© Copyright Motor Accidents Authority of NSW Guidelines for the management of associated disorders for 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 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 GradeClassification 0No complaint about the neck No physical sign(s). IComplaint of neck pain, stiffness or tenderness only. No physical sign(s). IINeck complaint AND musculoskeletal sign(s). Musculoskeletal signs include decreased range of movement and point tenderness. IIINeck complaint AND neurological sign(s). Neurological signs include decreased or absent tendon reflexes, weakness and sensory deficits. IVNeck 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 recoveryOutcome measures are the best way to identify people at risk of poor recovery. Outcome measures are the best way to identify people at risk of poor recoveryOutcome measures are the best way to identify people at risk of poor recovery. At the initial assessmentPeople 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 reviewPeople 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 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. 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. 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 Register for updates about the whiplash Guidelines

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