Anda di halaman 1dari 30

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)

Cohens
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

Post-exposure

Arousal and negative


affect

PTSD
(n = 33)

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

No PTSD
(n = 39)

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.