August Discussion Post

[nhoover17]

Last month (July) JOSPT released their second issue dedicated to WAD (the first was October 2016).

From what I have read, this has been a challenging diagnosis in our field and high quality evidence has been scarce due to the complex nature of these injuries.

From the new Clincal Practice Guidelines for Neck Pain:

For pt’s with acute WAD, moderate level evidence supports providing education for the pt to return to normal activities as soon as possible, minimize use of cervical collar, and perform postural and mobility exercises for decreasing pain and improving ROM in conjunction with reassuring the pt that recovery is expected to occur in 2-3 months. Moderate level evidence supports multimodal approach with manual therapy plus exercise. There is weak evidence for supporting a single session of early advice, exercise and education, a comprehensive exercise program, and TENS.

For pt’s with chronic WAD, weak evidence supports pt education and advice on assurance, encouragement, prognosis and pain management, manual therapy and exercise including cervicothoracic strength, endurance, flexibility and coordination, principles of cognitive behavioral therapy and TENS.

There is a great editorial by Julie Fritz discussing the implementation of new directions of care for WAD. She discusses a risk-stratification model for classifying pt’s based on behavioral and psychological factors similar to the STarT Back tool for IDing prognostic factors associated with low back pain.
She also discusses the role of psychological and behavioral factors and the use of cognitive and behavioral treatment strategies for treatment of WAD.

Trudy Rebbeck also wrote a clinical commentary discussing the role of exercise and patient education that provides a deeper analysis of the evidence presented in the clincal practice guidelines. She also discusses the idea of classifying pts into subgroups using risk stratification in addition to impairment classification and treatment response classification.

I have only had one patient this year that presented with WAD following an MVA. My initial reaction was to treat cervicothoracic with MT and exercise for motor control and endurance. This particular pt also had a previous spinal condition that resulted in a fusion from T1-L3 which threw a large and immobile hitch into my treatment plan. I was able to layer in some discussion about pain and nervous system response to traumatic injury and this pt ended up doing well with PT. However, I don’t consider this the standard for how most of these type of cases will play out in the future.

Especially after reading through the recent JOSPT, I am curious to see what other literature you guys have in your arsenal; or what previous experience you all have that may help us all have more efficient treatment of this patient group.

Please share your thoughts on any of the articles in this journal issue or your personal experience with treating patients with these injuries

[Erik Lineberry]

I have treated a fair amount of patients status-post MVA with and without WAD. I found the first WAD JOSPT issue to be insightful and was pleased to see the second one came out this past month. Thanks for posting this to finally make me open it up.

One of the things I find the hardest when treating patients with WAD is managing dizziness and nausea symptoms when they are present. Due to this I chose to review the clinical commentary by Julia Treleaven, PhD, Bphty. I thought this commentary did a great job at explaining appropriate assessment techniques and differential diagnoses for patients presenting with dizziness following trauma. The author called for a structured exam that includes cervical joint position sense, balance, oculomotor reflexes, and coordination assessment. The article points out a few times that the symptoms associated with WAD and concussion overlap quite a bit and are often seen as concomitant conditions. Common differentials that warrant referral were vertebral artery in sufficiency and perilymph fistula. I would include psychological presentations as a possible referral as well. This commentary helps to provide structure to a difficult exam for patients with dizziness and/or WAD following an MVA. I added the differentials table for review.

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