Whiplash Associated Disorder WAD- Preventing Chronic Pain and Disability

1. Rosie Hancock , 8th March 2011 Whiplash Associated Disorder (WAD)- Preventing Chronic Pain and Disability

2. Contents Introduction. RehabWorks background. What is whiplash associated disorder (W.A.D)? Kinematics. Incidence figures and statistics. Chronicity. Psychosocial barriers. Early intervention programme. Outcomes.

3. Objectives By the end of the session delegates should be able to: - Define W.A.D. - Explain the variety of Whiplash symptoms. - Summarise the key concepts of the management of acute whiplash.

4. Who are RehabWorks? A private, independent medical company specialising in the treatment of acute and chronic musculoskeletal disorders (MSD�s).  RehabWorks have been helping people �get back to normal life� for the past 15 years, especially when they are struggling to get back to their job.  We employ 75 Chartered Physiotherapists and train them thoroughly in our methodology to ensure a consistent approach. 19 Centres in UK. We were founded in 1987 as one of the first specialist return-to-work treatment and rehabilitation providers in the UK Leading provider in Rehabilitation and helping people get back to work and their normal life again. We were founded in 1987 as one of the first specialist return-to-work treatment and rehabilitation providers in the UK Leading provider in Rehabilitation and helping people get back to work and their normal life again.

5. What is W.A.D? First described at a research meeting in 1928 by Harold Crowe as a discrete spinal disorder. The term "railway spine" was used to describe a similar condition that was common in persons involved in train accidents prior to 1928.  Crowe used the term �whiplash� as an injury mechanism of sudden hyperextension followed by hyper flexion of the neck. Whiplash is most commonly caused by a motor vehicle accident in which the car the person is in, is struck from a vehicle from behind.

6. W.A.D definition �An acceleration-deceleration mechanism of energy transfer to the neck. It may result from rear end or side-impact motor vehicle collisions, but can also occur during diving or other mishaps. The impact may result in bony or soft tissue injuries, which in turn may lead to a variety of clinical manifestations� (Spitzer et al, 1995).

7. Kinematics of Whiplash Until recently it was thought that firstly the head and neck were forced into hyperextension, with horizontal translation as the head lagged behind the movement of the torso. Secondly, the head and neck overcame the resulting inertia and became hyper flexed. Thus tissues in the cervical spine were put under strain.

8. Kinematics of Whiplash More recent studies investigating high-speed cameras and sophisticated crash dummies have determined that as the car and seat are propelled forwards, the body and shoulders are moved forwards. The head resists forward displacement and is thrown into extension causing extension at C5/6 and flexion in the upper C/sp - increasing the �S� shape of neck. Once inertia is overcome, neck leverage propels the head into flexion, creating large shearing forces at each cervical level.

9. Varying symptoms of W.A.D. Pain and stiffness in the neck and interscapular region. Headaches. Reduced range of movement in cervical spine. Scapula pain. Loss of concentration. Paraesthesia in the arms or hands. Vertigo and dizziness. General tiredness. Short-term memory disturbances. Personality changes. Disturbances with word finding. Neurological deficit. Radicular symptoms. (Ronnen et al, 1996).

10. The Scale of the Problem Insurance statistics from motor vehicle accidents (MVA) suggest that current annual incidence of WAD in the UK is approximately 300,000 new cases per annum. Estimated annual cost to the economy of at least �1 Billion (Rashier and Monk, 2007). Incidence figures of WAD: 44 Per 100,000 106 cases per 100,000 in Australia. 302 cases per 100,000 in Canada. 188 cases per 100,000 in The Netherlands. Much research has been conducted into Whiplash injuries��mechanisms of injury�..pathology,�..types of management etc�..Much research has been conducted into Whiplash injuries��mechanisms of injury�..pathology,�..types of management etc�..

11. USA data A third of people involved in a car accident experience neck pain (33% overall number). A third of that number attend an accident and emergency department (11% overall number). A third of this number consult their GP or primary practitioner (3% overall number). A third of this number consult their GP etc more than once (1% overall number). A third of this number develop chronic neck pain referred to as W.A.D (0.33% overall number). This last number (0.33%) works out at approximately one person in 300 develops chronic neck pain symptoms after a car accident.

12. Chronicity Canadian insurance data suggests that for those with WAD the average time taken to return to work is roughly one month after injury. Quebec Task Force advocated that whiplash has a �favourable prognosis� and concluded that 97% of patients recovered within 12 months after their motor vehicle accident. A Canadian study found that after 1 year 4% of cases had still not recovered. Studies on recovery by Bunketorpe et al 2006 and Cassidy et al (2000) indicate that the outcome is twofold- either the symptoms will resolve in the first few months or it will persist with a high probability of becoming a chronic complaint.

13. Chronicity 53% males and 62% females report sustained symptoms ( 2 � 8 year follow up) Borchgrevink et al (1996) Barnsley et (al 1995) concluded that after 1 year between 14% and 42% of patients who had been involved in MVA�s still had symptoms. In a postal survey in Sweden 17 years after the MVA, 55% of people reported residual symptoms they related to the accident.

14. Quebec Task Force Spitzer et al (1995) Undertook a project to better appreciate biological, psychological and social anatomy of whiplash injuries. They established a grading system - 0-IV 0 � No symptoms I � neck pain/stiffness/tenderness II � neck pain/stiffness/tenderness/mechanical signs III � neck pain/stiffness and associated neurological signs IV � neck pain/stiffness associated with cervical fracture/dislocation.

15. Quebec Task Force Findings� Grades I and II represent 80% of �whiplash injury claims�. Link between biological damage and impairment was unclear More recently this has been further supported by the findings of Cassidy (2000). People complained of broad spectrum physical, social and psychological impairments The elimination of compensation for pain and suffering is associated with a decreased incidence and improved prognosis of whiplash injury. Effect of Eliminating Compensation for Pain and Suffering on the Outcome of Insurance Claims for Whiplash Injury J. David Cassidy, D.C., Ph.D., Linda J. Carroll, Ph.D., Pierre C�t�, D.C., Mark Lemstra, M.Sc., Anita Berglund, B.Sc., and �ke Nygren, M.D., Ph.D. � �   Full Text PDF   Editorial by Deyo, R. A. Letters   Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited   PubMed Citation ABSTRACT Background and Methods The incidence and prognosis of whiplash injury from motor vehicle collisions may be related to eligibility for compensation for pain and suffering. On January 1, 1995, the tort-compensation system for traffic injuries, which included payments for pain and suffering, in Saskatchewan, Canada, was changed to a no-fault system, which did not include such payments. To determine whether this change was associated with a decrease in claims and improved recovery after whiplash injury, we studied a population-based cohort of persons who filed insurance claims for traffic injuries between July 1, 1994, and December 31, 1995. Results Of 9006 potentially eligible claimants, 7462 (83 percent) met our criteria for whiplash injury. The six-month cumulative incidence of claims was 417 per 100,000 persons in the last six months of the tort system, as compared with 302 and 296 per 100,000, respectively, in the first and second six-month periods of the no-fault system. The incidence of claims was higher for women than for men in each period; the incidence decreased by 43 percent for men and by 15 percent for women between the tort period and the two no-fault periods combined. The median time from the date of injury to the closure of a claim decreased from 433 days (95 percent confidence interval, 409 to 457) to 194 days (95 percent confidence interval, 182 to 206) and 203 days (95 percent confidence interval, 193 to 213), respectively. The intensity of neck pain, the level of physical functioning, and the presence or absence of depressive symptoms were strongly associated with the time to claim closure in both systems. Conclusions The elimination of compensation for pain and suffering is associated with a decreased incidence and improved prognosis of whiplash injuryEffect of Eliminating Compensation for Pain and Suffering on the Outcome of Insurance Claims for Whiplash Injury J. David Cassidy, D.C., Ph.D., Linda J. Carroll, Ph.D., Pierre C�t�, D.C., Mark Lemstra, M.Sc., Anita Berglund, B.Sc., and �ke Nygren, M.D., Ph.D. � � Full Text PDF Editorial by Deyo, R. A. Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited PubMed Citation ABSTRACT Background and Methods The incidence and prognosis of whiplash injury from motor vehicle collisions may be related to eligibility for compensation for pain and suffering. On January 1, 1995, the tort-compensation system for traffic injuries, which included payments for pain and suffering, in Saskatchewan, Canada, was changed to a no-fault system, which did not include such payments. To determine whether this change was associated with a decrease in claims and improved recovery after whiplash injury, we studied a population-based cohort of persons who filed insurance claims for traffic injuries between July 1, 1994, and December 31, 1995. Results Of 9006 potentially eligible claimants, 7462 (83 percent) met our criteria for whiplash injury. The six-month cumulative incidence of claims was 417 per 100,000 persons in the last six months of the tort system, as compared with 302 and 296 per 100,000, respectively, in the first and second six-month periods of the no-fault system. The incidence of claims was higher for women than for men in each period; the incidence decreased by 43 percent for men and by 15 percent for women between the tort period and the two no-fault periods combined. The median time from the date of injury to the closure of a claim decreased from 433 days (95 percent confidence interval, 409 to 457) to 194 days (95 percent confidence interval, 182 to 206) and 203 days (95 percent confidence interval, 193 to 213), respectively. The intensity of neck pain, the level of physical functioning, and the presence or absence of depressive symptoms were strongly associated with the time to claim closure in both systems. Conclusions The elimination of compensation for pain and suffering is associated with a decreased incidence and improved prognosis of whiplash injury

16. Things to think about�. Whiplash symptoms are so diverse, and produce such a disturbance of health quality, can they possibly be produced merely on the basis of an acute injury? Why have experimental collisions never produced chronic whiplash symptoms, only acute symptoms? How come chronic whiplash symptoms rarely occur in the offending driver in litigation cases? How come chronic whiplash symptoms rarely occur in sports likely to cause acute neck sprains or from fairground rides?

17. More things to think about� The incidence of chronic disorder has been shown to be much lower in Lithuania than in the United Kingdom or the United States. Why do acute symptoms from whiplash in RTA�s cross cultural borders, the chronic symptoms and recovery rate do not? Muscle & ligament injuries in other areas of the body resolve in weeks or months and rarely become chronic.

18. Quebec Task Force In order to reflect this breadth of biopsychosocial symptoms they re-defined the whiplash injury to �.Whiplash Associated Disorder (WAD). Includes the symptom constellation of headaches, spinal pain, jaw pain, dizziness, limb pain, numbness, psychological, cognitive and somatosensory disturbances within their grading system.

19. RehabWorks Early intervention. Closely follows CSP clinical guidelines for physiotherapy management of WAD (2005). Within 48 hours of referral, the client receives a 30 minute telephone triage assessment with a Chartered Physiotherapist. Client is screened for the presence of �red flags�. Physiotherapist screens for potential psychosocial barriers to recovery.