Predicting chronic pain in whiplash injuries ?

Scientists identified who will develop chronic pain 1 to 2 weeks after whiplash injury:

• Large amount of fat in neck muscles predicts chronic pain, disability and PTSD
• Will enable earlier treatment for whiplash victims
• Fat indicates atrophy, shows the chronic pain is not psychological
• Whiplash affects more than 4 million Americans annually

While most people should expect to fully recover from whiplash injuries within the first few months, about 25 percent have long-term pain and disability that lasts many months or years.

Using special MRI imaging, Northwestern Medicine scientists have identified, within the first one and two weeks of the injury, which patients will go on to develop chronic pain, disability and post- traumatic stress disorder (PTSD). This is the earliest these patients have ever been identified, according to the scientists.

The ability to identify these patients so early will enable faster and more specialized treatment, which could be particularly beneficial for the PTSD.

After one to two weeks of the injury, Northwestern scientists found unusual muscular changes in the chronic pain group using a sophisticated MRI that measures the fat/water ratio in the muscles. The imaging revealed large amounts of fat infiltrating the patients' neck muscles, indicating rapid atrophy.
The presence of fat in the muscle does not appear to be related to a person's body size or shape.

"We believe this represents an injury that is more severe than what might be expected from a typical low-speed car crash," said lead investigator James Elliott, assistant professor of physical therapy and human movement sciences at Northwestern University Feinberg school of Medicine. The study was published in the journal Spine.

"This opens up a new door for research on whiplash," Elliott said. "For a long time whiplash has been treated as a homogenous condition. Our study has shown these patients are not all the same; they have different clinical signs and symptoms."

Whiplash-associated disorders from motor vehicle collisions affect more than 4 million Americans annually, harming their quality of life and costing an estimated $30 billion for medical/rehabilitative care per year.

The study, which used standard MRI imaging, also found a large amount of fat in neck muscles of whiplash patients at one and three months post injury. Those patients went on to develop chronic pain and disability.

Not everyone needs a MRI scan after a whiplash injury from a motor vehicle collision. However, these findings help physicians understand water/fat MRI, in tandem with other clinical signs/symptoms can be used to identify who is likely to develop post-traumatic stress disorder. This then could be used to justify the referral of the patient to a psychiatrist or psychologist, Elliott said. PTSD is a disorder caused by experiencing or witnessing a traumatic event.

The patients have shown to not respond well to traditional rehabilitation such as physical therapy. It appeared that they may require a more concerted effort for pain management from their physician and help from a psychologist. Emerging, yet preliminary evidence suggests this to be a reasonable strategy.
The findings may indicate the importance of changing standard imaging protocols to identify these individuals early and start accelerated treatment. Routine imaging does not reveal this fat infiltration in individuals with whiplash injuries.

A small preliminary study previously done by Elliott and Northwestern colleagues shows whiplash victims with chronic pain also have a high level of muscle fat in their lower legs, indicating muscle atrophy.

Elliott hypothesizes these patients may have partially damaged their spinal cord. They reported feeling fatigued and clumsy when walking and weakness in their legs, with difficulty pushing hard on the gas pedal of a car or standing on their tiptoes.

Effective treatment for these patients with chronic whiplash is not yet available. This is mainly due to the fact that it has nt been figured out what's wrong with them.

The findings help to demystify the condition and let individuals know their chronic pain is not all in their heads. A basic exam will not consistently show a fracture, herniated disc or ligament tear.
Whiplash patients with ongoing chronic pain, but no objective imaging, are frequently informed that nothing is wrong with them, the author concluded. However, it appears to be a response to the injury. But what has actually been injured remains to be found out.

Read more: Northwestern University. (2015, April 6). "Predicting chronic pain in whiplash injuries ." Medical News Today. Retrieved from http://www.medicalnewstoday.com/releases/291899.php. 

Keywords: "Dr Pietsch", "The-Expert-witness.de", "Neck pain",  Whiplash", "Chronic whiplash"

Pre-operative absence from work is a predictor for the return to work after arthroplasty

For patients who undergo total hip or total knee arthroplasty, the most significant predictor of incomplete or no return to work is preoperative absence from employment, new research shows. Preoperative absence from work is a potentially modifiable factor and modification could prevent productivity loss.

Of patients undergoing total hip or total knee arthroplasty, 15% to 45% are of working age. Most return to work after surgery, but some experience a reduction in work hours, and 5% to 30% do not return at all.

A study by Lichtenberg identified the determinants of incomplete or no return to work 1 year after surgery. Leichtenberg presented results from the prospective cohort study here at the 16th European Federation of National Associations of Orthopaedics and Traumatology Congress in Prague.

Of the 123 study participants, 67 underwent total hip arthroplasty and 56 underwent total knee arthroplasty. All were younger than 65 years and had a paid job at the time of surgery.

Sociodemographic characteristics were matched in the hip and knee groups using pain, other symptoms, function in daily living, function in sport and recreation, and quality of life subscores of the Hip Disability and Osteoarthritis Outcome Score or the Knee Injury and Osteoarthritis Outcome Score.

Patients were evaluated before surgery and 1 year after surgery. The primary outcome — return to work 1 year after surgery — was classified as complete, incomplete, or not at all.

The researchers categorized the physical demands of each patient's work as light, medium, or heavy. The rate of patients with physical work categorized as light was lower in the hip group than in the knee group (70% vs 87%).

 Work Characteristics and Outcomes

Variable	Hip Group, %	Knee Group, %
Characteristic
Self-employed	18	15
On workers' compensation the month before surgery	8	11
Need for work adaptations	24	35
Absence from work due to pain	32	32
Work at 1 year
Complete	79	71
Incomplete	13	18
Not at all	8	11

Preoperative absence from work was the only factor associated with no or incomplete return to work in both the hip group (odds ratio [OR], 8.6; 95% confidence interval [CI], 1.9 - 39.0) and the knee group (OR, 4.2; 95% CI, 1.0 - 17.1).

In the hip group, self-employment was strongly associated with no or incomplete return to work (OR, 7.6; 95% CI, 1.5 - 39.8), as was a higher Hip Disability and Osteoarthritis Outcome Score.

A return-to-work appears completely dependent on the insurance system in the specific country. In Sweden, from a financial income standpoint, it doesn't matter if you go back to work; you would be pretty well off on public support. In the United States, it is not that way. Patients were not asked for the reasons why they stopped working after surgery, which is one of the limitations of the study.

However, despite this, the researchers conclude that the proportion of hip and knee patients not returning to work full time is substantial, and that the only predictor of this is preoperative absence from work, which can be changed. 

Leichtenberg, Malchau: More Could Return to Work After Joint Surgery. 16th European Federation of National Associations of Orthopaedics and Traumatology (EFORT) Congress. Presented May 27, 2015.

Posture matters in radiographs of clavicle fractures

Objectives: To determine whether clavicle fracture displacement and shortening are different between upright and supine radiographic examinations.

Picture: Dr Pietsch notfallambulanz.blogspot.com

Design: Combined retrospective and prospective comparative study.

Setting: Level I Trauma Center.

Patients: Forty-six patients (mean age, 49 years; range, 24–89 years) with an acute clavicle fracture were evaluated.

Intervention: Standardized clavicle radiographs were obtained in both supine and upright positions for each patient. Displacement and shortening were measured and compared between the 2 positions.

Main Outcomes Measurements: One resident and 3 traumatologists classified the fractures and measured displacement and shortening. Data were aggregated and compared to ensure reliability with a 2-way mixed intraclass correlation.

Results: Fracture displacement was significantly greater when measured from upright radiographs (15.9 ± 8.9 mm) than from supine radiographs (8.4 ± 6.6 mm, P < 0.001), representing an 89% increase in displacement with upright positioning. Forty-one percent of patients had greater than 100% displacement on upright but not on supine radiographs. Compared with the uninjured side, 3.0 ± 10.7 mm of shortening was noted on upright radiographs and 1.3 ± 9.5 mm of lengthening on supine radiographs (P < 0.001). The intraclass correlation was 0.82 [95% confidence interval (CI), 0.73–0.89] for OTA fracture classification, 0.81 (95% CI, 0.75–0.87) for vertical displacement, and 0.92 (95% CI, 0.88–0.95) for injured clavicle length, demonstrating very high agreement among evaluators.

Conclusions: Increased fracture displacement and shortening was observed on upright compared with supine radiographs. This suggests that upright radiographs may better demonstrate clavicle displacement and predict the position at healing if nonoperative treatment is selected.

Keyword: Clavicle fracture, Dr Pietsch, x-ray clavicle fracture and posture

 Backus JD et al. Upright Versus Supine Radiographs of Clavicle Fractures: Does Positioning Matter? J Orthop Trauma 2014; 28: 636–641; doi: 10.1097/BOT.0000000000000129

Study identifies low back pain risk factors

New research presented at the 2015 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) identifies nicotine dependence, obesity, alcohol abuse and depressive disorders as risk factors for low back pain, a common condition causing disability, missed work, high medical costs and diminished life quality. 

According to the U.S. Centers for Disease Control and Prevention's (CDC) 2012 National Health Survey, nearly one-third of U.S. adults reported that they had suffered from low back pain during the previous three months. For many adults, low back pain is debilitating and chronic. Determining modifiable risk factors for low back pain could help avoid or diminish the financial and emotional costs of this condition.

Researchers reviewed electronic records of more than 26 million patients from 13 health care systems across the U.S., including 1.2 million patients diagnosed with low back pain (approximately 4.54 percent of the patient records).

The review found that 19.3 percent of the patients diagnosed with a depressive disorder reported lower back pain, as did 16.75 percent of patients diagnosed as obese (a body mass index, or BMI, >30kg/m²), 16.53 percent of the patients diagnosed with nicotine dependence, and 14.66 percent with reported alcohol abuse. Patients with nicotine dependence, obesity, depressive disorders, and alcohol abuse were had "statistically significant" relative risks of 4.489, 6.007, 5.511 and 3.326 for low back pain, respectively, when compared to other patients.

"This study used an electronic health care database to identify modifiable risk factors--obesity, depressive disorders, alcohol and tobacco use--in patients with low back pain," said lead study author and orthopaedic surgeon Scott Shemory, MD. "The findings will allow physicians to better counsel and more closely follow their high-risk patients." 

Read more:  http://www.aaos.org/


Keywords: Dr Pietsch, "The-Expert-witness.de", "Low back pain""

No Good Evidence That Pharmacological Interventions Relieve Achilles Tendinopathy

There is no convincing evidence that any of the pharmacological interventions for Achilles tendinopathy work, according to a systematic review.

Current treatments include injectable corticosteroids, high-volume saline solution, prolotherapy, autologous blood, platelet-rich plasma and a variety of other substances, as well as transdermal topical application of glyceryl trinitrate and other drugs.

There are few studies, however, to establish which of these interventions are safe and effective.The recent study found 13 randomized controlled trials (with 528 patients) of pharmacological interventions for the treatment of Achilles tendinopathy.

There were three studies of platelet-rich plasma (PRP), two studies of autologous blood injection, two studies of polidocanol, and one study each of corticosteroids, skin-derived fibroblasts, prolotherapy and aprotinin injections. Two studies investigated the application of glyceryl trinitrate (GTN) patches on the tender site.

The follow-up times averaged 7.3 months (range, three to 14 months). Although some of the studies showed promising results, none of the interventions showed unequivocal evidence of remarkable benefits in terms of pain, disability, quality of life or histological changes.

Promising potentials were shown by different substances administered in combination with physical therapy, but there are not enough data to confirm their real additional benefit.

"There is a need for more long-term investigations, studying large enough cohort(s) with standardized scores and evaluations shared by all the investigations to confirm the healing potential, and provide a stronger statistical comparison of the available treatments," they write.

Maffulli N, Papalia R, D'Adamio S, Diaz Balzani L, Denaro V: Pharmacological interventions for the treatment of Achilles tendinopathy: a systematic review of randomized controlled trials. Br Med Bull. 2015 Jan 12

Brace Not Essential for Spinal Compression Fractures

Among patients with compression fractures, outcomes of disability, back pain, and progression of anterior body compression were similar among those treated without a brace or with soft or rigid braces, according to findings of a randomized clinical trial published in the December 3 issue of the Journal of Bone & Joint Surgery.

"In addition to the cost and discomfort associated with braces, the findings in this study suggest that brace treatment for osteoporotic compression fractures may not provide any additional improvement in fracture healing, mobility and pain," lead author Ho-Joong Kim, MD, PhD, orthopaedic surgeon and assistant professor, Seoul National University College of Medicine, said in a news release.

"Moreover, the gradual deterioration in life quality, including mental and social wellbeing, associated with this condition reemphasizes the need for prevention of osteoporotic compression and other fractures."

Within 3 days of injury, the researchers randomly assigned 60 patients (aged 65 years and older) with acute, one-level osteoporotic compression fractures to the no-brace, soft-brace, or rigid-brace groups. The baseline adjusted Oswestry Disability Index score at 12 weeks after fracture was the main study endpoint, with a noninferiority margin set at an average of 10 points.

At 12 weeks after fracture, this main study endpoint in the no-brace group was not inferior to that in the soft-brace or rigid-brace groups.

During follow-up, the groups did not differ significantly in terms of overall Oswestry Disability Index scores, visual analog pain scale scores for back pain, anterior body compression ratios, general health status, or patient satisfaction rates.

In all three groups, the Oswestry Disability Index scores and the visual analog pain scale scores for back pain improved with time after fracture (P < .001), and the body compression ratios significantly decreased with time (P < .001). Short Form 36 health survey scores decreased at 12 weeks after compression fractures in all groups, confirming earlier evidence of reduced quality of life after a compression fracture.

The researchers point out that annual incidence of spinal compression fracture is nearly 700,000, making them nearly twice as common as other osteoporosis fractures. More than 30% of women aged 70 or more years have had one or more osteoporosis-related spinal fractures, according to the news release.

Although soft or rigid bracing is often recommended to stabilize the spine, reduce pain, and prevent further fracture site deterioration and collapse, compliance is often poor because of discomfort. Prolonged bracing may also cause muscular atrophy, deconditioning, skin irritation, higher healthcare costs, and rehabilitation delays.

The authors concluded that the disability outcomes of treatment without a brace for osteoporotic compression fractures are not inferior compared with those associated with treatment with soft or rigid braces. The progression of the anterior body compression ratio at the fractured vertebral body does not seem to be different with orthosis use compared with treatment without braces.

J Bone Joint Surg Am. 2014;96:1959-1966

Synovitis predicts the onset of OA

Objectives It is unknown whether joint inflammation precedes other articular tissue damage in osteoarthritis. Therefore, this study aims to determine if synovitis precedes the development of radiographic knee osteoarthritis (ROA). 

Methods The participants in this nested case–control study were selected from persons in the Osteoarthritis Initiative with knees that had a Kellgren Lawrence grading (KLG)=0 at baseline (BL). These knees were evaluated annually with radiography and non-contrast-enhanced MRI over 4 years. MRIs were assessed for effusion-synovitis and Hoffa-synovitis. Case knees were defined by ROA (KLG≥2) on the postero-anterior knee radiographs at any assessment after BL. Radiographs were assessed at P0 (time of onset of ROA), 1 year prior to P0 (P-1) and at BL. Controls were participants who did not develop incident ROA (iROA) from BL to 48 months). 

Results 133 knees of 120 persons with ROA (83 women) were matched to 133 control knees (83 women). ORs for occurrence of iROA associated with the presence of effusion-synovitis at BL, P-1 and P0 were 1.56 (95% CI 0.86 to 2.81), 3.23 (1.72 to 6.06) and 4.7 (1.10 to 2.95), respectively. The ORs for the occurrence of iROA associated with the presence of Hoffa-synovitis at BL, P-1 and P0 were 1.80 (1.1 to 2.95), 2.47 (1.45 to 4.23) and 2.40 (1.43 to 4.04), respectively. 

Conclusions Effusion-synovitis and Hoffa-synovitis strongly predicted the development of iROA. 

Read more:

Atukorala I et al. Synovitis in knee osteoarthritis: a precursor of disease? Ann Rheum Dis 2014; online 8. Dezember; doi: 10.1136/annrheumdis-2014-205894

Keywords: OA, synovitis, osteoarthritis of the knee, osteoarthritis, MRI osteoarthritis, Dr Pietsch