Chronic Pain Syndromes: Current Concepts and Treatment Strategies _ _______________________________
Encouraging the patient to maintain good range of motion is important. Soft-collar cervical immobilization should be discouraged as active mobilization during acute phase WAD can actually reduce pain intensity [99]. Multimodality therapy programs that include joint mobilization, relaxation therapy, electrotherapies, exercise, and a cognitive-behavioral compo- nent that address pain and functional deficits are effective in patients with subacute or chronic WAD who have not improved with simple activity-related approaches [99]. Patients with severe symptoms should be enrolled as soon as is feasible following injury. However, patients with cold hyperalgesia and/ or widespread allodynia may not respond to this intervention. Early referral to a pain clinic is advisable for patients at risk of developing chronic symptoms [111]. Patients should also be assessed and monitored for symptoms of anxiety and depres- sion, then treated accordingly. Pharmacotherapy Prompt, effective pain control should be achieved early, because high pain levels can interfere with recovery. There is little available guidance on the effectiveness of specific opioid and non-opioid analgesics. Some recommend initiating acetamino- phen or NSAIDs for pain and adding codeine if appropriate and necessary [111]. If a patient remains symptomatic despite optimal analgesia, adding a TCA, such as amitriptyline, may be beneficial [99]. Methylprednisolone infusion may improve recovery in moder- ate-to-severe acute WAD. In addition, intra-articular dextrose and lidocaine injections may reduce pain and disability [111]. Medial branch block of the cervical zygapophyseal joints effectively reduced sensory hypersensitivity in a small group of patients with chronic WAD, but these results need larger-scale prospective replication [111]. Supportive evidence is equivocal for botulinum toxin injections and lacking for intra-articular or selective nerve root block or corticosteroid injections in chronic WAD [111]. Surgical Interventions Moderate evidence indicates that radiofrequency neurotomy is effective in reducing pain in chronic WAD, although relief is not permanent [111]. Some patients benefit from occipital nerve decompression, carpal tunnel decompression, and cer- vical discectomy and fusion. In addition, combined surgical fasciectomy and spinal accessory nerve neurolysis is effective in patients with severe, refractory WAD with spinal accessory nerve entrapment and/or chronic compartment syndrome of the trapezius muscle. Patients with chronic WAD often complain of headache, dizzi- ness, and nausea, symptoms also experienced by patients with CSF leak. Ishikawa et al. explored the relationship between chronic WAD and CSF leak and investigated the efficacy of epidural blood patch in chronic WAD [109]. Of 66 patients (mean duration of WAD: 33 months) imaged with radioiso- tope cisternography, CSF leak was detected in 37 patients who then received epidural blood patch. Compared with baseline,
symptom reduction one week after epidural blood patch was noted in most patients, including improvements in headache (100% vs. 17%), memory loss (94% vs. 28%), dizziness (83% vs. 47%), visual impairment (81% vs. 25%), and nausea (78% vs. 42%). Treatment response remained at six-month follow-up, and work status was also significantly improved at follow-up. The authors concluded that in some cases of chronic WAD, the possibility of CSF leak should be assessed, and that epi- dural blood patch may be beneficial for patients with positive findings. There are no other published studies confirming these observations. Alternative Therapies Massage therapy, chiropractic, physical therapy, and occupa- tional therapy constitute adjunctive modalities that may be of benefit in all phases of WAD [111]. Acupuncture has also been shown to reduce pain in chronic WAD, although evidence of functional improvement is lacking [88; 111; 112]. Pulsed electromagnetic field therapy can decrease pain intensity and increase cervical range of motion in acute WAD. Myofeedback training may be beneficial for some patients with chronic WAD [88; 111; 112; 120]. An RCT of 51 patients with chronic nonspecific neck pain compared a self-help exercise program with Iyengar yoga [121]. Following a nine-week trial of both yoga and neck pain inter- ventions, yoga resulted in significantly greater improvement than home-based exercise for pain, pain intensity, disability, mental health-related quality of life, and neck muscle func- tional status. Patients randomized to yoga were further evalu- ated one year after completing the nine-week formal protocol [122]. Statistically significant improvements from baseline were found in pain intensity, neck-related disability, and bodily pain. Sustained yoga practice was the strongest predictor of long-term effectiveness. Optimal treatment of WAD continues to be a challenge, which may be related to the need for better understanding of the subjective experiences and perceptions of patients living with the condition. In one study, researchers conducted individual telephone interviews with patients with WAD and then ana- lyzed the transcribed audio tapes. Two main themes emerged from the interviews. First, the participants described what it was like to navigate the healthcare system to understand their injury, interpret therapeutic recommendations, and find the right healthcare practitioner to help with the process. Addi- tional navigational complexities were related to compensation and funding systems. Second, participants described a journey of trial and error in establishing self-management strategies to prevent and relieve pain. This included the gradual realization that they could be faced with an ongoing residual deficit. Early identification of the patient’s expectations for recovery and validation of their injury by the healthcare practitioner can aid the recovery process [123].
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