering. Kierkegaard, the great Christian existentialist said Life is suffering unto death.

Yet I have recovered addicts who take narcotics for their physical pain, plates in broken bones, and they don't abuse their pain medication while they used to 'abuse' the very same medications for it's 'psychological' effect.

I had a marijuania addict trying to convince me he had a pain disorder. Trouble was he was an addict and when I offered him another drug that would take away the pain he described he said, "Nah, I just want you to fill out the paperwork so I can get my herb." He didn't want to work either. There's a perfectly good drug, not like the drug cannabis, which specifically treated the pain he described. Any patient with that particular pain would leap have leaped at the treatment. There are these incongruences. The sad part is the addict so often thinks they're 'fooling' you or they are unwilling to 'admit' to themselves. The key feature of addiction is the 'dishonesty' linked to denial.

My detective friend took a video of an 'academy' teaching people to jump in front of cars so that they could get hit but not hurt. They actually charged students for the knowledge and practice. As a consequence insurance all over goes up exponentially. Fraud is what it's called but often it's masquerades a "medical" or 'psychiatric disorder'. Not only that there are those who have 'factitious disorders' ,these are people who actually 'feign' physical or mental disorders to get medical or psychiatric treatments. The police know of the same sort that do things to get cops to shoot them. It's true that life is stranger than fiction.

Psychiatrists recently were advised against diagnosing "malingering' and told that increasingly judges are afraid to make such a diagnosis. Just as politicians are running countries based on popularity polls increasingly no one wants to take the risk of 'offending' anyone. The last wheel chair I took away was given back to this person because they 'psychologically' needed it. Overnight I became suspicious of the disabled parking signs and the politics of priviledge increasingly infiltrating 'disability'.

Yet even as I validate a person's pain I have to say that not exercising is also not good for them. Sadly the surgical treatments for pain disorders, removing the nerves to a region, also removes the danger sensations. Workman's compensation locally found that people who had injuries commonly went home and lay about on the couch compounding their injury where as now they have a club house and get the person to come out and socialize rather than become agoraphobic. Depression is best treated in community. This approach cut down on the alcoholism associated with work disability. Home alone injured , what better to do that crack a brew, and another ,and another. Of course it's also cut into the second family businesses but for those who are wanting to get back to work the club house approach and physiotherapy certainly expedited the process.

The contribution of mind over matter is sometimes 30% versus 70% or vice versa. Personally I've found that rarely has the pain that I remember I said prevented me from an evening with a mother in law interfered with hunting or fishing. Then there has been pain that stopped me even fishing. Now that's pain. I understand when the mother crying says she can't pick up her baby. However when I asked a woman if her pain affected her sex life, she told me "I can't have sex with my husband." Did you have sex with him before the pain? "No, I never liked sex with him," she said.

The sad part is when a man or woman is trying to work to the limits of their pain to strenghthen their muscles or ligaments and a camera catches that moment. Suddenly he looks bad, but shouldn't he do what his chiropractor told him. One patient after a morning in the gym loses the whole next day with pain and fatigue. I can relate, but he's only 20. My doctor wants me to exercise more but I'll probably only listen because I got the dentist bill and he said, "It would have been better if you'd flossed."

But the worst 'act' I ever saw of pain was a guy claiming he was having a heart attack and demanding a shot of morphine. If I'd not have done an EKG I'd not have 'caught' the massive MI. In contrast my native woman didn't make a sound but only turned her head to the side as tears flowed out her eyes when in an emergency procedure I took blood clots out of her post partum womb without anesthesia. Cross culturally pain is even more difficult to assess.

Regardless, acute pain and chronic pain are different. What is done for acute pain is commonly diametrically opposed to what is done for chronic pain. Acute pain requires rest usually where as chronic pain requires exercise. Yet how do you explain that to someone who is personally and culturally faced with a paradox.

Psychosomatic pain doesn't mean it 'doesn't exist', "it's imaginary' but rather that it's 'complex'. Indeed the new term is "complex pain disorder" is increasingly being used because it saves everyone a lot of bother.

Nothing has changed much but the 'term'. There's more to it than that but even that is 'complex'. No 'it's not all in my head" Really. It's complex. You know, like our relationships these days.

 

 

Psychiatric Medication in Recovery

Psychiatric Medications are an acceptable part of a good Recovery Program. That said, there are clear guidelines which while not written in stone should be well known to those in recovery or those prescribing to those in recovery should the need for medications arise.
Abstinence from all substances is clearly the aim in the first year of recovery. A study out of Hazelton showed that there was greater relapse in those who used antidepressants than those who did not. There were factors of what was controlled for in this study but it did give an indication of the potential hazard 'treating a drug' problem with a drug might be.
Any drug that has a "price" on the street has potential for abuse and should be seriously considered before use in early recovery. This specifically refers to all the benzodiazepine class and the the amphetamines and pain killers.
The benzodiazepine class includes valium, diazepam, alprazolam, ativan, clonazepam, and temazepams as examples. The amphetamine class includes the dexedrine and ritalins. The pain killers are the narcotic class of drugs codeine, tylenol#1,2and 3, oxycontins, demerols etc.
This doesn't however refer to antidepressants or antipsychotics which necessarily have a positive place in recovery. Medications such as the SSRI's, paxil, prozac, zoloft, celexa, cipralex and the more broad spectrum antidepressants, effexor, duloxetine, remeron, wellbutrin are often beneficial in recovery. Antipsychotics or tranquillizers such as seroquel, zyprexia, rispiridone, zeldox, loxapine, flupethixol are very beneficial and commonly used instead of the benzodiazepine class for anxiety.
At an addiction medicine conference this summer the presenter asked how many of the hundreds of addictionists present had prescribed benzodiazepines or amphetamines or pain killers and 90% admitted to this practice. The majority of those doctors there were in 12 step recovery programs themselves.
The presenter said that the key factor was the 'recovery' program and the duration of recovery before the introduction of medication.
Each case required individualization within the context of strong guidelines putting recovery in the forefront.