As an academic anesthesiologist practicing pain medicine, I find the clinical, educational, and research mission daunting. The half-life of truth in the field of pain medicine is short, reflecting the pace of ongoing exploration and discovery across multiple disciplines. Finding time outside of clinical practice to attend high-impact conferences can be challenging, especially because international travel is needed in many instances.
The International Association for the Study of Pain (IASP) presents a unique solution to these challenges through its publication of proceedings and compilations from research symposia on key topics in pain science. The organizers of the 2014 IASP Whiplash Research Symposium have edited Whiplash Injury: Perspectives on the Development of Chronic Pain.
Whiplash is largely a compression injury when the trunk is forced upwards into the cervical spine.1 The global prevalence of whiplash-associated disorders (WAD) as illustrated by emergency department visits is 300 in 100,000 people.2 Most frequently due to motor vehicle collision and often associated with considerable pain, suffering, disability, and cost, whiplash-associated injury is a debilitating and common form of neck pain with a range of clinical manifestations including neck, shoulder, and back pain, numbness, fatigue, nausea, cognitive deficits, and low self-reported physical and mental health.1,3
Among the topics considered at the IASP symposium were research, neurophysiological mechanisms, prevention, and treatment. The 14 chapters emphasize the study and treatment of whiplash injury as a model for the transition from physiologic to chronic pain. Clinicians and researchers alike will find many chapters relevant to their work.
The book begins with a comprehensive discussion of the mechanisms of chronic facet joint pain. The complex neurobiological interplay between intraarticular nociception and the neuroimmune and neuroplastic effects of ongoing joint injury are illustrated with a pathway approach. This first chapter, as well as several others later in the book, provides a very approachable explanation of the molecular mechanisms thought to contribute to the development of chronic pain. The second chapter, which discusses the biomechanics of the cervical facet joints, focuses on capsular stretch and strain and the resultant physiological cascades that result.
The third chapter on cervical spinal morphology explores factors that affect rear impact injury such as vertebral geometry, variations in head and neck anatomy, and biomechanics. The epidemiology of whiplash injury and techniques for the rehabilitation of people with WAD are covered in Chapter 4. Myriad motor and sensorimotor dysfunctions can manifest from WAD with neck-specific exercise programs reducing disability most effectively. The fifth chapter examines the complex relationship between cervical pain from whiplash trauma and trigeminal nerve pain, specifically painful temporomandibular disorders.
In Chapter 6, WAD is used as a model for other pain syndromes in which imaging studies prove negative even though patients suffer profound disability. Several verifiable explanatory pathways are suggested for persistent impairment with WAD, pathways that are often dysfunctional in other pain syndromes such as cortical plasticity, stress system dysfunction, and sensorimotor dysfunction of the cervical spinal cord from high-energy transfer. The seventh chapter offers research methodology for studying predictors of recovery from WAD. Whether the reader is designing studies or reading them, this chapter discussion is a valuable stand-alone read.
Chapters 8 and 9 will be valuable to the clinician treating acute or chronic pain. Potential techniques for preventing the transition from acute injury to chronic pain are presented. A detailed assessment and examination of a patient with whiplash appears in Chapter 9.
The remaining chapters explore the unique biopsychosocial factors that influence morbidity and mortality after motor vehicle crashes or whiplash injury. The state-of-the-art psychological and physical therapies for these conditions are discussed in Chapters 12 and 14.
Read cover to cover, this book is a comprehensive gateway to countless references of high-impact research on the pathophysiology and management of whiplash-associated injury. Occasional redundancy exists because several authors incorporate similar discussions of the neurobiological and molecular mechanisms of chronic pain. These key concepts, however, underlie assessment and treatment and are worthy of some degree of repetition.
The publication is limited in providing a discussion of treatment options beyond psychological, manual, and exercise therapies, however. A chapter on pharmacologic or interventional treatment options is needed and represents a shortcoming.
This book will be kept readily available in our clinic for visiting medical students, residents, and fellows because it provides a succinct review of basic and applied topics central to current pain practice and research. Without the demands of attending a conference or symposium, the busy clinician who reads this text will find much cutting edge material for managing the patient with whiplash injury while advancing his or her understanding of pain study and neurobiology.
David M. Dickerson, MDDepartment of Anesthesia and Critical CareUniversity of ChicagoChicago, IllinoisDDickerson@dacc.uchicago.edu
1. Bogduk N. The anatomy and pathophysiology of whiplash. Clin Biomech (Bristol, Avon). 1986;1:92–101.
2. Bussières AE, Stewart G, Al-Zoubi F, et al. The treatment of neck pain-associated disorders and whiplash-associated disorders: a clinical practice guideline. J Manipulative Physiol Ther. 2016;39:523–564.e27.
3. Johansson MS, Boyle E, Hartvigsen J, Jensen Stochkendahl M, Carroll L, Cassidy JD. A population-based, incidence cohort study of mid-back pain after traffic collisions: factors associated with global recovery. Eur J Pain. 2015;19:1486–1495.