© copyright motor accidents authority of nsw guidelines for the management of associated disorders...

© Copyright Motor Accidents Authority of NSW

Guidelines for the management of

associated disordersfor health professionals 2014

acute whiplash

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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

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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)?

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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?

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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

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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)?

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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

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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

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Motor Accidents Authority of NSW

Resources

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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

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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

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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

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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

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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

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• 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

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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

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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

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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

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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

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Motor Accidents Authority of NSW

Provide treatment

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Motor Accidents Authority of NSW

Provide treatment

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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

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• 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

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• 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

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• 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 –

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RECOMMENDED

Motor Accidents Authority of NSW

Review and take recommended action

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RECOMMENDED

Motor Accidents Authority of NSW

Review and take recommended action

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RECOMMENDED

Motor Accidents Authority of NSW

Review and take recommended action

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RECOMMENDED

Motor Accidents Authority of NSW

Review and take recommended action

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RECOMMENDED

Motor Accidents Authority of NSW

Summary of key messages

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• 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

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Motor Accidents Authority of NSW

Additional information

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• 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

• whiplash@maa.nsw.gov.au

Motor Accidents Authority of NSW

Feedback

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We welcome your thoughts about how useful you have found this

presentation.

• Please email your comments to whiplash@maa.nsw.gov.au or

• complete our five-minute online survey.