© copyright motor accidents authority of nsw guidelines for the management of associated disorders...
TRANSCRIPT
© Copyright Motor Accidents Authority of NSW
Guidelines for the management of
associated disordersfor health professionals 2014
acute whiplash
1
Motor Accidents Authority of NSW 2
This slide set is endorsed by the following professional associations:
Motor Accidents Authority of NSW
The MAA and CTP scheme
Whiplash in the CTP scheme
What is whiplash
Guideline resources
Key recommendations for managing whiplash in the first 12 weeks
Outline of this presentation
3
Motor Accidents Authority of NSW
The Motor Accidents Authority is the NSW Government body that:
• regulates the insurers who provide compulsory third party (CTP)
insurance policies (Green Slips) and manage the claims of
injured people
• monitors and regulates the CTP scheme
• supports injury management, developing resources and funding
research to promote best practice
• supports injury prevention and road safety initiatives.
Who is the Motor Accidents Authority (MAA)?
4
maa.nsw.gov.au
Motor Accidents Authority of NSW
• A compulsory third party personal injury scheme for motor vehicles registered in NSW
CTP insurance provides cover in two ways
• as a vehicle owner, for the cost of claims made against your vehicle
• as a road user, if you are injured in a crash you can claim against the Green Slip of the vehicle that caused your injuries
Two ways to access the scheme:
• Accident notification form (ANF)
• Personal Injury claim form (PICF)
What is the NSW CTP scheme?
5
Motor Accidents Authority of NSW
• 46% of all CTP claimants in NSW reported a whiplash-associated disorder
• Most commonly occurs:• as a result of crashes in metropolitan areas• in people aged 26-45 years• to females
• 40% of people with whiplash have complete resolution within 12 weeks
Whiplash in the CTP scheme
6
Some adults have persisting symptoms and take longer to recover
Motor Accidents Authority of NSW
What is a whiplash injury or whiplash-associated disorder (WAD)?
7
The QuebecTask Force (QTF) definition
• an acceleration-deceleration mechanism of energy transfer to the neck• the result of motor vehicle crashes• the impact may result in bony or soft tissue injuries (whiplash injury)• leads to a variety of clinical manifestations
Motor Accidents Authority of NSW
Quebec Task Force Classification of Grades of WAD
8
Grade Classification
0 No complaint about the neckNo physical sign(s).
I Complaint of neck pain, stiffness or tenderness only. No physical sign(s).
II Neck complaint AND musculoskeletal sign(s).Musculoskeletal signs include decreased range of movement and point tenderness.
III Neck complaint AND neurological sign(s).Neurological signs include decreased or absent tendon reflexes, weakness and sensory deficits.
IV Neck complaint AND fracture or dislocation
Motor Accidents Authority of NSW
Resources
9
Motor Accidents Authority of NSW
Resources
10
More resources
maa.nsw.gov.au
Motor Accidents Authority of NSW
The Guidelines are developed to guide management of people with whiplash in the CTP scheme
11
Best possible management of adults with whiplash
The Guidelines are for: • adults (over 18 yrs)• use within 12 weeks of injury• WAD grades I, II and III
The Guidelines are not for: • children (under 18 yrs)• treatment beyond 12 weeks post injury • WAD grade IV
refer to Emergency Department
Motor Accidents Authority of NSW
Resources – Quick reference guide
12
Implementation tool - summarises the recommendations of the Guidelines.
A traffic light system is used to easily identify treatments that are recommended based on the strength of the clinical evidence and the consensus of clinical experts.
Motor Accidents Authority of NSW
What to do in the first 12 weeks after injury
13
1. Do an examination
2. Identify patients at risk of poor recovery
3. Provide treatment
4. Review and take recommended action
Take action if injured person shows signs of poor recovery
Motor Accidents Authority of NSW
Do an examination
14
Do an examination to make a diagnosis and to plan treatment
• Take a patient history • Do a physical examination• Canadian C-Spine Rule• Classify whiplash severity
• Grade of WAD
RECOMMENDED
Motor Accidents Authority of NSW
Do an examination
15
• MRI, CT, EEG, EMG, or specialised peripheral
neurological test for WAD I and WAD II
• X-ray or CT - except to diagnose fracture or dislocation
(avoid unnecessary exposure to radiation)
NOT RECOMMENDED
Motor Accidents Authority of NSW
Identify patients at risk of poor recovery
16
Outcome measures are the best way to identify people at risk of poor recovery.
At the initial assessment People at risk of poor recovery
Neck Disability Index (NDI) NDI score greater than 15/50
Visual Analogue Scale (VAS) VAS score greater than 5/10
Expectation of recovery Poor expectation of recovery
RECOMMENDED
Motor Accidents Authority of NSW
Identify patients at risk of poor recovery
17
At the 3 or 6 week review People at risk of poor recovery
Impact of Events Scale (IES)
IES score of more than 25 / 75
Patients with an IES score of greater than 25 (moderate symptoms)
- refer to a psychologist with experience in managing posttraumatic stress symptoms
RECOMMENDED
Motor Accidents Authority of NSW
Identify patients at low risk of poor recovery
18
Patients with the following outcome measure scores ARE AT LOW risk of poor recovery:
• low disability - NDI score less than 15/50 • low pain - VAS score less than 5/10 • people with a good expectation of recovery
DO NOT provide complex assessments, physical therapy referral or referral to a clinician with expertise in the management of whiplash.
Motor Accidents Authority of NSW
Identify patients at low risk of poor recovery
19
These factors DO NOT predict risk of poor recovery
• age, gender, marital status and education• seat belt use, awareness of impending collision, position in vehicle
and speed of collision• pre-collision pain or general health status • high healthcare utilisation for treatment of whiplash
Motor Accidents Authority of NSW
Provide treatment
20
Motor Accidents Authority of NSW
Provide treatment
21
Motor Accidents Authority of NSW
Provide treatment
22
These physical treatments may be used in conjunction with the
recommended treatments
• Manual therapy
• Thoracic manipulation
• Acupuncture
• Kinesiotaping
• Trigger point needling
Monitor closely. Continue ONLY if
there is evidence of benefit.
At least a 10% improvement on
VAS and NDI at each review.
USE WITH CAUTION – AND MONITOR CLOSELY
Motor Accidents Authority of NSW
Provide treatment
23
• Reduction of usual activities for more than 4 days
• Immobilisation collars
• Pharmacology – anti-convulsants and anti-depressants
• Muscle relaxants
• Botulinum toxin type A
• Intra-articular and intrathecal steroid injections
• Pulsed Electromagnetic Treatment (PEMT)
NOT RECOMMENDED
These treatments
SHOULD NOT be
used.
Motor Accidents Authority of NSW
Provide treatment
24
• apply for short periods
• use with evidence based treatments
TREATMENTS WITH NO EVIDENCE FOR OR AGAINST THEIR USE
Monitor closely. Continue ONLY if there is evidence of benefit of at least 10% improvement on VAS and NDI at each review.
Motor Accidents Authority of NSW
Provide treatment
25
• Traction• Pilates• Feldenkrais• Alexander technique• Massage• Homeopathy*• Cervical pillows• Magnetic necklaces• Spray and stretch
• Heat • Ice• Transcutaneous
Electrical Nerve Stimulation(TENS)
• Electrical stimulation• Ultrasound• Laser• Shortwave diathermy
TREATMENTS WITH NO EVIDENCE FOR OR AGAINST THEIR USE
Motor Accidents Authority of NSW 26
RECOMMENDED
Review and take recommended action
Outcome measures in the first 12 weeks:
• part of the treatment program to monitor progress
• indicators of recovery
• identify those at risk of poor recovery
• what action to take
• guide only
When the initial assessment is more than 7 days after the injury
use these intervals as a guide.
Motor Accidents Authority of NSW
Review and take recommended action –
27
RECOMMENDED
Motor Accidents Authority of NSW
Review and take recommended action
28
RECOMMENDED
Motor Accidents Authority of NSW
Review and take recommended action
29
RECOMMENDED
Motor Accidents Authority of NSW
Review and take recommended action
30
RECOMMENDED
Motor Accidents Authority of NSW
Review and take recommended action
31
RECOMMENDED
Motor Accidents Authority of NSW
Summary of key messages
32
• Identify patients at risk of poor recovery
• Provide recommended treatment and/or treatments
• Monitor progress of recovery
• Take recommended action
Flowchart – Early management of whiplash
Motor Accidents Authority of NSW
Resources – MAA website
33
Motor Accidents Authority of NSW
Additional information
34
• NHMRC
• method for developing clinical guidelines
• levels of evidence hierarchy
• chronic whiplash
• University of Queensland
• http://www.som.uq.edu.au/whiplash
• Register for updates about the whiplash Guidelines
Motor Accidents Authority of NSW
Feedback
35
We welcome your thoughts about how useful you have found this
presentation.
• Please email your comments to [email protected] or
• complete our five-minute online survey.