Neck Pain With Movement Coordination Impairment (WAD) PDF

NECK PAIN WITH MOVEMENT COORDINATION IMPAIRMENT (WAD) Davide Seri PT, MSc, OMPT Tommaso Cavicchi PT, MSc, OMPT Giulia Montefusco PT, OMPT...

NECK PAIN WITH MOVEMENT COORDINATION IMPAIRMENT (WAD) Davide Seri PT, MSc, OMPT Tommaso Cavicchi PT, MSc, OMPT Giulia Montefusco PT, OMPT Jessica Cammareri PT, OMPT Giuliana Rosso PT, OMPT «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Definition of WAD ‘Whiplash-associated disorders’ (WAD) is the term given to the variety of symptoms often reported by people following acceleration/deceleration injury to the neck, most commonly via a road traffic crash Sterling, 2014 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Diagnostic Criteria WHIPLASH AND ASSOCIATED DISORDERS CONCUSSION DIZZINESS «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Epidemiology and economical burden (WAD) Most common outcome in noncatastrophic motor vehicle collisions (MVCs): >300/100,000 in ED in Europe and North America (Carroll, 2008) ∼75% of all survivable road traffic crash injuries in Australia (Connelly, 2006) Economic burden of WAD is increasing: $350M (2011-2012) in Queensland, AU (MAIC, 2012) $1.5MLD (1989-1998) in New South Wales, AU (NSW Motor Accidents Authority, 1999 ) >3MLD/Year in UK (Joslin, 2004) 230MLD/Year (2000) in US (Blincoe 2002) Total costs for WAD > spinal cord injury + traumatic brain injury (MAIC, 2012) «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome What is the problem with WAD? HIGH ECONOMIC BURDEN «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Clinical Course/Prognosis Traumatic Neck Pain Mild problems Moderate problems Severe problems Rapid recovery Incomplete recovery No recovery 45% 40% 15% Recovery happens mainly in the first 6-12 weeks ≃ 50% will not recover but report ongoing pain and disability at 1 year Sterling, 2010; Carroll, 2008 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Clinical Course/Prognosis Sterling, 2014 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome What is the problem with WAD? HIGH POOR ECONOMIC RECOVERY BURDEN «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Mental Health Prevalence of Psychiatric disorders in people with persistent WAD: PTSD(25%) MDE(31%) GAD (20%) Sterling, 2010; Mayou, 2002 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Mental Health PSYCHIATRIC PHYSICAL DISORDERS DISORDERS Disability Healthcare utilisation Pain Time off work Physical function Dunne, 2012; Sterling, 2011 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome What is the problem with WAD? HIGH POOR ECONOMIC RECOVERY BURDEN POOR MENTAL HEALTH OUTCOMES «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Compensation claim Sterling, 2010 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome What is the problem with WAD? HIGH POOR ECONOMIC RECOVERY BURDEN POOR MENTAL COMPENSATION HEALTH CLAIM OUTCOMES «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Mechanism of injury «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Mechanism of injury «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Four Phases Model Cusick, 2001; McConnell, 1995; Svensson, 2000 Phase 1: Phase 2: Pre-impact Inertial acceleration (T- Resting position spine and CTJ pushed forward) S-shaped curve LCS ext + UCS flex First joint trauma Phase 3: Phase 4: LCS & UCS Hyperext Rebound LCS & UCS Hyperflex Anterior tissues strain Posterior tissues strain Posterior components compression Anterior components compression «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Pathoanatomical lesions Strain, partial or complete rupture of capsule, anuli fibrosi, ligaments Intrarticular contusions, fractures Dorsal root ganglion Likely there is a lesion, but Cervical Artery Dysfunction it can’t be detected by Muscle tears (SCM, clinical imaging Semispinalis capitis, multifidus Curatolo, 2011 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Pathoanatomical lesions Could they be relevant for persistence of symptoms? “It has become clear that purely tissue-based models are unable to satisfactorily explain the experience and presentation of WAD.” Walton, 2017 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Classification of WAD QUEBEC TASK FORCE CLASSIFICATION GRADE SYMPTOMS WAD 0 No physical signs No complaints of pain WAD I No physical signs Complaints of neck pain/tenderness WAD II MSK signs and symptoms Complaints of neck pain/tenderness WAD III Neurological signs and symptoms MSK signs and symptoms Complaints of neck pain, often radiating into and down the arm WAD IV Fracture and/or dislocation Complaints of pain Spitzer, 1995 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Other management models Leeuw, 2007 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Processes underlying WAD Motor control dysfunction Sensorimotor disturbances Altered pain-processing mechanisms Psychological factors PTSD and stress-related factors Sterling, 2014 Walton, 2017 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Sensory hypersensitivity Van Oosterwijck, 2012; Sterling, 2003 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Is it the same as nontraumatic neck pain? Scott, 2005 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Stress response Andersen, 2022 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Stress response Andersen, 2022 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Is that all? «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome EXAMINATION Clinical Algorhytm Component 1: Medical Screening Component 2: Classification (based on ICF and ICD) Component 3: Determination of condition stage Component 4: Intervention strategies for patients with neck pain «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Subjective examination Identification of Provisional related symptoms Rule in/out serious identification of pain (sensorimotor pathology mechanism(s) disturbances, sleep disturbances) Aggravating/relieving Screening for Determination of factors and functional psychological or diagnostic limitations social moderators hypotheses Prognostic factors assessment «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Screening for referral Fracture «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Screening for referral Ligaments «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Screening for referral Vascular «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Neurological examination Subjective examination Objective examination Cranial nerves Peripheral nerves (motor, sensory, reflexes) UMN signs Neurodynamic tests «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome What if I have a WAD III? «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Prognostic factors assessment Can we predict those who won’t recover? «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Can we predict those who won’t recover? Sterling, 2014 Ritchie, 2015 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Can we predict those who won’t recover? Blanpied, 2017 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Outcome measures Physical Perceived Psychological Quality of Pain Work/social Functioning recovery Functioning Life Functioning Neck Disability Global Rating PFACTS-C EQ-5D-5L NPRS Single-item Index (NDI) of Change questions (current Scale work status, % of usual work) Whiplash PSEQ SF-6D VAS Disability Questionnaire PCS Harvard Trauma Questionnaire Posttraumatic Diagnostic Scale (PDS) Sterling, 2023 Diagnostic Criteria Cranio-Cervical Flexion Test (CCFT) Neck flexors muscle endurance test Pressure algometry Strenght and endurance deficits of the neck muscles NP at mid-range that worsens at end- range Point tenderness/sore spots/trigger points Sensorimotor impairments Neck and referred pain reproduced by provocation of cervical segments «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Physical examination Rule out WAD IV Screen for WAD Clinical Assessment of Assessment of (C-spine rules III/ Assessment of Neuromuscular Sensorymotor etc.): Differentiation Pain Sensitivity Function: System: between WAD I- (when indicated): III: Midline tenderness C AROM (quantity, Mechanical Axioscapular Function Ie. JPS, Smooth C rotation quality, NM control, hyperalgesia (Manual C Flexors and Pursuit, Neck Torsion fear/hesitancy/guardin palpation, PPT, ULNT1) Extensors (CCFT, Test, Balance, Gaze g) Thermal hyperalgesia endurance) stability Neurological (Cold/ice) examination (when indicated) C manual assessment (be careful) «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  What does the CPG TREATMENTrecommend? Treatment – Acute/Subacute «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Collar? «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Collar? «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Treatment - Chronic «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Do our current treatments work? Sterling, 2019 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Acute WAD Key points: ✓ Provision of active management consultation did not show additional benefit. A package of physiotherapy gave a modest acceleration to early recovery of persisting symptoms but was not cost effective from a UK NHS perspective ✓ Usual consultations in emergency departments and a single physiotherapy advice session for persistent symptoms are recommended ✓ No difference between usual care and early multiprofessional intervention ✓ No in difference in recovery rates between groups «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Chronic WAD «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Do our current treatments work? «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  So what can we do? Key points: ✓ Improve the quality of our performance, monitoring it and applying evidence-based recommendations (“High-value care”) ✓ Doing this improves patients outcomes overall ✓ Develop and cultivate advanced communication skills and knowledge in the fields of neuroscience and behavioural psychology ✓ In general, consider additional interventions that target those at high risk «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Risk-based management Low risk Medium/high risk Guideline based advice 1. Continue current 2. Specialist provides and exercise by 3. Specialist refers for care- supported by care: physical and CBT primary health care alternate care specialist approach provider: 1-3 sessions «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Psychological interventions Training modules at: https://mywhiplash.com.au/ «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Psychological interventions «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Exercise-based interventions «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Internet-based interventions «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Take-home messages Whiplash-associated disorders are a very complex entity, resulting from non-linear interactions between many different systems Despite decades of research, current guideline-based treatments such as education, advice and exercise, typically demonstrate modest effects at best, and there is a high percentage of patients who develop chronic WAD. Anyway, people need activity/exercise! Patients that are more likely to develop chronic WAD can and should be identified in an early phase to direct appropriate management Treatment should be individualised to target all relevant components of the clinical “picture” and requires skills on different levels «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Bibliography Blanpied PR, Gross AR, Elliott JM, Devaney LL, Clewley D, Walton DM, Sparks C, Robertson EK. Neck Pain: Revision 2017. J Orthop Sports Phys Ther. 2017 Jul;47(7):A1-A83. doi: 10.2519/jospt.2017.0302. PMID: 28666405. Sterling M. Physiotherapy management of whiplash-associated disorders (WAD). J Physiother. 2014 Mar;60(1):5-12. doi: 10.1016/j.jphys.2013.12.004. Epub 2014 Apr 24. PMID: 24856935. Carroll LJ, Holm LW, Hogg-Johnson S, Côté P, Cassidy JD, Haldeman S, Nordin M, Hurwitz EL, Carragee EJ, van der Velde G, Peloso PM, Guzman J. 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PMID: 31443149; PMCID: PMC6723111. «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Thanks for your attention