1 Can Chronic Post-Whiplash-Injury Pain Be Avoided? (Pt. 2)
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Dynamic Chiropractic – January 1, 2021, Vol. 39, Issue 01

Can Chronic Post-Whiplash-Injury Pain Be Avoided? (Pt. 2)

By Steven G. Yeomans, DC and Jeffrey Fitzthum, DC, MD, MPH

To date, most of the research investigating the prevention of chronic pain has focused on identifying individuals at risk, with little effort directed at treatment. Therefore, an educated guess as to the best means of preventing chronicity is proposed.

Preventing Chronicity: Four Elements

First, the obvious: Because chronicity typically develops despite ongoing treatment, the nature of that treatment, whatever that may be, must be inadequate.

Most treatment programs employ just a few modalities, so logically a multifaceted program may be superior.

Second, based on the foregoing discussion, the treatment program will want to identify and address the many potential factors that may delay or prevent recovery. A caveat is that those factors used to identify someone at risk for chronicity may not be the most important factors requiring treatment.

Third, aberrant pain beliefs have been shown to intervene in recovery,23 so a successful program will want to address issues such as catastrophization. We would include in this category the belief that imaging studies unerringly identify sources of pain; and that more aggressive treatments such as surgery or injections are inherently superior to more conservative care.

Finally, reliance solely on passive care is probably inadequate for those at risk, so introducing an active component is vital in reducing chronicity progression risk.24-27

Chronic Pain: Multifaceted Approaches

An example of a successful multi-faceted approach is the "pain management program" utilized by some worker's compensation systems. These programs immerse the injured worker in an intensive outpatient experience, providing educational, cognitive, behavioral and exercise components to address pain that has become recalcitrant to usual care. Multidisciplinary pain programs have demonstrated greater improvement for pain and disability than usual care.5,25

Another example is the group-based, outpatient, two-month GLA:DTM program in Denmark, which has shown good outcomes for chronic hip and knee pain in non-industrial settings. The program is currently studying chronic and recurrent back pain.26 Of particular interest, the GLA:DTM program strongly supports patient self-management.

Before Chronicity Sets In: Early Intervention Strategies

The foregoing examples of multifaceted programs address pain that has already become chronic. To date, there has been limited research evaluating multifaceted programs as an early intervention in MVC injuries. A 2013 study of individuals with WAD of less than four weeks duration compared usual care with stratified treatment based on findings of motor dysfunction, sensitization and psychological distress.27 Those at lower risk were offered physical therapy, while those at greater risk were offered multifaceted treatment including medication and psychological support.

No difference in outcome was found between usual care and stratified care. Importantly, the authors of that article point out that less than half of those offered medications continued taking the medication because of unacceptable side effects, and nearly half of those who were offered psychological support completed less than half of the sessions. Chiropractic was not part of the stratified treatment algorithm.

A study that may be of greater interest to a chiropractic audience is the ongoing PACBACK study at the University of Minnesota, led by Gert Bronfort DC PhD: preventing acute low back pain from becoming chronic through spinal manipulation and "supported self-management."28 We await the findings.

Putting a Program in Motion in the Private-Practice Setting

Assuming a multifaceted approach is an optimal one, how can a multifaceted program be accomplished in a private chiropractic office? We propose that a successful multifaceted program would have as its foundation chiropractic manipulative therapy. Other components could include soft-tissue mobilization techniques; some form of movement or exercise therapy tailored specifically to the patient; some form of cognitive behavioral intervention; and ultimately, progression to self-management. The precise elements and when they are added is the art of practice and case dependent.

For those less familiar with cognitive/behavioral intervention, it must be emphasized that addressing stress, psychological variables, and counterproductive belief systems is of paramount importance. Sometimes patients interpret discussion of these issues as an indication their pain is not being taken seriously. This can be addressed by reassuring the individual that the pain is real; and that the distress caused by pain is real as well, but if untreated, can lead to other conditions such as depression, anxiety and poor-quality sleep, which then amplify the pain experience.

The following is an example of how psychological factors may be managed. If a general questionnaire such as the YFQ is used to screen patients and a high score is elicited for anxiety, a more specific tool such as the GAD-7 can be used to confirm and quantify the finding.

If that person is already counseling or taking an anti-anxiety medication, notify whoever is providing that service of the finding. If not already under care, the patient can be referred to a mental health counselor skilled in pain management. Common techniques used by mental health providers for pain and other issues include cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT). If such care is not readily available, your patient's primary care provider may be a valuable resource.

When in-person mental health resources are not readily available, and often they are not, other options may be suitable as an interim solution. Telehealth counseling with remote providers has become increasingly popular and could even be a long-term solution. Online counseling services such as BetterHelp and Talkspace are available. There are also telephone apps such as "MoodKit," which utilizes a cognitive behavioral therapy approach and has demonstrated acceptable outcomes in a randomized, controlled study.28

The value of these electronic services for motor vehicle collision injuries is unknown, although benefit has been demonstrated with chronic musculoskeletal conditions.29

A novel counseling option is CBT or ACT provided by specially trained chiropractors or physical therapists. Chiropractors have been encouraged to utilize CBT and ACT more frequently in clinical practice, which supports working within the tenants of the biopsychosocial model.30 A useful guide is also available online.31

In our opinion, any worthwhile program must also have a wellness component emphasizing good sleep/rest, good nutrition, appropriate exercise, and positive outlook. Handouts and further information to improve sleep can be garnered from www.sleepfoundation.org/articles/sleep-hygiene. Mindfulness and relaxation-based interventions abound on the internet; for example, www.pocketmindfulness.com/6-mindfulness-exercises-you-can-try-today/. "Calm" is one of many telephone apps for relaxation and sleep.

Daily exercise is recommended, at least daily walking, and more condition-specific exercise as appropriate. "MapMyRun, Fitbit or other activity trackers can be used. "Suggestic" is an interesting telephone app that allows the user to select from among various diets, such as an anti-inflammatory diet, to achieve different outcomes.

Last, but not least, encourage patient self-treatment. Recommend use of massage tools, over-the-counter electrical devices and OTC topical preparations. Interestingly, Kroenke, et al., demonstrated that web-based self-management was inferior to web-based self-management plus collaboration with the health care provider.32 A pain-tracking app such as "Manage My Pain" can be used to track progress if so desired.

"An Ounce of Prevention Is Worth a Pound of Cure"

Chronic pain states are common, costly and difficult to resolve. The risk of developing chronic pain after MVC is high. Prevention, if it can be achieved, is key. Early recognition within the first 4-6 weeks is vital and can be facilitated with tools such as the YFQ. Although still yet unproven, a multifaceted treatment approach may offer the best defense against chronicity.

A multifaceted approach needs a leader. Chiropractic is in a position to provide that leadership.

Editor's Note: Part 1 of this article appeared in the November 2020 issue.

References

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Dr. Steven Yeomans is a third-generation DC with post-graduate teaching experience at numerous chiropractic colleges. He has also lectured in the U.S., Canada and abroad for more than three decades and is the author of the textbook, The Clinical Applications of Outcomes Assessment. He practices in Ripon, Wisc., and recently received the Wisconsin Chiropractic Association's Lifetime Achievement Award (2019).

Dr. Jeffrey Fitzthum maintains a private practice in Seattle, Wash., focusing on treating work-related injuries and performing forensic evaluations of motor vehicle injuries. He is also the physiatry consultant for a multidisciplinary chiropractic-owned clinic. Dr. Fitzthum has served as clinical instructor and clinic director at Western States Chiropractic College; assistant professor and clinical instructor in the Department of Physical Medicine and Rehabilitation at the University of Wisconsin Hospital and Clinics; and Clinic Director of the University of Wisconsin Hospital and Clinics Pain Clinic.

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