Whiplash Isn’t Just Neck Pain: What Clinicians Are Missing

Annina Schmid: [00:00:00] But indeed there is measures that we can do at bedside where we can look at, do these patients have nerve involvement?

Mark Kargela: Back in 1998. The Quebec Task Force gave us a way to classify whiplash associated disorders, and for decades, grade two has been treated just as a musculoskeletal issue, neck pain, stiffness, and maybe some limited movement.

What if that's not the whole picture? . In today's episodes, we're joined by Dr. Annina Schmid and Dr. Joel Fundaun, two researchers whose work is challenging that traditional view. The research shows that many of these patients are actually dealing with nerve related issues, and the best part, these signs are detectable with simple exams you can start doing in clinic immediately.

Before we dive in, make sure to subscribe so you don't miss future episodes. And if this one sparks new thinking, share it with a colleague who needs to hear it. Stick around to the end where we unpack simple clinic ready tools that could change how you assess and treat whiplash starting tomorrow.

Let's get into it.

Announcer: This is the Modern Pain Podcast with Mark Kargela.

Mark Kargela: [00:01:00] Annina, I wanted to start with you today. Glad to have you and Joel on the podcast really have enjoyed your work, both your works as you've published recently on Whiplash Associated Disorders. Before we get into the details of that, I'm wondering if you could introduce yourself and a little bit about the lab that you kind run there in Oxford.

Annina Schmid: So my name is Annina. I'm a physiotherapist by training, and I did my musculoskeletal, kind of specialization in Australia then a PhD in Australia, and then moved to Oxford, quite a. Now, 13 or so years back, and so in Oxford, I am I'm, leading a team called the Neuro Musculoskeletal Health and Science Lab.

And we are a bunch of really nice people, I have to say, but I'm biased of people looking at neuropathic pain specifically but also nerve injuries and certain musculoskeletal conditions that might or might not include a nerve injury. Obviously me being a physiotherapist, we still have somewhat a physio focus.

So we are also interested in physiotherapeutic interventions for people with nerve [00:02:00] injury and neuropathic pain. But we also have a focus that is much more neuroscience based. So, we are looking at the mechanisms of nerve injury, the mechanism of nerve degeneration, the mechanisms of neuropathic pain specifically, and we use a translational approach.

For example combining. Bio sample analyzes in from humans, including nerves, skin, blood, et cetera, with clinical phenotypes in patients as well. And so that we can get an understanding of what exactly is happening when people have a nerve injury or neuropathic pain.

Mark Kargela: Joel, I wonder if you could discuss your development and how your paths crossed with Annina, obviously with your PhD and where you're at now.

Joel Fundaun: so I was working clinically as a physical therapist in the us. I had completed my residency in orthopedics at Northwestern and Shirley Orion Ability Lab. And from there I was treating many patients that had whiplash injury and was especially interested in that subgroup that had nerve related symptoms or neuropathic [00:03:00] symptoms that just didn't make sense and were much harder to treat.

And so then it was after my residency that I realized that I did want to do a PhD. So I reached out to Annina. Her work has for a long time shown physiotherapeutic ways that we can intervene in different neuropathic conditions as well as different mechanisms related to those. So I was very interested in trying to understand whiplash from that perspective.

So then I was very fortunate to get to do my PhD with Annina focused on this project that we'll talk about today further looking at whiplash and nerve related conditions. And now I'm trying to continue some of that work here as a postdoc at Stanford. And I continued to work clinically as well as a physical therapist.

Mark Kargela: So you've been not doing much since graduation after school. That's a pretty impressive journey to go from Oxford to Stanford postdoc. That's amazing. So kudos to you for that. Some of the things that kind of laid the groundwork for some of your work was the systematic review y'all did in 2022 that kind of looked at the presence of [00:04:00] neuropathic or nerve symptoms.

'cause it was thought maybe you can get a little bit into kind of the. Staging of whiplash associated disorders that's used out there and how it may be traditionally it was looked at and how your study or your systematic review kind of questions, some of the maybe traditional categorization of whiplash associated disorders.

Joel Fundaun: The Whiplash associated Disorders is a term that's been used for a very long time. The Quebec Task Force grading system has been developed since the nineties to try to. Find a clinical approach to help us understand this very heterogeneous and complex condition.

So they group it into kind of five levels from zero to having kind of no pains or problems to four, which is the most severe, where someone would have a fracture or dislocation of their neck. And most people from the literature. Fall into whiplash grade two. So that's neck pain and musculo ske musculoskeletal signs.

So reduced neck range of motion or stiffness. But they don't have frank neurological deficits. So that'd be reductions in light [00:05:00] touch, in strength or reflexes. But since that grading system has come out basically ever since then there's been pushback about how complex this. Whiplash grade two is, and how heterogeneous even that group is.

And we were interested in that because that's what we see clinically as well and what kind of more research in the past has led to. So that's what's led us to do the systematic review to try to look at all of the literature that's currently out there to see what is present.

Mark Kargela: Annina. I'm wondering if you could talk about how that question arose in your work in your lab as far as what kind of led you all to start looking into this from what you've been seeing as you've been studying

Annina Schmid: Yeah, absolutely is very similar to what Joel said. My, my spark in to whiplash was started in my clinical practice when, at that time in the UK we were still seeing these patients mainly coming through insurance claims, and then they had to go and have physio so that the insurance claim could go through.

So that has since changed. But at that time we were seeing a lot of patients with plaque associated [00:06:00] disorder in private practice. And to me it just became clear that some of these patients have something else than just tenderness or just, a bit of neck stiffness, what we consider truly musculoskeletal kind of problem.

When you listen to them. You examine them a bit more carefully. You often found symptoms of neuropathic pain, things that cannot truly be attributed to say, a muscle problem or maybe a facet joint, or maybe also not just to, fear. Fear of what has happened to you. I. During an injury.

So I remember, when the World Physio Congress was in Singapore? I can't remember, was it like 2016 maybe or so that is when I contacted Michelle Sterling, who I knew from Australia. I did my PhD in the same department that Michelle Sterling was in Australia. And I told her, we really should look at whiplash at some point because my, my work has mainly focused on nerve injuries, and I [00:07:00] was discovering that a lot of these people with minor nerve injuries like compression, neuropathies, et cetera, they seem to have deficits and structural changes to small fibers dominantly in their nervous system.

Them before we even see frank lesions to the large fibers on say, standard bedside neurological testing or electrodiagnostic testing. So, so I was observing the same thing in clinics with these patients and with Michelle Sterling. And that was led by his Ferre who was a postdoc or is still a postdoc in Michelle's lab.

We did study in patients with. Chronic whiplash associated disorders and we showed that in patients with chronic whiplash, so these were patients who had five years or so of symptoms and have not recovered. So these were all non recover patients really show that these patients did have. Changes to the small fibers in the skin.

They also had changes to sensory changes that suggested something is happening with the nervous system. And so that was quite intriguing [00:08:00] at that time. But obviously what the question that this paper couldn't answer was. Was this something just secondary, potentially due to longstanding changes, longstanding inflammatory responses, for example, in these people in activity over time in patients who have chronic symptoms?

Or was that in indeed something that happens acutely related to the whiplash injury? Rather than develops later as a consequence of chronic pain. So for that reason, we were quite interested to set up a longitudinal study and I was lucky at that point that. Who is a researcher in Brighton he got in touch and wanted to do a study as well looking at neuroinflammation in these patients using MRI.

And so we combined forces basically, and we're lucky enough to get some funding to do a longitudinal study, to look at at big plus injury from the acute stages to the more chronic stages. That's how it came about.

Mark Kargela: There's a paper this year [00:09:00] recently that a couple that have come out recently in the last year or so with the evidence for peripheral neuroinflammation. I know Colette Ridehalgh . Had led that paper. I'm wondering if you could speak to that, Joel, I know you were second author on the paper.

I'm wondering if you could speak to a little bit of what y'all found when you were looking at that as how that study was set up and what kind of findings were.

Joel Fundaun: So this was led by Colette, but this is importantly all from the same group of people. So working with Collet and Andrew and our other collaborators this was one focus of our project and that was looking at signs of neuroinflammation. So when participants came, they were within a month of their injury, so within four weeks of having their whiplash injury.

And then we track them over time and do another assessment six months later. So this paper is looking at signs of neuroinflammation using MRI. So a specific type of MRI scan that we can look at the dorsal root ganglia and the brachial plexus. And then we did a host of other measures to look at inflammation as well.

Serum, so blood [00:10:00] markers of inflammation. We compared that from the whiplash group to participant two were just healthy non-pain controls. And then we also looked at many other clinical measures that included a typical clinical examination just like we do in the clinics ourselves. We looked at signs of nerve mechanical sensitivity, so upper limb neurodynamic tests palpation pressure to certain nerves over the brachial plexus and throughout the arm.

So we try to use all of those as clinical correlates or like composite scores that we might be able to do to classify if some of these patients acutely after whiplash injury did have signs of neuroinflammation.

Mark Kargela: And I'm, some of these tests are, obviously in a research setting, work wonderfully in MRIs and all that things, and a lot of the tests you talk about neurodynamics and palpatory exams and things like that. I'm wondering if you can distill that down a little bit for the clinician on the front line as far as, obviously some of that technology ought to reach for most of us, but o obviously there's ways we can [00:11:00] assess this in our, from, in our patients that we're seeing who are dealing with whiplash. I'm wondering if you could speak to either of you as far as. What kind of neurodynamics, I gotta imagine being one of them. What other kind of modes can we start assessing this to get a understanding of this? If we're assessing somebody who might have whiplash associated, that's categorized as type two, where we're determining how much nerve involvement is present.

Annina Schmid: We did actually quite a lot of different tests and we should probably highlight, these two papers that I've just recently published, like tool set. These are part of the. Same cohort, but looking at slightly different aspects. Neuroinflammation versus nerve pathology, which we classify more with loss of function, so actual nerve structural or functional nerve deficits.

So we purposely did combine, really heavily research-based methods, like you say, advanced neuroimaging as like serum inflammatory markers skin biopsies, et cetera. Blood markers of axonal damage. But we also combined [00:12:00] this. With simple clinical measures that we can use in clinics.

And the idea behind that is obviously all of us coming from a clinical field that, that is interesting. So we find these kind of changes in patients with V plus grade two across the board, not just in the very sensitive kind of research meshes, but also in, in some clinical measures. So a simple ex.

Kind of thing is, if we use the Neuropathic Pain Grading Scale, which is a grading system that has been described by non op where we basically can decide the certainty that somebody has neuropathic pain. We did find that about 65% of patients are classified as having. Possible or probable neuropathic pain.

Using this very simple clinical grading system, we also showed that simple bedside testing of neurological bedside testing, including light touch, muscle strength, pinprick, thermal [00:13:00] tests, reflexes does show changes in quite a substantial proportion of patients, about 50%. Of patients, 54% of patients, I believe it was, had sensory deficits on a neurological examination.

And again, we showed that. The main test to show that was the small fiber testing. So this is mainly thermal and pinprick sensations that short these changes more sensitively than say, large fiber testing like mortar dysfunction, reflex testing, or light touch testing. And then the neurodynamic tests, we use them as a proxy for a neuroinflammation.

The reason behind that is coming from preclinical work where Andro Delia and his team has shown, if you inflame a nerve artificially in a animal model the nerve becomes sensitive to pressure and stretch, which is basically what we are doing in a neurodynamic test. So we put. Tension on a nervous system or if we palpate, we put pressure over the nervous system.

So, if we can extrapolate [00:14:00] from, say, human from preclinical work, we would expect that if there is neuroinflammation, that's quite likely that nerve might be sensitive. To tension or to pressure. So this is why we use those neurodynamic tests and the nerve palpation as well. And indeed, again, we did find about 55% of patients had positive neurodynamic tests that we can detect in clinics.

So there was not always perfect overlap, I should say, between these different measures. And we also believe these measures. Partly measure probably different things of nerve health as well. But indeed there is measures that we can do at bedside where we can look at, do these patients have nerve involvement?

Joel Fundaun: So I'd also just to reemphasize what I mentioned earlier, but the group of people that we looked at after whiplash injury were all classified as grade two. So we wanted to take a really in-depth approach that Annina just. Mentioned to look at nerve health in many different ways [00:15:00] because clinically we did suspect and previous literature has also supported that a subgroup of these patients do have signs of neuropathic pain or nerve involvement.

And so this whole group was classified in that way. So I think that. That's important to highlight some of the context of what we're talking about. But like Annina mentioned, all of us had been working clinically and also didn't wanna just do the big fancy expensive research methods, but we also wanted to see if there was clinical tools or something that we could take away in our clinical practice that might be important.

And so, like she mentioned, one of them was, as we a main aim of this project was to see if there's any measures that we could take within that acute or about one month time point. To see if any of those measures could predict who goes on to develop more persistent or chronic pain. We know from the literature that there are a few markers those that have really high neck related disability or NDI scores acutely.

Those that are older and those that have kind of signs of. Post-traumatic stress or hyper [00:16:00] arousal, those have been linked to be associated with worse outcomes as well. But the evidence on this is fairly mixed and we don't know exact confidence of how strongly we can rely on some of those factors.

So one of our aims is to see, can we look at other factors that haven't been looked at before? And one of those that our paper, discusses is looking at hypoesthesia, so signs of loss of sensory function. So this was only from the clinical examination, like we mentioned before, strength, light, touch, reflexes, pinprick, and thermal sensations.

And then we just lumped those together into composite scores of how many measures of loss of function that someone would had. And we did find that the more signs of loss of function that a participant had acutely, so within that one month period, was able to predict at least some portion of their pain scores.

Six months later we looked at many other different measures and this was one of the strongest that kind of came through in our data. And so. As we talk [00:17:00] about this needs to be further validated. It's not the end all be all of measures that if you have hypoesthesia or loss of function, you know, with full certainty that you'll have chronic pain later on.

But it's still an exciting clinical tool that we can like further look at and try to better understand. That might help us explain who would go on to develop more persistent symptoms.

Mark Kargela: I'm wondering if you can speak to a little bit of, 'cause I've both been out in the profession a bit and have seen maybe the management of these patients evolve over time to where now with our understanding of more neuropathic components, neurogenic components of their condition, I'm wondering if you could speak to how you've seen the progression of how we maybe manage these patients. Change over time and maybe how our current data with all the great work you're both doing, might influence how we might manage these folks moving forward.

Annina Schmid: exactly. Plash is quite an interesting condition and obviously a relatively new condition also because road traffic accidents are [00:18:00] obviously, we haven't been driving for so long and other types of plash have been rare and probably more horse related injuries in ancient times, et cetera.

But Whiplash has received a bit of a stigma right over time, especially in regards to malingering. There have been some landmark papers suggesting that, for example, litigation plays a role in terms of chronicity, of whiplash. But these papers have actually attracted quite a lot of criticism in recent years.

And there is no, at the moment, no clear indication that litigation or compensation claims, open compensation claims, et cetera, have a clear prognostic role and predict clearly who develops. Chronic pain or not. But of course this has led to a bit of a stigma stigmatization of patients, right?

In terms of malingering, are they really telling the truth or, is it mainly, is it mainly psychological problem as well that patients have, and of course, all of us know, even if you just fall off your bicycle without an injury or somebody hitting [00:19:00] you, it, it shakes you, right?

It, it will lead to, feeling a bit. Stressed or in some patients this is clearly apparent that they do have some symptoms that are going towards post-traumatic stress, for example, et cetera. So that is probably not a surprise. Now, if we look at treatment in these patients, there is quite a lot of literature on that, and if we summarize the literature, it probably simplified.

We can say that there's some effects for, say, therapeutic interventions or physiotherapeutic interventions, for example, for people with whiplash. But the effect sizes are very small, at best, very small. And that includes usually exercise-based programs, but that also includes programs that involve psychologically informed care, behavioral type approaches as well.

All of them. If any effect, it's very small effects. Now, if we think about do some of these patients with a plus grade two have [00:20:00] neuropathic pain, then technically we should think about should we potentially provide treatments that are targeting. Neuropathic pain. And again, if we look in the literature, there's hardly anything on neuropathic pain treatments in these patients.

In fact, guidelines at the moment in the UK, for example suggest we should not be given these patients, for example, neuropathic pain type medications. So it's even indicated that we shouldn't do that. In our cohort of patients. If I remember correctly, one of the 129 or so patients had a first line neuropathic pain medication, even though about 60 or so percent had neuropathic pain according to clinical grading.

So one could argue maybe these patients are somewhat. Traded on the neuropathic pain side of things, and there are two very small feasibility and pilot studies that have been done. One in Australia, one in the US where they looked at giving neuropathic pain drugs, like one is duloxetine and one [00:21:00] was pregabalin.

Two patients with whiplash injury. Acutely in A and d and both of these studies show quite promising effects, but they're obviously heavily underpowered. And I know in Australia, for example, there is an effort underway at the moment to look at the lar to do the larger trial giving pregabalin acutely to patients who had a v plus injury to see whether indeed that might prevent persistent pain in these people. So that, that is one aspect. But we could also think, in, in terms of physiotherapeutic interventions, if you don't wanna go down to pharmacology. Side of things. That is actually to my knowledge, and correct me, I'm wrong if I'm wrong, Joel, but there's not much data at all about, say, for example, neurodynamic interventions, despite about 50, 55% of patients having positive neurodynamic tests.

From the literature, we know in spine related leg pain, spine related arm pain, [00:22:00] we know those that have positive neurodynamic tests are the ones that seem to benefit more from these kind of treatments, but it hasn't really been studied in that population and very likely not been studied.

Dominantly because it's considered, it's usually considered a musculoskeletal condition. So I believe we probably have to rethink that a bit. At the moment, we do not have a good large scale trials to suggest that this is what we should be doing, but I think as researchers we should look at that as.

Mark Kargela: Sounds like another PhD opportunity, maybe through the lab to, to start studying some of those things. Joel, what's your thoughts on that too as far as like, obviously you both have a good physiotherapy background as far as with some of these results, what they've been shown with, Hey, there's probably some neuropathic components to these patients.

We shouldn't just assume. It's a strict, musculoskeletal issue. Without considering that how does that change your approach clinically with those patients, and maybe how do you, what research? I know a [00:23:00] Nina's kind of teed it up a bit as far as what research needs to be done to help us understand what's maybe the best way to intervene with these folks.

Joel Fundaun: I think one important clinical takeaway that our project and others is trying to say is that even just as a first step as clinicians, oftentimes, we're very busy. You see a lot of people. You're trying to do your best to manage all of the expectations and things that you have to. To handle as a clinician and even just like some of our quick concepts of whiplash in that person that we're gonna see in the clinic often.

Even just the potential for neuropathic or nerve related pain isn't really even on a radar. So just to first emphasize that even just in the subjective history in patients that have had traumatic neck pain or whiplash injuries, that just asking about subjective questions about their. Quality and type of pain.

And obviously a lot of clinicians are already doing that, but just really giving someone the opportunity to describe their symptoms well and that we're just not assuming that because they've had a whiplash injury. It's mostly musculoskeletal. I. [00:24:00] Because even in our research study when we would discuss this with patients, the predominant symptom that most people have is neck pain.

But then when you give them the time and further ask about their symptoms and what they're experiencing, they often point to, yeah, I do experience numbness or my, like, my hands have been tingly since the accident. The pain does radiate or does feel sharp or electric at times. But you don't always get that at first question.

And so just incorporating that early on in the subjective in patients with whiplash injury can be very helpful. Annina has a great video describing, we've talked about it quite a few times, but one of the clinical guidelines for grading neuropathic pain is from the Neuropathic Pain Special Interest Group.

And that classifies patients on different levels from unlikely to have neuropathic pain to probable. Or definite neuropathic pain. And so those classifications require kind of different components. And Annina has a great video that's available on YouTube that describes some of this. But that's one [00:25:00] of the first takeaways that I would say some of our work does. That could be, that I think about clinically is that, am I really doing a thorough job in understanding the pain that this person's presenting with? And then the second that we've touched on briefly before is my clinical examination again, because we assume most of these patients just have predominant neck pain or stiffness a lot of times.

In the busyness of our clinics, we don't always do a full detailed neurological assessment. Our work that we show here, we show that like a Nina mentioned before, acutely over two thirds of patients did have signs of loss of function or reduced sensation in that area. But most of those findings came from pin prick or thermal testing.

And that's not always something that we consider or do in the clinic. And so not that. Every single person should always have a 45 minute neurological assessment. But when people have these signs and are reporting things like this that a more detailed neurological assessment, [00:26:00] including both the large nerve fibers, which would be our typical exam, light touch strength and reflexes.

It's also important to add in findings of small in fiber deficits. So that would be pin prick testing using neuro tips or like just a sharp pin as well as potentially thermal. Annina has done great work validating a clinical tool of this, of just using coins. There's other clinical tools that can very cheaply and quickly test thermal sensation as well.

But just making sure that we don't ignore those because those. Early changes of pinprick or thermal sensation have been shown in preclinical and clinical studies to show that they can further go on to develop into the bigger problems. And so just acutely making sure that we do a thorough examination is also a second big takeaway from our work in this project.

Mark Kargela: , these are tools that aren't

massively exp hard to come by a pin prick or a coin or things. And I wonder if you could speak to a little bit about that. I know you've been involved in the. Nig [00:27:00] working group with kinda classifying neuropathic pain, meaning I, I'm looking at this study, spine related leg pain, but one of the criticisms,

around like CST that you or QST, that clinicians always, I don't have all this equipment

but again, and we just spoke to the fact

that this doesn't

require. A lot of major like

expenditures.

Think these are things you can put together. I'm wondering what you would recommend as like a clinician toolkit. Joel Al already spoke to it a bit, but like what do you think a clinician should have as, as part of their neurologic examination skillset and

toolbox and maybe how also to determine what are you hearing that might help somebody say, Hey, I maybe need to go into more significant

depth in my examination versus

Maybe more of our kind of base neurologic

exam.

Annina Schmid: , exactly. It's a good question and probably would do it exactly like what tool says. So I think it's important to test motor strength reflexes and light touch sensation. Obviously with these ones you can pick really quite advanced, big deficits that [00:28:00] often, let's say, if we go away from Plash now, but to say spine related leg pain, for example you could potentially pick up very important, big neurological deficits that weren't, for example, onward referral, talk about a drop foot, et cetera. So these things are of course, very important, but as we said quite often, especially in entrapment neuropathies, we and others have shown that these small fibers seem to be changed relatively early.

And so no one could say, okay, so that's not so important because it might not be meaningful for a referral, et cetera. Especially if you think about neuropathic pain is actually quite important because what kind of medications patients are given is dependent on whether we think somebody has neuropathic pain or not.

And one part of deciding whether or not somebody has neuropathic pain is a sensory loss. So in a sensory loss, therefore in a standard neurological examination, and it might be a bit, I might be a bit biased because in my clinic I see mainly patients with nerve problems. But I would always [00:29:00] include, as we said large fibers, light touch reflexes, muscle strength, but also small fibers pain prick examination.

And if pain prick is normal, then I would move to thermal. And that is because of the work that we have done together with Collette, right holes where we have shown, how the sensitivity specificity works of these tests, that this would be the recommended route, but at least pinprick I would recommend to do in a screening.

Examination in a way, and these kind of, if I do a screening examination in patients. I would say this takes me three minutes maximum. But it has potentially quite important implications for, a, if I identify, for example, something is more related to neuropathic pain, that might be important on how I.

Help people make sense of what is happening with them. Right? How I explain a neuropathic pain will be completely different to how I explain, say, a muscle pain, for instance. And we already touched on pharmacology, which might be influenced by these kind of things. So I [00:30:00] believe it's quite important that people have a relatively comprehensive neurological examination.

Let me give you one other reason for that is, when we test a shoulder, we would also not be happy to just say, okay, somebody has flexion deficit, right? We would probably test many different things around the shoulder. Then we put the puzzle pieces together and we see whether the puzzle pieces fit or not.

So if I only have a neurological examination with muscle strength, I have like one puzzle piece. Which might well not be enough for me to make sense of it, but if I have many different puzzle pieces and they fit together, that will tell me something. But it will also importantly tell me something if the puzzle pieces don't fit together.

So therefore, I think it's slightly risky to rely on a very abbreviated version of a neurological examination. We would also not do that for the shoulder or for the knee, et cetera.

Mark Kargela: Makes complete sense,

I'm wondering with [00:31:00] my. Speculative, theoretical

look at this. For, 'cause I haven't dug deeply

into

the literature, but I know there's been some work to show kind of

prognostic indicators, of how people are gonna progress based on some psychosocial things. I'm.

just wondering where you see this fit.

Maybe big picture with, because clinically we'll see people who may have this injury, but they have

Great support. They're financially able to manage this. Well, they maybe don't have some of the PTSD

symptoms and

different things. How do you see this? And Joel, maybe you can Speak to it. As far as maybe a more comprehensive approach, obviously

being able to detect these things and be able to maybe

suggest if you're on a team, especially with a pain physician or a physician.

who can prescribe medications, but also looking at, okay, what are the top down influences of this condition?

1. His, well, this person's got a limbic system that's, really, upregulated and in a more

Facilitatory state and

where we

can maybe treat with, things like pain, neuroscience, education, mindfulness strategies, different things. of that. Where do you see like big picture treatment of these patients? Obviously some great things we can

do for [00:32:00] neurodynamic

treatments, and things like that

which are of course a part of the

equation.

But I'm wondering what you think as far as more kind of that whole, if we're thinking biopsychosocial lens of things, what do you think there, Joel?

Joel Fundaun: That's a great question and something that Annina brought up earlier. The pendulum is certainly just like most things in medicine or physical therapy. The pendulum has definitely swung in this a few different ways. But it started with these initial injuries back when it was considered railway spine, when there, was not even motor vehicle collisions and it was purely psychosis.

And then it, it swung to. We shouldn't even consider that at all is purely a biomedical approach, and I don't think either are correct. Right. More literature that's coming out, just like Annina mentioned with the fall from a bike. It's important that we screen for these things. It's common that psychosocial contributions are present after whiplash injury.

Like you mentioned before, acutely the strength of these as predictors of how you will do is a bit [00:33:00] messy. In the literature, there is more consistent a finding of hyper arousal or one kind of aspect of post-traumatic stress to be predictor of how you do later on. But it's certainly by no means, perfectly clear.

Some great work by Michelle Sterling and colleagues in Australia is one of kind of the strongest evidence that we have lately of a nice combined and balanced clinical approach. And that was published a few years ago, but I. Basically they use a physio, a physical therapy exercise routine paired with the combination of stress reduction techniques and show much bigger effects compared to those that don't have the stress reduction techniques.

And so that can look different for all of us clinically. I know they've. Established a way of educating clinicians about the specific interventions that they used. But I think even just from a bigger picture lens, taking that away is making sure that. In patients that do have whiplash injury or have had these traumatic accidents [00:34:00] that we're definitely asking and screening for these questions to see if they are present.

If they are, that might mean that in addition to the other beneficial services, exercise, immunotherapy, other things that we can intervene on that this also, whether it's in our skillset or another provider skillset should be something that we should consider or that a person should receive if they are experiencing those symptoms.

Mark Kargela: Annina, anything you'd add to that as far as what as that well-rounded approach with somebody who's dealing with this

Annina Schmid: Yes, I would absolutely agree with Joel Sis and I actually quite like that there's different. Approaches, right, to look at patients because already if we look at the Quebec task force, it's already very clear that this is not black or white, right?

It's a spectrum of things that can happen to people on the biomedical side, but surely also on the psychosocial side, et cetera. So we have to just make sure that we look at individual patients, like to rightly set very carefully. Try and [00:35:00] understand in that person in front of us, what is the most important thing.

Now in research that might also mean that we might have to be a bit more careful. What kind of patients are we selecting to certain trials? Say for example. Should there be trials on neuropathic pain? You probably wanna understand neuropathic pain interventions. You probably wanna understand.

Does, is that specifically useful to, for, to those people who have mainly that component? Right. Because it probably would not make sense to give that intervention to somebody. We wrote what two that mainly has the more post-traumatic stress dominant mechanism. So I believe this will become quite important in the future.

How are we looking at these patients? And I think physios are very good at that, in, in clinics. As researchers, we are still learning how do we best do that and how do we get around the problem of, to make sense of different groups of patients in trials, et [00:36:00] cetera.

Mark Kargela: Joel, I'm wondering what you think about mixed

Methods studies, I know that's an undertaking and a

half I've I'm being not a researcher, I'm just a greedy

clinician who wants all the answers, and doesn't

recognize all the hard work that goes

into

some of that. But I'm wondering what your thoughts are on

mixed methods

where we could have kind of the narrative of that patient unfolding qualitatively.

as we're studying some of these objective measures, especially when we look longitudinally at people and how they progress over time.

Joel Fundaun: It's a great point, and obviously as. Researchers, we want to try to do it all. And if we can look at it from every lens, but more and more kinda research organizations are emphasizing the importance of this. And so just like you said, we need to look at it both from a biomedical perspective.

Our studies found things that hadn't been looked at in terms of nerve health and nerve pathology, but we also wanna make sure that we're. Including a patient's voice and patient perspective, because if what we're researching doesn't match what they actually want better or want improved or need help with, then [00:37:00] there's a big dissonance that we need to solve and make sure that we're both working towards a common goal.

Like you said. Pragmatically, these can be challenging to incorporate, but there's more and more great examples of how you can have a strong research objective that both patient and researcher are interested in, as well as researchers who have great qualitative experience that can help capture that experience and that patient's voice and perspective alongside that.

So yeah, definitely no perfect answers to your question about the mixed methods, but. Just highlighting that the more that we can incorporate patient involvement and patient voices in our research, that everyone will benefit.

Mark Kargela: And I think you're seeing a bit of that patient advocacy groups being more involved in journals and journals, having more of a active kind of engagement with patient communities to make sure that voice is present. We've had some pioneers in that field, Gillette belt, and probably being one of the bigger ones here in the States, among other great folks in in the UK and other areas of the world who have rightfully recognized [00:38:00] that the voice of the patient has been missing from a lot of the research.

But thankfully, again it's being addressed. A, I'm wondering if you could speak to what questions you feel like are the biggest burning questions out there that you may already be tackling with some of your research. But I'm wondering if you could speak to where this goes forward from here when it comes to whiplash patients.

Annina Schmid: So specifically in regards to whiplash, I do think we have to but, well, one thing that I still would like to understand is there any chance that this might have been preexisting from injury? Because that our study cannot answer that. So our study looked for within four weeks of injuries or nicely and acutely.

But we of course don't quite know whether something has been preexisting. There are certain reasons in our data why we believe it's not a preexisting problem that, that tell us that. But to know that we basically would almost have to test them probably immediately after injury, right? The day that they get into A and d or something like that.

The other thing is indeed understand a bit better what kind of treatments these [00:39:00] patients would benefit from, and is there specific subgroups of patients that would benefit more from this or that type of treatment? So. That would be quite nice. In terms of the prognostic side of things, like TOL mentioned, we had a really interesting prognostic factor that came up in our work that was that sum score of the hyperesthesia measures, the bedside clinical sensory examination that predicted certain proportion certain with certain strengths, better people.

Develop chronic pain. Now, if we would wanna take that forward to a clinically useful tool, which it is not at the moment because this is a relatively small sample done in two centers only then we would have to move that to a multicenter larger study with much more people. So these are I think, very logical next things.

And then of course we are working on a few very exciting things as well, but we might not quite give these away as yet. Maybe next, once we have published them, maybe.

Mark Kargela: We might have to talk. We'll have to talk to y'all in [00:40:00] future episodes once you start letting us in on some of the great work you're doing. Joel, I'd love to hear what questions you're asking now. I know you're doing your postdoc over there in Stanford. What kind of things are you looking to answer and maybe move forward as far as our understanding of things around this?

Joel Fundaun: Especially around this topic. My research right now is in a different population, but still building on some of the quantitative neuroimaging. So trying to look at what specifically both clinical MRIs that people get, MRIs normally, as well as more advanced research methodologies for MRIs. What that can help tell us about both prognosis and mechanisms.

Some great literature in the past has. Tried to dive more deeply into the mechanisms related to why people get persistent pain after whiplash. It's obviously just like the other literature in this area, it's very complicated when you have a big heterogeneous, complex subgroups. But further trying to identify.

The actual biological mechanisms between what is happening [00:41:00] in addition to all the clinical points that a Nina said. I think that's a really interesting and important area of research that we are working on a little bit, but that could definitely use much bigger, much larger, important studies.

Mark Kargela: Research just seems to ask, have us ask more questions and things keep rolling forward. And I just wanted to respect both of your time today and thank you both for all the work you're doing. I think you're great examples of folks who can wear clinical hats and also research hats and understand both sides of that equation.

I think there's criticisms on, on, that sometimes research doesn't land with clinical, and you're both good examples. Folks who are translating it well to how this will hopefully impact clinical practice, and most importantly, how we're gonna help people better, help people who are dealing with whiplash associated disorder.

So thank you again for your time.

Annina Schmid: Thank you for having us. I, well, one thing I would like to say as well, a massive thank you to all the team that has been involved in this research. So this trial has been leading a lot of it from the Oxford side. In Brighton, that was Colette Rha and Rod as the principal [00:42:00] investigators, a massive thank you to them and of course to our funders as well that made this possible because it's not a trivial study and tool can probably sing a bit of a song of how difficult it is to get this amount of people in for such detailed and extensive testing.

So, so thank you as well to versus arthritis in the Medical Research Foundation UK that supported us financially doing this work.

Mark Kargela: Research for surely is a team sport and you all have a great team. It looks like over, there's some great collaborative work going on and thankfully more work to be done that will benefit from hearing from y'all. For those of you listening, I would love if you could subscribe wherever you're listening to your podcast.

And if you're watching on YouTube, we'd love if you could subscribe there. We will link some of the research and things mentioned in today's episode in the show notes. But we'll leave it there this week. We will talk to you all next week.[00:43:00]