2.  Traumatic event + Reaction  Symptoms  Reexperiencing  Avoidance  Hyperarousal  Duration > 1 mo. (< 1 mo Acute Stress Disorder)  Functional impairment  Diagnosis vs symptoms (subclinical)

4.  Higher rates of PTSD in Whiplash patients 1,2,3.  Overlapping epidemiologic and clinical features 1  May involve stress system dysregulation 4 › Cortisol abnormalities in both Whiplash 4,5 and PTSD 6 › 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

5. PTSD (n=33) No PTSD (n=39) Cohen’s 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 Headaches75.8%84.6% Dizziness51.5%53.8% Number of pain locations2.55 (0.90)2.10 (0.68) 0.56 - Neck100% - *Back51.5%28.2% - *Shoulders81.8%53.8% - Arms24.2%28.2% - Legs6.1%2.6% * = p <.05; ** = p <.01.

6. *= p <.01; ** = p <.05.

7.  Higher initial pain and disability 1, 2  Posttraumatic stress reaction 1, 3, 4, 5  Cold hyperalgesia 1, 3  Older age 1,2 1. Sterling, Jull, Vicenzio, Kenardy & Darnell, 2005 2. Buitenhuis, Spanjer, Fidler, 2003 3. Sterling, Kenardy, Jull & Vicenzio, 2003 4. Buitenhuis et al, 2006 5. Jaspers, 1998

8.  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.

9.  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.

10. Baseline Trauma cue exposure Post-exposure No PTSD Minimal changes in arousal, affect and pain. PTSD ↑ Arousal and negative affect ↓ Pain threshold (n = 33) (n = 39) PTSD – higher baseline arousal and negative affect and lower pain threshold. Between groups = PTSD, No PTSD Repeated Measures = Baseline and Post-Exposure

11. Heart rate Heart rate Blood pressure Blood pressure Respiratory Rate Respiratory Rate Skin Conductance Skin Conductance Skin Temperature Skin Temperature

12.  Heat and Cold - cervical spine Pressure Pressure - Local - cervical spine - Remote - Median nerve & tibialis anterior & tibialis anterior

13. -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.

14. - 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. Blood Pressure Heart Rate

15. Cervical Spine - PTSD group lower across time. - Further decrease in PTSD group after trauma-cue. Remote Sites - PTSD group lower across time - Minimal changes after trauma-cue. C2

16. -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.

17.  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.

18.  Can we treat PTSD in patients with WAD?

19.  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. Back, Coffey, Foy, Keane & Blanchard, 2009 2. Shipherd, Back, Hamblen, Lackner & Freeman., 2003 3. Taylor et al., 2001 4. Jaspers, 1998

20.  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.

21.  Measures the same as study 1.  Participants recruited from PTSD group in study 1.  Randomly allocated to Treatment and Waitlist conditions.  Assessed pre, post (10-12weeks) and 6months post (treatment group only).

22. Assessed as eligible from Study 1 (PTSD and WAD) (n = 33) Consented to participate – Random allocation (n = 26) Allocated to TREAT condition (n = 13) Allocated to WL condition (n = 13) Analysed at post (n = 11) Lost to follow up (n =2) 1 declined to participate further and 1 unable to contact Analysed at post (n = 12) Discontinued treatment (n =1) due to moving interstate Analysed at 6-mo follow-up (n = 11) Discontinued participation (n = 1) 1 participant completed questionnaire data but not physical measures Did not consent to participate (n = 7) 4 due to time, 2 due to transport and 1 was already receiving psych treatment

23.  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

24.  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

25. - S ig 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.

26. -TREAT group showed significantly greater improvement in neck disability post-treatment, compared to WL group. - Improvements were maintained at 6month follow-up.

27. - Overall trend (p=.08) for greater reductions in baseline arousal measures (BP and HR) in TREAT group compared to WL. - Reduced physiological reactivity to the trauma cue (comparison of difference scores pre-post cue) in TREAT group compared to WL group for all 3 arousal measures. HR

28.  Minimal changes between groups or over time for PPTs (remote or local) or HPT.  Trend (p=.07) for greater reductions in Cold Thresholds for TREAT compared to WL.  Also trend (p=.08) for reduced Cold thresholds in TREAT Group from pre-6mo. Cold

29.  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.

30.  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.

31. 1. Identify high risk of PTSD using a screen. 2. Provide information-based intervention 3. Confirm with clinical assessment. 4. If ASD/PTSD comorbid with WAD pre- treat with Trauma-Focussed CBT +1 mo., then intervene with WAD.