CONROD, The University of Qld,

Traumatic event + Reaction Symptoms

Reexperiencing Avoidance Hyperarousal

Duration > 1 mo. (< 1 mo Acute Stress Disorder)

Functional impairment Diagnosis vs symptoms (subclinical)

Higher rates of PTSD in Whiplash patients1,2,3.

Overlapping epidemiologic and clinical features1

May involve stress system dysregulation4 Cortisol abnormalities in both Whiplash4,5 and PTSD6

Sensory hypersensitivity (lower pain thresholds)7

impaired sensory nervous system functioning 71. McLean, Clauw, Abelson & Liberzon, 2005

2. Buitenhuis et al , 2006

3. Sullivan, et al., 2009

4. Wessa, Rohleder, Kirschbaum & Flor, 2006

5. Gaab, Baumann, Budnoik, Gmunder, Hottinger, Ehlert, 2005

6. Liberzon, Abelson, Flagel, Raz & Young, 1999

7. Sterling and Kenardy, 2006

PTSD (n=33)

No PTSD (n=39)

Cohens d

Neck Disability (NDI) 41.09 (15.88) 34.31 (13.43) 0.46Neuropathic pain (s-lanss) 11.91 (5.85) 9.67 (6.17) 0.37Headaches 75.8% 84.6%Dizziness 51.5% 53.8%Number of pain locations 2.55 (0.90) 2.10 (0.68) 0.56

-Neck 100% 100%- *Back 51.5% 28.2%- *Shoulders 81.8% 53.8%-Arms 24.2% 28.2%-Legs 6.1% 2.6%

* = p < .05; ** = p < .01.

*= p < .01; ** = p < .05.

Higher initial pain and disability1, 2

Posttraumatic stress reaction1, 3, 4, 5

Cold hyperalgesia1, 3

Older age1,2

1. Sterling, Jull, Vicenzio, Kenardy & Darnell, 20052. Buitenhuis, Spanjer, Fidler, 20033. Sterling, Kenardy, Jull & Vicenzio, 20034. Buitenhuis et al, 20065. Jaspers, 1998

Aim Investigate the effect of co-morbid PTSD on

physiological arousal and sensitivity to induced pain in patients with chronic Whiplash.

Participants (N = 72) 17-65yrs (M = 35), 65% female Chronic Whiplash to Grade 3 (3mths 5yrs, M

= 2.5yrs) Exclusions: fractures, head injury, history of

neck pain.

Neck Pain and Disability (NDI) Neuropathic pain (S-LANSS)

Assessment of PTSD Posttraumatic Stress Diagnostic Scale (PDS) Structured Clinical Interview for DSM (SCID)

Allows screening out of symptoms attributable to injury/environment.

Challenge assessment Derive individual recall of trauma events Assess pre- and post-trauma cue Physiological arousal, pain sensitivity, affect.

BaselineTrauma cue

exposure Post-exposure

No PTSD Minimal changes in arousal, affect and pain.

PTSD

Arousal and negative affect

Pain threshold

(n = 33)

(n = 39)

PTSD higher baseline arousal and negative affect and lower pain threshold.

Between groups = PTSD, No PTSD

Repeated Measures = Baseline and Post-Exposure

Heart rate

Blood pressure

Respiratory Rate

Skin Conductance

Skin Temperature

Heat and Cold- cervical spine

Pressure- Local - cervical spine - Remote - Median nerve

& tibialis anterior

-PTSD group reported more negative affect across time.-Increase in negative affect for both groups after trauma-cue-Stronger increases in PTSD group compared to the No PTSD group.-Similar results for self-reported Pain on NRS.

- PTSD group higher arousal (HR and BP) across time.- Increased arousal in both groups after trauma-cue.- Significantly greater increases in PTSD group compared to No PTSD.

Blood PressureHeart Rate

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120

140

160

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240

Baseline Post trauma cue

PTSD No PTSDCervical Spine- PTSD group lower across time. - Further decrease in PTSD group after trauma-cue.

Remote Sites- PTSD group lower across time- Minimal changes after trauma-cue.

C2

-PTSD group had lower thresholds to cold and heat across time.- Significant decrease in cold threshold for PTSD after trauma cue. - Minimal change in heat thresholds after trauma-cue.

PTSD in WAD patients is associated with: greater negative affect and

physiological arousal. Lower sensory pain thresholds Further decreases in cold and

cervical pressure thresholds after trauma-cues.

Can we treat PTSD in patients with WAD?

Trauma focused CBT has been shown to have moderate effectiveness in treating PTSD within chronic pain samples.1,2,3

A case study has shown CBT aimed at PTSD within Whiplash resulted in improved chronic pain management and coping.4

1. Back, Coffey, Foy, Keane & Blanchard, 20092. Shipherd , Back, Hamblen, Lackner & Freeman., 20033. Taylor et al., 20014. Jaspers, 1998

CBT for PTSD will result in: reduced PTSD symptoms reduced negative affect and physiological

arousal to trauma-cues improved functional disability and quality of life

Previous research indicates minimal impact of CBT for PTSD on pain measures.

Assessed as eligible from Study 1 (PTSD and WAD) (n = 33)

Consented to participate Random allocation (n = 26)

Allocated to TREAT condition (n = 13)

Allocated to WL condition(n = 13)

Analysed at post (n = 11)Lost to follow up (n =2)

1 declined to participate further and1 unable to contact

Analysed at post (n = 12)Discontinued treatment (n =1)

due to moving interstate

Analysed at 6-mo follow-up (n = 11)Discontinued participation (n = 1)

1 participant completed questionnaire data but not physical measures

Did not consent to participate (n = 7)4 due to time, 2 due to transport and 1 was

already receiving psych treatment

10 weekly sessions with clinical psychologist CBT for PTSD based on Bryant program Treatment components included:

Relaxation training (e.g. deep breathing, PMR) Cognitive restructuring Imaginal Exposure (recalling accident with

thoughts, physical sensations and emotions) Invivo Exposure (fear hierachy of avoided

accident related activities, people and places)

Relapse prevention

Participants in Treatment (n=13) and WL (n=13) were comparable on: demographic and accident variable initial and current WAD symptoms. trauma symptoms (SCID, PDS and IES-R) depression, anxiety and stress (DASS) Fear of re-injury (TSK) Neck pain intensity (NRS) and disability (NDI) Medication use

- Sig more people in TREAT group (8/13) no longer met PTSD criteria at post-assessment, compared WL (1/13).- Treatment effects were maintained at 6mo FU with 9/13 no longer meeting criteria for PTSD.

15.4

61.5

76.9

0102030405060708090

Post 6month

WLTREAT

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35

40

45

Pre Post 6mo

WLTREAT

-TREAT group showed significantly greater improvement in neck disability post-treatment, compared to WL group .- Improvements were maintained at 6month follow-up.

- Overall trend (p=.08) for greater reductions in baseline arousal measures (BP and HR) in TREAT group compared to WL.

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70

72

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78

Pre Post 6mo

WLTREAT

- Reduced physiological reactivity to the trauma cue (comparison of difference scores pre-post cue) in TREAT group compared to WL group for all 3 arousal measures.

HR

Minimal changes between groups or over time for PPTs (remote or local) or HPT.

Trend (p=.07) for greater reductions in Cold Thresholds for TREAT compared to WL. Also trend (p=.08) for reduced Cold thresholds in TREAT Group from pre-6mo.

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12

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16

Pre Post 6mo

WLTREAT

Cold

The trauma cue was found to have less impact in TREAT group compared to WL for Cold pain at post-treatment and this was maintained at 6mo.

CBT was found to be effective in treating PTSD within chronic WAD.

Need to replicate in acute WAD. CBT for PTSD had impact on pain thresholds. Future research on treatment for this

comorbidity should look at using CBT first to reduce PTSD symptoms and then focus on physical therapy for WAD symptoms.

1. Identify high risk of PTSD using a screen.2. Provide information-based intervention3. Confirm with clinical assessment.4. If ASD/PTSD comorbid with WAD pre-

treat with Trauma-Focussed CBT +1 mo., then intervene with WAD.

Cognitive behaviour therapy for whiplash injury (?)What is Posttraumatic Stress Disorder (PTSD)?Event vs injury related distressPTSD & WhiplashPTSD and WADSelf-reported Pain and DisabilityWAD and PTSD: SF-36Disability and Quality of LifeWhiplash Recovery vs ChronicityStudy 1MeasuresDesign and hypotheses2x2 Mixed Experimental designArousal MeasuresThe Lifeshirt SystemSensory Pain ThresholdsResults Negative AffectResults ArousalResults Pressure ThresholdsResults Thermal Pain ThresholdsSummarySo, what can we do about it?Slide Number 19HypothesesSlide Number 22Treatment ProtocolBaseline comparisonsPTSD Diagnosis% no longer meeting SCID criteria for PTSDNeck Disability IndexPhysiological ArousalSensory Pain ThresholdsSensory Pain and Trauma cueImplications and Future Research DirectionsEarly intervention: Screen and Treat