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Content-Location: file:///C:/E67D4A27/WhiplashInjury-DrWong_files/master05.xml
Content-Transfer-Encoding: quoted-printable
Content-Type: text/xml; charset="utf-8"
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Chronic Pain after Whiplash Injury
Dr Steven Wong
Department of Anaesthesiology
Queen Elizabeth Hospital
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Terminologies
n<=
/span>Whiplash &=
#13;
<=
span
style=3D'font-size:86%'>•Describes =
the
lashlike effects of sudden acceleration-decelerati=
on
forces on the neck and upper trunk due to external forces
<=
span
style=3D'font-size:86%'>•Defined in=
1995 by
the Quebec Task Force on WAD
<=
/div>
<=
span
style=3D'font-size:86%'>•Describes =
a wide
variety of clinical manifestations resulting from whiplash injury<=
/span>
Whiplash Associated Disorders =
=
(WAD)
nGrade 1:
&=
#8226;Injury and symptoms:
=
;
nProbable
muscle sprain
nNeck
stiffness only
&=
#8226;Signs:
nNo tenderness and normal=
range
of motion
nNormal reflexes and muscle strength in the limbs
Whiplash Associated Disorders =
=
(WAD)
nGrade 2:
•Injury and symptoms:
nProbable muscle and /or ligament
sprain
nAny combination of neck pain with /wi=
thout back pain, jaw pain, jaw
locking, jaw clicking, limb numbness, dizziness
•Signs:
nParaspinal tenderness and restricted =
spine range of motion
nNormal reflexes and muscle strength i=
n the limbs
=
n<=
span
lang=3DEN-US style=3D'font-family:\65B0\7D30\660E\9AD4;mso-fareast-font-fa=
mily:
\65B0\7D30\660E\9AD4;mso-fareast-language:ZH-TW;mso-special-format:lastCR;
display:none'>
Whiplash Associated Disorders =
=
(WAD)
nGrade 3:
•Injury and symptoms:
nProbable disc protrusion with nerve r=
oot impingement
<=
/span>
nNeck pain, often arm pain or numbness=
•Signs:
nAbnormal reflexes and /or muscle weak=
ness, often with sensory chang=
es in a
dermatomal pattern
suggesting nerve root impingement (typically due to disc protrusion)=
3;
•
Whiplash Associated Disorders =
=
(WAD)
nGrade 4:
•Injury and symptoms:
nCervical fracture and / or dislocatio=
n
nNeck pain, possible neurological symp=
toms in limbs, urinary incont=
inence
due to spinal cord involvement
•Signs:
nPossible hyperreflexia, positive Babi=
nski’s sign, motor weakness and=
sensory
changes suggesting
spinal cord injury
nRadiograph reveals fracture and / or =
dislocation
![](3D"slide0013_image003.gif")
Epidemiology of WAD
nAt 6 months after injury:
Partheni et al, 2000
Patras, <=
span
style=3D'position:absolute;top:63.74%;left:52.62%;width:17.79%;height:4.75=
%'>Greece
180
1
353
117
210
Number of
<=
/span>
Patients (n)
Brison et al, 2000
Kingston, Canada
35
Radanov et al, 1995
Berne, Switzerlan=
d
30
Oblieniene et al, 199=
9
Kaunas, <=
span
style=3D'position:absolute;top:52.25%;left:52.62%;width:17.79%;height:4.75=
%'>Lithuania =
0
Authors / Date
City / Country=
Incidence
<=
/span>
(%)
![](3D"slide0014_image004.gif")
Epidemiology of WAD
nAt 1 year after injury:
Gargan & Bannister,=
1990
Bristol & Oxford, UK=
43
28
353
117
210
Number of
<=
/span>
Patients (n)
Brison et al, 2000
Kingston, Canada
34
Radanov et al, 1995
Berne, Switzerlan=
d
24
Oblieniene et al, 199=
9
Kaunas, <=
span
style=3D'position:absolute;top:53.25%;left:52.62%;width:17.79%;height:4.75=
%'>Lithuania =
4
Authors / Date
City / Country=
Incidence
<=
/span>
(%)
![](3D"slide0015_image005.gif")
Epidemiology of WAD
nAt 2 years after injury:
Gargan & Bannister,=
1990
Bristol & Oxford, UK=
43
32
353
117
Number of
<=
/span>
Patients (n)
Brison et al, 2000
Kingston, Canada
35
Radanov et al, 1995
Berne, Switzerlan=
d
18
Authors / Date
City / Country=
Incidence
<=
/span>
(%)
![](3D"slide0016_image006.gif")
Epidemiology of WAD
nAt >2 years after injury:
Berglund et al, 2000
Sweden
232
40
(at 7 years)
43
Number of
<=
/span>
Patients (n)
Gargan & Bannister,=
1990
Bristol & Oxford, UK=
30
(at 10 years)
Authors / Date
City / Country=
Incidence
<=
/span>
(%)
![](3D"slide0005_image007.gif")
What is causing the pain?
nCervical <=
/span>zygopophys=
ial
joint identified as the source of pain by diagnostic=
block
in up to 80% of patients in whiplash injury (Lord e=
t al,
1996)
nBiomechanic
studies
<=
span
style=3D'font-size:86%'>nWide variation in epidemiolo=
gy
<=
span
style=3D'font-size:86%'>nRare in car-crash contests&#=
13;
Archives of Neurology 2000;57:pp590-4
FUNCTIONAL
ORGANI=
C
vs
Biomechanic studies
![](3D"slide0021_image009.jpg")
Grauer et al. Spine
1997;22:2489-94
Biomechanic studies
<=
span
style=3D'font-size:88%'>nDuring rear impact, the lower cervical =
vertebrae =
are
forced into hyperextension while the upper ones are in rel=
ative
flexion resulting in a S-shape curve (Grauer=
et al.
Spine 1997;22:2489-94)
<=
span
style=3D'font-size:88%'>nImpingement of cervical zygopophysial <=
/span>joint and
stretching of anterior longitudinal ligament
demonstrated by motion analysis of deformation of cervical s=
pine
during rear-end collision (Kaneoka et al, 1999=
)
Why does the pain become chronic?
nPost-inju=
ry
sensitization
nPsychosoc=
ial
factors
Post-injury sensitization
nTissue trauma leads to reversible increase in excitability of the nociceptive system
<=
/span>
nPatients after whiplash injury had lower pain threshold than
healthy subjects
(Curatolo
et al, 2001)
<=
span
style=3D'visibility:hidden'>n
=
<=
span
style=3D'visibility:hidden'>n
Biopsychosocial model of pain in WAD
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Minor =
physica=
l =
injury<=
/b>
=
Chronic=
pain
Anger
Fright
Symptom
amplification
=
Anxiety wh=
ile
driving
Expecta=
tion of
chronic pain
Media
Culture fa=
shion
Rumour
Frightening
diagnosis
=
Failure of
multiple therapies
aiming at =
physical
injury
Lack of
reassurance
Poor postu=
re
Frightening
prognosis
Symptom
amplification
=
Battles wi=
th
insurance
company
Symptom
attribution
Ferrari, 2002
Treatment
•e.g. analgesics,
physiotherapy
nIdentify a=
nd treat
nociceptive sources
•e.g. diagnostic cervical
facet block followed by radiofrequency neurotom=
y
nPrevention=
of
chronicity
•e.g. identify psychosoc=
ial
factors
nRestoratio=
n of
function
•e.g. rehabilitative pro=
gramme
' + ENDSHOW_MESG + '
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