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Whiplash Associated Disorder: the Pathway from Acute to Chronic Pain (Hours 7-8) James J

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Whiplash Associated Disorder: the Pathway from Acute to Chronic Pain (Hours 7-8) James J Whiplash Associated Disorder: The pathway from acute to chronic pain (Hours 7-8) James J. Lehman, DC, FACO Associate Professor of Clinical Sciences Director of Community Health Clinical Education University of Bridgeport Learning Objectives • Able to demonstrate: • Clinical plan to evaluate and manage a post-traumatic, whiplash type injury and past history of a “widow maker,” and numerous nerve compression syndromes • Appropriate interview and differential diagnosis process • Appropriate evaluation process to rule-in and rule-out diagnoses • A differential diagnosis that includes a working diagnosis • A continuum of diagnosis as patient progresses with care • Therapeutic recommendations • Prognosis Patient Presentation • 60 year-old, male, university professor • Chief concern is pain and numbness in the left lower extremity with history of whiplash associated disorder, which started 3 weeks post-stent implant • Past history • Suffered myocardial infarct of the left anterior descending coronary artery 12 months prior to this visit • Several motor vehicle incidents over past 30 years with whiplash associated disorders • Ulnar neuropathy left upper extremity 17 years prior to this visit • Axillary nerve compression left upper extremity 15 years prior to this visit • Cervicobrachial neuropathy right upper extremity 14 years prior to this visit • Radial tunnel syndrome right upper extremity 10 • Wartenberg’s syndrome left upper extremity 5 years prior to this visit • Responds well to chiropractic management What is your list of subjective questions regarding the Chief Concern? Did you consider a list of Differential Diagnoses for Lower Extremity Condition? What tests would you perform to rule-in and rule- out your differential diagnoses of Chief Concern? Did you investigate the post MI care including surgery and medications? Create list of differential diagnoses regarding Chief Concern Rule-in and Rule-out with specific questions Rule-in and rule-out with objective testing and determine working diagnosis Definition of an orthopedic test • Most often, a provocative maneuver that reproduces the patient’s chief concern pain by stretching, compressing and/or contracting of tissues in order to identify the involved tissues. Working diagnosis is “Statin Myopathy with resultant piriformis syndrome • Statin myopathy is a common dilemma that causes persistent myalgia. • Fernandez G, Spatz ES, Jablecki C, and Phillips PS. Statin myopathy: a common dilemma not reflected in clinical trials. Cleveland Clinic Journal of Medicine, Vol 78, Number 6. June 2011. The working diagnosis is statin myopathy with resultant piriformis syndrome Diagnosis and Management of Piriformis Syndrome • Piriformis syndrome is a neuromuscular condition characterized by hip and buttock pain. This syndrome is often overlooked in clinical settings because its presentation may be similar to that of lumbar radiculopathy, primary sacral dysfunction, or innominate dysfunction. • Boyajian LA, et al. Diagnosis and Management of Piriformis Syndrome: An Osteopathic Approach. The Journal of the American Osteopathic Association, November 2008, Vol. 108, 657-664. FAIR Test Flexion, Adduction and Internal Rotation of the affected hip RHABDOMYOLYSIS • Muscle symptoms with a CK level 10 times the upper limit of normal or higher. Evidence of renal dysfunction is not required for the diagnosis, as pre-existing renal disease and hydration status are more closely related to kidney damage than the degree of muscle injury. • Linares LA, Golomb BA, Jaojoco JA, Sikand H, Phillips PS. The modern spectrum of rhabdomyolysis: drug toxicity revealed by creatine kinase screening. Curr Drug Saf. 2009 Sep;4(3):181-7. Epub 2009 Sep 1. Statin Myopathy Syndromes • Statin Myopathy • Any muscle complaint with onset coincident with start of statin therapy • Myalgia with normal CK • Myositis with elevated CK • Rhabdomyolysis • Thompson, PD, Clarkson, P, Karas, RH. Statin-associated myopathy. JAMA. 2003;289:1681-1690. Caveat Emptor • Perhaps more dangerous, statins provide false reassurances that may discourage patients from taking the steps that actually reduce cardiovascular disease. • According to the World Health Organization, 80 percent of cardiovascular disease is caused by smoking, lack of exercise, an unhealthy diet, and other lifestyle factors. • Statins give the illusion of protection to many people, who would be much better served, for example, by simply walking an extra 10 minutes per day. JOHN D. ABRAMSON and RITA F. REDBERG. Don’t Give More Patients Statins. NYT. Published: November 13, 2013. Statin Myopathy • Statins are associated with adverse side effects of skeletal myopathy. Statin Myopathy • Statin treatment reduces ubiquinone levels in the cholesterol synthesis pathway, which may be associated with mitochondrial dysfunction. In addition, reactive oxygen species (ROS) production and apoptosis induced by statins may provide cellular and molecular mechanisms in skeletal myopathy. • Kwak HB. Statin-induced Myopathy in Skeletal Muscle: the Role of Exercise. J Lifestyle Med. 2014 Sep;4(2):71-9. doi: 10.15280/jlm.2014.4.2.71. Epub 2014 Sep 30. Statin Myopathy Symptoms • The myopathies are neuromuscular disorders in which the primary symptom is muscle weakness due to dysfunction of muscle fiber. Statin Myopathy Symptoms • Other symptoms of statin myopathy can include muscle cramps, stiffness, and spasm. Types of Statin Myopathy • Myalgia—muscle weakness, soreness, tenderness, stiffness, cramping, or aching, either at rest or with exertion, without any elevation in CK. • Myositis—elevated CK with or without muscle symptoms. The “-itis” suffix is unfortunate since myositis does not correspond to inflammation on biopsy. • Rhabdomyolysis—muscle symptoms with a CK level 10 times the upper limit of normal or higher. Evidence of renal dysfunction is not required for the diagnosis, as preexisting renal disease and hydration status are more closely related to kidney damage than the degree of muscle injury. • Linares LA, Golomb BA, Jaojoco JA, et al. The modern spectrum of rhabdomyolysis: drug toxicity revealed by creatine kinase screening. Curr Drug Saf 2009; 4:181–187. Physician Denial Eighty-seven percent of patients reportedly spoke to their physician about the possible connection between statin use and their symptom. Golomb BA, McGraw JJ, Evans MA, Dimsdale JE. Physician response to patient reports of adverse drug effects: implications for patient-targeted adverse effect surveillance. Drug Saf. 2007;30(8):669-75. Physician Denial • Patients reported that they and not the doctor most commonly initiated the discussion regarding the possible connection of drug to symptom (98% vs 2% cognition survey, 96% vs 4% neuropathy survey, 86% vs 14% muscle survey; p < 10(-8) for each). • Physicians were reportedly more likely to deny than affirm the possibility of a connection. • Golomb BA, McGraw JJ, Evans MA, Dimsdale JE. Physician response to patient reports of adverse drug effects: implications for patient-targeted adverse effect surveillance. Drug Saf. 2007;30(8):669-75. Physician Denial CONCLUSIONS • Since low reporting rates are considered to contribute to delays in identification of adverse drug reactions (ADRs), findings from this study suggest that additional putative cases may be identified by targeting patients as reporters, potentially speeding recognition of ADRs. • Golomb BA, McGraw JJ, Evans MA, Dimsdale JE. Physician response to patient reports of adverse drug effects: implications for patient-targeted adverse effect surveillance. Drug Saf. 2007;30(8):669-75. Pelvic Obliquity • Pelvic obliquity can be caused by leg length inequality, contractures about the hips, as part of a structural scoliosis, or as a combination of two or more of these causes. Careful physical and radiologic evaluations are necessary to establish the correct diagnosis. • Pelvic obliquity. Its causes and its treatment. – BioMedSearch. www.biomedsearch.com/nih/Pelvic- obliquity-Its-causes-its/3715623.html Pelvic obliquity and Long Sit Test Long Sit Test • https://www.bing.com/videos/search?q=long+sit+test+fo r+leg+length+discrepancy&&view=detail&mid=E649DA15 CBC51E245890E649DA15CBC51E245890&&FORM=VDRV RV • Terry Bemis, et al. Validation of the Long Sitting Test on Subjects with lliosacral Dysfunction. JOSPT January 1987. https://www.jospt.org/doi/pdf/10.2519/jospt.1987.8.7.3 36 Is this patient presenting with a post- traumatic chronic pain syndrome? Why so many neuropathies? Nerve Damage Nerve damage The effects of compression on peripheral nerves can be attributed to alterations of blood circulation to and from the nerve as well as direct injury to the axonal transport systems. Venous blood flow from the peripheral nerves is shown to be reduced at 20 to 30 mm Hg, whereas frank ischemia can occur at pressures of 60 to 80 mm Hg. Neuropraxia The mildest grade is called neuropraxia, a reduction or complete block of conduction across a segment of a nerve with axonal continuity conserved. Neuropraxia • More specifically, it is dysfunction and/or paralysis without loss of nerve sheath continuity and peripheral Wallerian degeneration • Nerve conduction is preserved both proximal and distal to the lesion but not across the lesion. Neuropraxia A person's foot "falling asleep" after her legs have been crossed is an example of a functional loss without abnormal change. Axonotmesis Axonotmesis is a more severe grade of nerve injury compared to neurapraxia. Axonotmesis is a result of damage to the axons with preservation of the neural
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