Traumatic Neck Pain: Challenges and Complexity

[Aaron Hartstein]

In our first weekend course we discussed the complex interaction of factors associated with neck pain. This is most certainly the case in the presence of neck pain following a motor vehicle accident. Treating this patient population somewhat parallels the management of chronic non-specific low back pain. While biopsychosocial models of care highlight the convergence of several factors that influence an individual’s pain experience, translating this patient care model into clinical practice remains elusive and a struggle at times. For example, Fritz (2017) describes the necessary de-implementation of historically ineffective treatments, such as cervical collar application, which is still commonly used, despite 20 years of evidence suggesting the benefits of active mobilization over immobilization. Interestingly, some researchers suggest an approach that emphasizes physical impairments, while more recently, others have suggested a multimodal approach “informed by trauma and psychological factors” (Elliott & Walton, 2017).

Have a look through a few of these short clinical commentaries on the subject (if you cannot access these, please let me know):

Neck Pain: Much More Than a Psychosocial Condition

Toward Improving Outcomes in Whiplash: Implementing New Directions of Care

Here are a couple others that describe the role of exercise and education in this population and the sensorimotor impairments of the cervical spine often found after trauma.

Based on the learning resources provided, consider the following for this discussion board (you do not have to answer all of these talking points; these are just a guide).

– What are your experiences with the physical therapy management of individuals who present with whiplash?

– Consider these commentaries, what do we need to do as a profession to improve the care of this challenging population?

– How do we balance the need to treat multiple domains at the same time in this population – physical impairments, social-emotional factors, psychological needs, etc.?

– Given the evidence that consistently reveals impairments to multiple systems in this population, can we really abandon an approach directed towards physical impairments?

– If more physical therapists worked in the emergency room and screened patients after an MVA, do you think this would help or hinder outcomes? Why or why not?

– What did you learn about this patient population that you did not know before?

[David Brown]

During my clinical rotations, I saw a fair amount of whiplash injuries following car accidents. Much of these incidents were acute and they would seem to resolve within the matter of weeks. I did discover, which was surprising to me, that several of my patients did not recover at the rate I thought they would given the degree of tissue pathology. I figured this was mostly due to the severity of the injury or patient’s inability not to overwork the neck while it is still healing due requirements of their job or ADLs. I found it to be interesting to me as Julie Fritz in her editorial cited research showing that only 50% of patients following this kind of trauma recover in a time frame that is typical of soft tissue healing and that the severity of tissue pathology has little to no prognostic value. I think that this demonstrates the need to look further into what is driving the pain than simply the biological impact. I found that in my experience with these patients that when the pain becomes persistent for over 3-4 months and/or the incident in which the injury originally occurred was emotionally traumatic for the patient, I had to take on a more pain neuroscience and psychosocial approach much like I would with persistent low back pain patients. I found this approach, especially in patients that identified post-traumatic stress in conjunction with their mechanism (most often a car accident in these cases), to be impactful and helpful for the patient. I enjoyed reading how this approach was documented as successful to a certain extent in Trudy Redbeck’s clinical commentary where she discussed how Cognitive Behavioral Therapy can have a significant degree of beneficial impact for patients with persistent neck pain and associated PTSD. For me and my patients, CBT mainly looked like education towards knowing the warning signs of overworking the neck while driving or at work and the associated symptoms (some of my patients had headaches or vertigo spells) and focusing on function instead of pain and what they were able to do successfully that day instead of unsuccessfully. In addition, I would also perform active exercise with these patients with the hope that through strengthening and mobility, this will aid in the reduction of their symptoms. Reading further into Redbeck’s commentary however, I discovered that there is far more evidence from higher quality RCTs showing that exercise for persistent whiplash has little to no impact on outcomes. This shows me that in retrospect, I should have spent more time on the behavioral aspect instead of trying to improve their symptoms through exercise.
I think a very challenging factor to treating these types of patients is knowing when, and how much CBT should be implemented into my treatment so I use the patient’s time as wisely as possible. I think it is also difficult to discern the extent to which the psychosocial factors are driving pain as the interactions between the psychosocial and the biological aspects are difficult to measure and discern. Based on Michele Sterling’s editorial, I am not alone in the challenge I face in trying to ascertain the level of psychosocial implications in a patient’s neck pain. She exposes that there unfortunately is not enough literature discussing the interaction between the psychosocial and biological factors and the effect that they can all have on the patient presentation. I found this to be very eye opening because we have learned a great deal in school and clinically about pain neuroscience and the warning signs of fear avoidance beliefs/behaviors, and we also have a detailed, intimate understanding of the anatomy of the spine and tests to assess it to the point where we can rule out a fracture almost just as well as any imaging study, but we struggle to understand how one may impact the other and contribute to the overall wellbeing of the patient. My main takeaway from this literature is that, like the low back, there is a significant prevalence of emotional implications with neck pain, and if properly identified, quantified, and treated appropriately, can lead to far better outcomes for the patient.

[Sarah Frunzi]

David,

I appreciate your honesty in your reflection on needing to have utilized more of a behavioral aspect compared to exercise, as I am finding I do this as well. As important as exercise is to our treatment and our profession, I find I am sometimes hesitant to address the behavioral aspect or don’t recognize the need for it soon enough. I also agree with your statement on where the challenge is knowing when and how much to integrate CBT into the treatment. I think there is a level of difficulty or challenge in gauging how receptive the patient may be to that method of treatment, and subsequently implementing it at the appropriate time for this reason. We may recognize the need for it, but the patient may not feel ready or willing to implement the strategies into their daily life. We can always educate and “plant the seed”, but it really is up to the patient to put into practice the recommendations we provide. I think as long as we spend the appropriate amount of time educating the patient and conveying the possible value of our different treatments, building that therapeutic alliance, like you said, outcomes can be better for this population.

Thank you for your thoughts!

[David Brown]

Thanks so much! I think a great deal of the challenge of providing CBT adequately and appropriately lies in the difficulty in providing education/ conducting research on a topic that really isn’t tangible and varies so much from person to person. I think much of this comes through experience, cultural competence, and simply understanding the person in front of you. And I agree with you with the “plant the seed” concept! I feel like you can compare the idea to a strengthening progression; you start out with lighter weight and progress from there. I think this idea can be applied to educating a patient on how pain is driven in the body and mind. Simply explain the fundamental ideas initially without overwhelming the patient and then circling back in future sessions and expand on it and maintain a consistent focus on the idea of pain neuroscience. Thanks so much for your response!

[Sarah Frunzi]

I have had the chance to work with a couple of patients who sustained whiplash, and fortunately, majority of them have been on the positive end of the spectrum with their recovery. Some recovered quicker than others, and I do believe the psychological, or lack of involvement/impact in this domain, had a positive part to play in their successful outcomes. The ones that recovered well also had active lifestyles, or physically active jobs, that required and/or encouraged them to return to movement and activity sooner than later, which would support the statement of promoting returning to regular activity compared to immobilization treatments. They all had varying presentations and symptoms, however, the ones that did have slightly more psychosocial or emotional involvement did take longer to recover compared to those that didn’t.
I have noticed they are a challenging population to treat, and after reading the articles posted, I believe our core method of treating this population should remain the same – to treat the whole person. I don’t think we can abandon an approach directed towards physical impairments, because there are likely going to be some physical impairments present that we need to address. No one person is the same, and not all whiplash disorders present the same way. Therefore, I believe it is more imperative to implement evidence-based practice and the concept of “treating the whole person” with this population just as much as it is important to do with chronic low back pain patients. Just like in chronic low back pain, in WAD there is some level of physical impairment as well as other layers of possible central hyperexcitability, emotional distress from the event, and high pain levels. We have to evaluate how much of each area is involved between physical impairments, social-emotional, and psychological needs. This may be requiring a referral to another provide to build a more team-based approach or can be managed within the clinic alone. I believe finding the best balance in treating these varying areas comes from what is most impactful on the patient’s life at that moment in time we are seeing them and adjusting each visit accordingly. Initially, it may be more social-emotional and may transition to more physical impairments as the emotion of the event calms and more local impairments are able to be addressed. I think this method would challenge us to constantly keep an open mind with each visit, and to analyze how the patient is presenting during that specific visit, allowing for an ebb and flow between addressing different domains along the course of their care.

[David Brown]

Sarah,

I really enjoyed your response and I’m glad many of your patients responded well and recovered. I am with you completely with you in that we have to treat the whole patient and the physical impairments which involves discerning how much MSK pathology is driving the patient’s pain versus a heightened sympathetic response by the brain. I think the tricky part is knowing when to shift from using the majority of your time treating the physical impairments to treating more the emotional/hyperalgesia impairments that can begin to develop when the pain shifts from acute to persistent. In the absence of further trauma, the body will follow predictable tissue healing times yet sometimes the pain will continue to affect the patient well beyond that normal healing time frame. How would you handle this situation? If the patient after 5-6 months is still experiencing WAD type of symptoms, would you shift more towards a non-specific approach like we often do with the low back with CBT principles thrown in there? I’m curious for your thoughts because this is something that is hard for me to discern when faced with this situation.

[Sarah Frunzi]

Hey David!

Thanks for your question! Personally, I like to sprinkle in pain science early on and only if appropriate/after assessing if the patient is willing to hear it, as it can sometimes not be accepted well if the patient isn’t ready. However, I did just find an article with an interesting result. The article was titled, “The effect of neck-specific exercise with, or without a behavioral approach, on pain, disability, and self-efficacy in chronic whiplash-associated disorders: a randomized clinical trial” by Ludvigsson et al. The article shared that between the neck-specific exercise group and neck-specific exercise group with a behavioral approach, that there was no significant difference between groups. They did note that there was a potential trend toward better improvements with the behavior approach, but not enough to be significant. In my opinion, I think adding a behavioral approach is still worth implementing if appropriate for the specific patient. Try to identify any possible factors in the patients life that might be able to be modified that could aid in improving progress early on in the course of care, and address them as you see appropriate!

Hope this helps!

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