While on my rural placement I encountered a patient who was admitted for pain management following a whiplash injury three months previously. A CT Scan eliminated a fracture. The patient complained of pain in the cervical spine radiating into the head causing headaches, and thoracic spine pain with generalised pain in the surrounding muscles and shoulders. The patient was on very high dosages of pain relieving medications, however still complained of pain ranging from 8-10/10. The patient was discharged with a physio outpatient appointment, however did not attend, then was soon re-admitted for pain relief. This patient had also been seen previously in the outpatient setting by the previous student when the individual was approximately two months post injury, where he received ultrasound, however did not attend follow up appointments. This patient had a few yellow flags such as chronic pain, fear avoidance behaviours and reporting high amounts of pain. He was also receiving input from the Psychologist.
Assessment showed loss of cervical lordosis, significant stiffness throughout the cervical and thoracic spine and “tightness” in rhomboids, upper traps and erector spinae. The patient would not tolerate mobilisations (passive physiological, accessory and distractions) and only allowed us to treat through gentle massage. This situation was particularly frustrating because although we explained the need for mobilisations to decrease the hypomobility, which was contributing to his pain, he refused this treatment each time we attempted it. Although he stated the massage eased the pain during the session, it soon increased the pain. I felt like I was not able to help this patient because he would not allow me to treat him with the optimal treatment strategies. We were also receiving criticism from a doctor who didn’t believe in the value of Physiotherapy.
From this experience I realise the need for early treatment for whiplash injuries to prevent further complications arising. The need for education is also vital to ensure the patient understands the need for treatment. For complicated patients such as this a multi-disciplinary approach is also required. Does anyone know what other techniques we could have used?
1 comment:
This situation brings up some good points.. Firstly, it is important to identify people early post whiplash who might have a poorer recovery - particularly those with psychosocial risk factors for chronicity and ongoing disability. The "Orebro musculoskeletal pain questionnaire" is useful for this (linton and Boersma Clinical Journal of Pain 2003). Secondly, one needs to consider what is "driving" a disorder as the patient moves into the chronic stage. It would seem like a few yellow flags were clearly identified. These patients , as mentioned, often need a ACTIVE, self management approach with Multidisciplinary intervention if possible. Continuing with "hands on" is often not the best approach. Pacing, functional restoration, exercises, graded return to activity are all good approaches for this sort of client and is well supported in the literature. I suggest going to the following web site: www.maa.nsw.gov.au and download the whiplash guidelines. Also of interest, for management of soft tissue injuries: www.workcover.nsw.gov.au and download the document: "improving outcomes: integrated, active management of workers with soft tissue inury".
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