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 7 1. 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) Cohen’s d Neck Disability (NDI) 41.09 (15.88) 34.31 (13.43) 0.46 Neuropathic pain (s-lanss) 11.91 (5.85) 9.67 (6.17) 0.37 Headaches 75.8% 84.6% Dizziness 51.5% 53.8% 2.55 (0.90) 2.10 (0.68) -Neck 100% 100% - *Back 51.5% 28.2% - *Shoulders 81.8% 53.8% -Arms 24.2% 28.2% -Legs 6.1% 2.6% Number of pain locations * = p < .05; ** = p < .01. 0.56 *= p < .01; ** = p < .05. Higher initial pain and disability1, 2 Posttraumatic stress reaction1, 3, 4, 5 Cold hyperalgesia1, 3 Older age1,2 1. 2. 3. 4. 5. Sterling, Jull, Vicenzio, Kenardy & Darnell, 2005 Buitenhuis, Spanjer, Fidler, 2003 Sterling, Kenardy, Jull & Vicenzio, 2003 Buitenhuis et al, 2006 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. Baseline Trauma cue exposure ↑ Arousal and negative affect PTSD (n = 33) PTSD – higher baseline arousal and negative affect and lower pain threshold. No PTSD (n = 39) Post-exposure ↓ Pain threshold Minimal changes in arousal, affect and pain. Between groups = PTSD, No PTSD Repeated Measures = Baseline and Post-Exposure Heart rate Blood pressure Respiratory Rate Skin Conductance Skin Temperature Pressure - Local - cervical spine - Remote - Median nerve & tibialis anterior Heat and Cold - cervical spine -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. Heart Rate Blood Pressure - 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. C2 Cervical Spine - PTSD group lower across time. - Further decrease in PTSD group after trauma-cue. 240 PTSD No PTSD 220 200 180 160 140 120 100 Remote Sites Baseline - PTSD group lower across time - Minimal changes after trauma-cue. Post trauma cue -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. 2. 3. 4. Back, Coffey, Foy, Keane & Blanchard, 2009 Shipherd , Back, Hamblen, Lackner & Freeman., 2003 Taylor et al., 2001 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) Did not consent to participate (n = 7) Consented to participate – Random allocation (n = 26) 4 due to time, 2 due to transport and 1 was already receiving psych treatment Allocated to TREAT condition (n = 13) Allocated to WL condition (n = 13) Analysed at post (n = 12) Analysed at post (n = 11) Discontinued treatment (n =1) due to moving interstate Lost to follow up (n =2) 1 declined to participate further and 1 unable to contact Analysed at 6-mo follow-up (n = 11) Discontinued participation (n = 1) 1 participant completed questionnaire data but not physical measures 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 90 80 70 60 50 40 30 20 10 0 76.9 61.5 WL TREAT 15.4 Post 6month - 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. 45 40 35 WL TREAT 30 Pre Post 6mo -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. HR 78 76 74 WL TREAT 72 70 68 Pre Post - Reduced physiological reactivity to the 6mo trauma cue (comparison of difference scores pre-post cue) in TREAT group compared to WL group for all 3 arousal measures. Minimal changes between groups or over time for PPTs (remote or local) or HPT. 16 Trend (p=.07) for greater reductions in Cold 14 Thresholds for TREAT compared to WL. 12 Also trend (p=.08) for reduced Cold thresholds in10 TREAT Group from pre-6mo. Cold WL TREAT Pre Post 6mo 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. 2. 3. 4. Identify high risk of PTSD using a screen. Provide information-based intervention Confirm with clinical assessment. If ASD/PTSD comorbid with WAD pretreat with Trauma-Focussed CBT +1 mo., then intervene with WAD.