A Lawyer With Whiplash


14

A Lawyer With Whiplash



Gwendolen Jull, Michele Sterling, Darren A. Rivett, Mark A. Jones



Patient Interview


Emma K was a 38-year-old woman who was referred to physiotherapy by her general practitioner (GP) for management of neck pain as a result of a motor vehicle crash 10 days earlier. She had no previous history of neck pain or headache. Emma was a partner in a law practice and worked full time. She was involved in various fields of law, but her predominant work was in wills and conveyancing. She was married with two children (aged 11 and 9 years).


Ten days earlier, after dropping the children off at school on her way to work, she was stationary at red lights. She heard screeching of brakes the instant before her car was hit from the rear. She felt the jolt and immediately had a sudden twinge of pain in her neck. Her car had been hit directly in the rear, and the bumper bar and boot had crushed. The police attended the accident, her car was towed to a repair shop and the police advised her to have her neck checked as a precaution. Emma felt that her neck was not too bad, so she caught a taxi to work. However, during the day, her neck pain increased progressively, and by the day’s end, a headache had developed. She went home, took two Nurofen (over-the-counter anti-inflammatory) and went to bed early.


Emma had a restless night with neck pain and woke up with her neck stiff and very sore. Her husband did the school run, and Emma made an appointment with her GP. Her GP advised her to have the day off work, ordered an x-ray and asked her to return with the x-ray later in the afternoon. The x-ray revealed no lesion, and the GP diagnosed a soft tissue injury to the neck. He advised her to take Panadol Osteo (paracetamol) routinely for a few days for the pain (two tablets, three times per day); he advised that she could continue to work but should take it easy for a few days. He advised her to see him in a week if the neck pain had not subsided.


Emma returned to the GP after the week because her neck pain was not settling and, if anything, was getting worse. He prescribed Tramadol (opioid pain medication) for her pain, (two tablets, 6 hourly) and referred her for physiotherapy.


At the time of her initial consultation, Emma felt pain generally in the neck region but mostly on the right side of her neck, which, when it built up, developed into a headache (Fig. 14.1). She rated the overall neck pain intensity as around 6/10 on a visual analogue scale (VAS), with headache intensity about the same. Emma also noticed that she felt a little light-headed and unsteady when the headaches were bad.


image

Fig. 14.1 Body chart depicting symptoms. GH, Good health; NAD, no apparent disorder; NDI, Neck Disability Index; Tabs, tablets.

Emma’s neck pain was constant but fluctuated. It built up if she sat at the computer at work for too long (30–60 min) without moving. The pain could be sharp (VAS 8/10) if she turned her head without thinking. The sharp pain settled in a few minutes, but once the overall pain had built up, it was difficult to get relief. Headaches usually developed in the afternoon as the neck pain built up. The light-headedness was intermittent, occurring only when the headache was bad. It only lasted a few seconds or minutes, but it was bothersome. She obtained pain relief by taking medication and lying down with a hot pack for 30 minutes when she got home. She thought the Tramadol was helping. She reported no noticeable side effects, and when asked, she did not think her symptoms of light-headedness were linked with her taking Tramadol; rather, she felt this when she had a headache. She could still function at work but was anxious about her productivity because she knew she was not functioning very efficiently. The firm’s paralegal had been very supportive this last week, but she could not expect that level of support indefinitely.


At home, Emma was still cooking, but the previous weekend, her husband and children had cleaned the house and had done the washing and shopping. Sleep was still disturbed but getting a little better. Emma slept on her side with two soft pillows. Emma said she had experienced a few dreams about the accident, and the sound of screeching brakes would wake her. Without a car, she was catching a taxi to work and requested that the driver take a specific route that avoided the intersection of the crash.


Emma was otherwise in good health, with, apart from childbirth, no other medical or surgical history. She did not participate in any formal sport but did walk with friends for exercise three times per week. Weekends were busy with the children’s, household and social activities.


She had no experience with whiplash injuries, personally or professionally, but had heard they could be problematic for some people. She had not as yet lodged a claim for third-party insurance but was intending to do so to ensure that costs for the car and her treatment were covered. Emma’s scores at the initial consultation are shown in Table 14.1.



TABLE 14.1






















THE PATIENT’S NECK DISABILITY INDEX AND PATIENT-SPECIFIC FUNCTIONAL SCALE SCORES AT THE INITIAL CONSULTATION
Neck Disability Index (NDI) score 22/50
Patient Specific Functional Scale (PSFS)
Turning her head 1
Computer work (60 min) 3
Cooking (lifting pots) 5
Walking with friends 0

Emma was screened at being of a medium risk of poor recovery, based on the Whiplash Clinical Prediction Rule (NDI score 22/50; Age: 38; Hyperarousal Symptoms 3/6 (Ritchie et al., 2015, 2013), www.recover.edu.au/recover-clinical/).



Reasoning Question:



  1. 1. After the patient interview, what was your hypothesis about the source(s) of the symptoms? What evidence supported or negated your hypothesis?

Answer to Reasoning Question:


The source of nociception was most likely in the upper cervical segments, given the area of pain as well as the referral of pain into the head. The difficulty with turning the head would suggest C1–C2 dysfunction. Symptoms of light-headedness and unsteadiness are more frequently (but not uniquely) associated with an upper cervical problem, and in Emma’s case, they appeared to have a direct relationship to her neck pain and headache (Treleaven, 2017). They could also have a vestibular origin or could be a side effect of a concussion, although the latter was unlikely in Emma’s case because she reported no knock to her head or unconsciousness at the time of the car crash.


Symptoms of dizziness and vertigo are common side effects of Tramadol use, and this could negate the hypothesis of these symptoms being a result of upper cervical spine injury. Emma was questioned about the temporal relationship of these symptoms and taking Tramadol, and there appeared to be no relationship.


Reasoning Question:



  1. 2. What were your thoughts regarding the ‘pain type’ (nociceptive, neuropathic or nociplastic)? How did the acute nature of the presentation in this case influence your hypothesis of the pain type involved?

Answer to Reasoning Question:


As a primary hypothesis, the neck pain was reasoned to be nociceptive, most likely with an inflammatory component (sharp pain on movement on a background of a constant aching pain). The acute nature of the pain, response to movement and posture/activity and its relationship to an injury 8 days ago guided this hypothesis. Nevertheless, the possibility that the pain could be neuropathic (high pain, irritability, constant pain, not sleeping) with involvement of the C2 nerve also had to be considered.


The headache might be reflective of CNS sensitization. Some degree of central sensitization would be expected in the acute-injury stage due to the initial excitation and sensitization of nociceptors in the cervical spine (Graven-Nielsen and Arendt-Nielsen, 2010). In Emma’s case, this did not appear to be nociplastic because her pain was quite localized, and she did not demonstrate widespread hyperalgesia and pain, features proposed to be indicative of more maladaptive spreading central sensitization (Graven-Nielsen and Arendt-Nielsen, 2010). The temporal relationship of headache onset with neck injury and headache aggravation associated with pain was suggestive of a cervicogenic headache. Nevertheless, there is evidence that a whiplash injury can also trigger the onset of migraine and tension-type headaches (Drottning et al., 2002). Regardless of the headache type, all have been associated with CNS sensitization. The presence of allodynia (pain with a normally innocuous stimulus) in the physical examination would also indicate the presence of central sensitization.


Reasoning Question:



  1. 3. Was there anything in the patient interview that raised concerns about the prognosis for this patient?

Answer to Reasoning Question:


There were some features of Emma’s presentation which might suggest the possibility of a poorer prognosis. These included the higher neck pain (6/10) and Neck Disability Index (NDI) scores (22/50). She was also screened at medium risk of a poorer recovery based on the Whiplash Clinical Prediction Rule. In addition, there were other signs, albeit with lesser evidence, suggestive of a poorer prognosis: immediate onset of pain and an early onset of headache and light-headedness symptoms. Emma was also experiencing some symptoms of post-traumatic stress (intrusion – dreams about the accident, wakes up with the sound of screeching brakes; avoidance – requesting the taxi driver to avoid the site of the car crash), but hyperarousal symptoms were low. The presence of these symptoms can be predictive of poor recovery (Sterling et al., 2012) and are common after a motor vehicle collision (MVC), but in most people, they resolve (Sterling et al., 2003). For Emma, these symptoms would be monitored during her physiotherapy treatment. On a positive side, there was no evidence of cold hyperalgesia, which may be associated with a poorer prognosis (Goldsmith et al., 2012).


Clinical Reasoning Commentary:


As illustrated in this answer and discussed in Chapter 1, it is important to hypothesize about potential ‘sources’ for all symptoms, not just pain. For example, upper cervical dysfunction, vestibular, intra-cranial, secondary to a concussion and medication side effects are all recognized as potential sources for Emma’s light-headedness and unsteadiness. Analysis of the relationship of symptoms temporally through the history and behaviourally through aggravating and easing factors enable preliminary hypotheses regarding potential sources. In this case, recognition of these symptoms as common with upper cervical dysfunction, combined with a direct relationship to Emma’s neck pain and headache, support an upper cervical dysfunction source, whereas the specifics of the car crash don’t support concussion.


Understanding pain, including types of pain, differences between acute and chronic pain, referred pain and the associated neurophysiology, is essential knowledge to musculoskeletal clinicians because clinical judgment regarding pain type has implications for other reasoning judgments, including precautions in assessment and management, management strategies and prognosis. Although both subjective and physical clinical features of pain types have been reported (see Chapters 1 and 2), as discussed here and in Chapter 2, not all sensitization is ‘maladaptive’, and biomarkers of nociplastic pain are still not definitive (Curatolo and Arendt-Nielsen, 2015). Nevertheless, recognition of clinical features of sensitization, as with Emma, enables appropriate caution in physical testing and physical management interventions.


Prognosis is a difficult clinical reasoning judgment, yet something every patient wants to know. The Answer to Reasoning Question 3 identifies indicators of poorer prognosis from the subjective examination, including Emma’s higher neck pain intensity and neck disability scores (Walton et al., 2013), her immediate onset of pain and early onset headache and light-headedness and her symptoms suggestive of post-traumatic stress, and her Whiplash Clinical Predication Rule score placed her at medium risk of poorer recovery (Ritchie et al., 2013). As discussed in Chapter 1, in addition to research evidence regarding prognosis for different presentation categorizations, at the level of the individual patient, factors to consider throughout the subjective and physical examination and the ongoing management including the following:



It is helpful to consider a patient’s prognosis by reflecting on the positives and negatives as highlighted in this answer, where the immediate onset of pain and early onset of headache and light-headedness, plus symptoms of post-traumatic stress, are judged to support a poorer prognosis, whereas low hyperarousal symptoms and no evidence of cold hyperalgesia support a better prognosis.



Physical Examination


To respect Emma’s pain, it was planned to limit the physical examination to that necessary to gain sufficient information to understand the nature of the disorder and to institute initial treatment.



Posture


Emma sat in a reasonable, upright posture, and postural curves from the lumbopelvic region to head position were unremarkable. Emma was holding her head quite rigidly, with some muscle guarding evident in the right neck extensors. Scapular posture revealed minor downward rotation and anterior tilt of the scapulae bilaterally.









Tests of Neuromuscular Control


Craniocervical Flexion Test



The pattern of craniocervical flexion movement was taught and practiced in crook lying. Emma was taught to gently hold the craniocervical flexion position.


Re-evaluation of PPIVMs: pain and spasm restricting C1–C2 and C2–C3 rotation movement had reduced slightly.




Scapular Muscle Testing




Reasoning Question:



  1. 4. Your physical examination included a number of assessments of sensorimotor systems. Do you routinely perform these tests on patients presenting with neck pain after an MVC?

Answer to Reasoning Question:


Yes, the tests are performed routinely in patients following a whiplash injury. The evidence indicates that cervical sensorimotor disturbances are frequently present in whiplash-associated disorders (Treleaven et al., 2016). Light-headedness and unsteadiness are common symptoms of cervical vertigo, especially when directly related to neck pain/headache as Emma described. Tests of sensorimotor control were restricted to balance and some tests of eye movement. Other tests will be performed as cervical range of movement (ROM) improves.


When pain levels are high, as in Emma’s case, it is desirous that pain is not provoked in early stages of rehabilitation. Balance training can be performed without risk of aggravating neck pain and thus can be an early component of an active rehabilitation strategy.


Reasoning Question:



  1. 5. How did you interpret the findings of the sensorimotor tests with respect to your hypotheses on the source of the symptoms and pain type? Were they consistent with your experience of similar patients?

Answer to Reasoning Question:


Failure in the test of narrow stance after 10 seconds for a person of Emma’s age was interpreted as a symptom of altered cervical sensorimotor control. This fits well with the hypothesis of upper cervical segmental dysfunction, noting that the muscles of the upper cervical region have the highest concentration of muscle spindles per gram of muscle of any region in the body. The hypothesis on pain type did not particularly influence the interpretation of cervical sensorimotor dysfunction because sensorimotor dysfunction can occur with any pain type. Interestingly, idiopathic cervical vertigo can occasionally occur without neck pain.


Reasoning Question:



  1. 6. Other than being careful not to exacerbate the pain, did you identify any specific precautions or contraindications to treatment?

Answer to Reasoning Question:


The onset of neck pain was as a result of acute trauma; therefore, there are automatic precautions associated with an acute injury. Even though there is some assurance of no fracture from the x-ray report, in this acute phase, it is impossible to determine if there has been any injury which might be associated with, for example, potential instability. Thus, in this early phase, due care is required, and techniques such as high-velocity manipulation are contraindicated.


Reasoning Question:



  1. 7. Can you give your thoughts at this stage regarding the diagnosis and your planned management approach?

Answer to Reasoning Question:


The provisional diagnosis was a whiplash injury due to a rear-end MVC. VAS and NDI indicated moderate to severe pain and disability. From a biological perspective, there was pain and spasm at the C1–C2 and C2–C3 segments. It was possible this painfully restricted motion could explain the symptoms of cervicogenic headache. The articular dysfunction and associated reactions in the sub-occipital muscles could explain the cervical vertigo. From a psychosocial perspective, there were some symptoms of post-traumatic stress and some concerns/anxiety about her function at work.


Of concern, there were some indicators of a poor prognosis in Emma’s history, for example, high initial pain intensity, high neck disability score, early onset of headache and post-traumatic stress symptoms. The focus of treatment at this early stage was toward educating and assuring Emma, gaining symptomatic relief (neck pain, headaches and light-headed, unsteady feelings) and a graduated return to normal activity. Lifestyle activities and treatment should be non-provocative to respect pain levels and to allow the injury to heal and settle.


Clinical Reasoning Commentary:


Features of cervical vertigo and cervical headache are highlighted in Answers to Reasoning Questions 4 and 6 and linked to physical examination planning. Clinical patterns of musculoskeletal disorders typically include the characteristic symptoms, typical behaviour of symptoms (e.g. aggravating and easing factors) and history (e.g. common mechanism of onset and progression over time). Reasoning regarding the hypothesis category ‘precautions and contraindications to physical examination and management’ is evident in the judgement to restrict sensorimotor testing to balance assessment and avoid/minimize pain provocation in both the physical examination and early management.


Hypotheses formulated in the subjective examination are ‘tested’ through the physical examination. This is evident in the Answer to Reasoning Question 4 where the findings of upper cervical dysfunction and impaired balance are judged to support the hypothesis that sensorimotor disturbance secondary to upper cervical dysfunction is the primary source of Emma’s vertigo symptoms and balance impairment.


Reasoning Question 5 is aimed to further explore the hypothesis category ‘precautions and contraindications to physical examination and treatment’. Acute trauma and the potential for structural instability are highlighted as key features requiring precaution in the physical examination and contraindications for high-velocity manipulation. As discussed in Chapter 1, clinical judgment in this hypothesis category is based on a number of factors including the following:



In Answer to Reasoning Question 6, both physical and psychosocial ‘diagnoses’ are discussed with reference to findings in Emma’s presentation supporting those judgments (hypotheses). Whereas physical diagnostic reasoning is typically prominent in most clinicians’ clinical judgments, reasoning regarding patients’ psychological status, factors that may have precipitated or contributed to any apparent distress and explicit physiotherapy or other health management strategies to address those factors are often less explicit. In Chapter 3, the influence of stress, coping and social factors on pain and disability is discussed, and Chapter 4 addresses assessment, reasoning and management of psychological factors in musculoskeletal practice. Both the theory in Chapter 3 and the assessment strategies in Chapter 4 are helpful resources for our enhancing psychosocial reasoning in musculoskeletal practice.

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Apr 2, 2020 | Posted by in SPORT MEDICINE | Comments Off on A Lawyer With Whiplash

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