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Guidelines for the Management of Whiplash-Associated Disorders Flow Chart
Notes to accompany flow chart
Purpose, scope and methodology
Summary of Recommendations for clinical practice
Diagnosis 8
Prognosis 9
Treatment 10
Not relevant to acute WAD Grades I, II or III Glossary
Other publications
There is potentially great benefit in agreeing on effective ways to manage acuteWhiplash-Associated Disorders. Consequently, the MAA decided to take on the taskof developing guidelines for the management of Whiplash-Associated Disorders.
In October 1999 new legislation was enacted prognosis of whiplash and reviewed 10,000 governing the operations of the New South publications. In addition, a cohort of whiplash Wales Motor Accidents Authority (MAA) and the subjects from the injury claim files of the identified, and prognostic factors in therecovery process were examined. The QTF One aim of the legislative change under the released its findings in a scientific monograph Motor Accidents Compensation Act 1999, is to improve the capacity of the scheme to ensurethat “reasonable and necessary” care is In the MAA publication, Guidelines for the delivered to people with injuries and illness Management of Whiplash-Associated Disorders, changes to the QTF recommendations are based The legislation introduces these changes; on available new evidence published since • New procedures for resolving disputes about 1993. Where published evidence is lacking or inconsistent, a consensus of the Working Party possible based on the principles of evidence- is given. Comment and review by three external experts on the Working Party recommendationswas also taken into consideration during a • Medical assessors from a range of health backgrounds to resolve ‘medical’ disputes.
The MAA is aware that the work of the QTF has been criticised and noted the criticism of a biastowards viewing WAD as a self-limiting • New guidelines for the appropriate treatment, condition. This factor does not affect the rehabilitation and care of injured persons.
recommendations on diagnosis and treatment Whiplash-Associated Disorders (WAD) is the single most frequently recorded injury amongst guidelines. The MAA guidelines recognise that CTP claimants in NSW. It was a factor in the natural course of the condition can go 38.9% of claims and responsible for 25% of beyond the acute phase addressed here. These guidelines cover the first 12 weeks followingthe motor vehicle accident.
Recognising the potential benefit in havingeffective ways to manage acute Whiplash- Clinical utility has been uppermost in the minds of the team working on this project. The MAA hopes that the guidelines will be useful to (QTF) guidelines. The task was undertaken by primary care practitioners, consumers and the a Working Party made up of representatives from the health professions usually involved in recommendations of the Working Party which The QTF on Whiplash-Associated Disorders was are published in full in Guidelines for the convened to provide an “in-depth analysis of Management of Whiplash-Associated Disorders. clinical, public health, social, and financial Please turn to back page for details of how to determinants of the whiplash problem”. The Task Force focused on clinical issues,specifically risk, diagnosis, treatment, and Guidelines for early management of Whiplash-Associated Disorders X-ray as in guidelines, rarely for WAD Grades I and II, routine for Grades III and IV.
Manage pain, explain/reassure, encourage activity.
If Grade III consider short-term rest, collar and ice.
Reassurance and encouragement to return to usual activities.
If not resolving, reassess and consider manual and physical therapies.
If not resolving, seek Specialist advice*.
If not resolving, multi-disciplinary pain team or rehabilitation provider evaluation.
*Specialist advice – consultation with a health professional with specialist expertise in managing WAD.
‘Resolving’ – refers to both functional and symptomatic improvement.
Yellow Flags
More initial subjective complaints and concernregarding long-term prognosis If one or more of the following adverse prognosticindicators are present, more intensive treatment and/or earlier referral may be required.
Presence of specific symptoms such as headache;muscle pain; pain or numbness radiating from Notes to accompany flow chart
An ever-present problem in managingWhiplash-Associated Disorders as recommended There will be individual variations.
in this flow chart is possible delay between the GPs should reassess patients regularly, at least specialist, multi-disciplinary pain orrehabilitation team and the subsequent date of Consultations should include an assessment as the appointment. One solution, especially for to whether patients are gaining improvement cases with adverse prognostic indicators (yellow from therapy programs, including those being delivered elsewhere, e.g. physical or manual appointment before the need is urgent. GPs and therapy. If improvement is not evident, GPs specialists could negotiate an arrangement that should consider liaising with the therapist or enables the appointment to be cancelled if not Usually, referral for physical therapy or manual therapy is not required for the first few days, WAD Grades I to III in the acute and sub-acute phases, up to around three months from injury.
The exit points from here are indicated in the Whole person treatment includes managing any flow chart by a dark blue box. These are: accompanying anxiety and/or depression that • referral to a multi-disciplinary pain team or rehabilitation provider for WAD Grade I for a case which is not resolving after six weeks WAD Grade I has been considered separately • referral to a multi-disciplinary pain team or from WAD Grades II and III as more expedient rehabilitation provider for WAD Grades II and resolution is expected. Also, referral is III for a case which is not resolving at 12 recommended earlier for unresolving cases, especially if psycho-social factors appear to be • referral to A&E or a specialist surgeon for If the patient presents with any known adverseprognostic indicators (yellow flags), thepotential for more intensive treatment and/orreferral should be considered. The guidelines are intended to assist health professionals delivering primary careto adults with acute or sub-acute simple neck pain after motor vehicle collisions,in the context of third party insurance compensation.
Definition
Grade Classification
The QTF definition of Whiplash-AssociatedDisorders (WAD) has been adopted as the definition of acute or sub-acute simple neck Neck complaint of pain, stiffness, ortenderness only.
Whiplash is an acceleration-deceleration mechanism of energy transfer to the neck. It may result from “.motor vehicle collisions.”. The impact may result in bony or soft tissue injuries, which in turn may lead to a variety of clinical manifestations Neurological signs include decreasedor absent deep tendon reflexes, Grades I, II and III in the first twelve weeks The guidelines are applicable in the first twelveweeks when WAD is the only injury or when ithas occurred concurrently with other injuries.
Grades of WAD
The following clinical classification provided bythe QTF is noted.
Symptoms and disorders that can be manifest in all grades include deafness, dizziness,tinnitus, headache, memory loss, dysphagia and temporomandibular joint pain.
Methodology
was taken into account. Criteria in makingtheir recommendations were: opinion on • The draft developed by the technical working group was reviewed by the broader steering Working Party and then sent to a range of • Recommendations contained in the guidelines • Consultations on the draft clinical guidelines • A literature review collected information on were undertaken with industry representatives additional evidence published after 1993.
and consumers and substantially reworked in summarise the literature and rate the new • Reviews were requested from three experts, one in Australia and two overseas, and as a • QTF recommendations were reviewed in the result of their comments further changes were light of this evidence. In the absence of any made before final drafts were sent to the further evidence, the opinion of the Technical Group, a sub-set of the MAA Working Party NHMRC methodology for review
NHMRC rating scale for quality
of evidence
of evidence
• Clearly stated title and objectives for the Evidence obtained from a systematic review of all relevant randomised controlled trials.
• Comprehensive strategy to search for studies that address the objectives of the review Evidence obtained from at least one properly (relevant studies) to include unpublished as designed randomised controlled trial.
Grade III-1
• Explicit and justified criteria for the inclusion or exclusion of any study.
• Comprehensive list of all studies identified.
Grade III-2
• Clear presentation of the characteristics of Evidence obtained from comparative studies allocation is not randomised (cohort studies), • Comprehensive list of all studies excluded case-control studies, or interrupted time • Clear analysis of the results of the eligible Grade III-3
studies using statistical synthesis of data Evidence obtained from comparative studies (meta-analysis), if appropriate and possible.
with historical control, two or more single- • Sensitivity analyses of the synthesised data if • Structured report of the review clearly stating the aims, describing the methods and Evidence obtained from a case series, either materials and reporting the results.
post-test or pre-test and post-test.
This section summarises the Working Party recommendations for clinical practice inthe management of WAD. Complete details of the recommendations are publishedin Guidelines for the Management of Whiplash-Associated Disorders. See back pagefor details of how to obtain copies.
Diagnosis of Whiplash-Associated Disorders History taking
Physical examination
History taking is important during all visits for A focused physical examination is necessary for the treatment of WAD patients of all grades.
all patient visits. The physical examinationshould include at least: The history should include information about: • date of birth, gender, occupation, number of • prior history of neck problems including • ROM in flexion-extension, rotation and lateral • prior history of psychological disturbance sensorimotor function and tendon reflexes of • prior history of long-term problems in adjusting to symptoms of an injury or illness • current psychosocial problems, e.g. family, • assessment of general medical condition as • symptoms including pain, stiffness, numbness, weakness and associated extracervicalsymptoms – localisation, time of onset and A universal goniometer can be used to measure profile of onset should be recorded for all • circumstances of injury (sport, motor vehicle); Both positive and negative findings should be mechanism of injury, e.g. if the head moved recorded. A standard form may be used.
forwards, backwards, sideways or all of these;how the accident occurred; the position of Plain radiographs
the person in the car, i.e. passenger or driver;body position; type of vehicle involved • results of assessments conducted using tools WAD Grade I patients do not require a plain to measure general psychological state and pain and disability outcomes, e.g. the GeneralHealth Questionnaire (GHQ), a visual analogue pain scale or a neck disability index • show no signs of alcohol-related impairment – examples of these are available from the • are not obtunded by narcotics or other drugs • show no physical signs on examination History details should be recorded. A standard • have not been involved in a high speed or high impact injury, or in a collision whereanother occupant has been killed. Specialised imaging techniques
In patients presenting as WAD Grade II, plainX-rays of the cervical spine should be taken if: • the severity of the signs on examination techniques (e.g. tomography, CAT scan, MRI, • their level of consciousness or pain sensation myelography, discography etc.) in WAD Grades is impaired by brain injury or alcohol or other • they have been involved in high speed or high impact injury, or in a collision where Specialised imaging techniques might be used in selected WAD Grade III patients, e.g. nerveroot compression or suspected spinal cord Flexion and extension views may occasionally injury, on the advice of a medical or surgical Specialised examinations
All patients who present with WAD Grade IIIshould have baseline radiological investigation Considered by Working Party not relevant to of the cervical spine including anterior- management of WAD Grades I to III. Examples posterior, lateral and open-mouthed views. All include EEG, EMG and specialised peripheral seven cervical vertebral and the C7-T1 disc should be well visualised. Flexion-extensionviews may occasionally be indicated.
Prognosis of Whiplash-Associated Disorders Symptoms
Radiological findings
• severity of neck symptoms and radicular existing osteoarthritis on the initial cervical • presence of specific symptoms such as This yellow flag factor should alert the practitioner to the potential need for more intensive treatment or earlier referral.
radiating from neck to arms, hands orshoulders Psychosocial factors
• prior history of psychological disturbance • initial injury reaction (sleep disturbance, – these disturbances may be indicative of a proneness to emotional/affective problemsand somatisation reactions, which are • more initial subjective complaints and frequently based on affective disorders.
Somatisation reaction in the course of WAD • head rotated or inclined at time of impact and augmentation; without early identification and occupancy in truck/bus; being in head-on or proper treatment, this condition may lead to These yellow flag factors should alert the practitioner to the • prior history of long-term problems in potential need for more intensive treatment or earlier referral.
adjusting to symptoms of an injury or illness,e.g. coping mechanisms • current psychosocial problems, e.g. family, adverse prognostic indicator), other socio- demographic indicators associated with poor These yellow flag factors should alert the practitioner to the potential need for more intensive treatment or earlier referral.
Socio-demographic factors
In addition to the fact that management of this condition, by definition, is taking place in thecontext of compensation (recognised as an These yellow flag factors should alert the practitioner to thepotential need for more intensive treatment or earlier referral.
Treatment of Whiplash-Associated Disorders Reassure
Manual and physical therapies
- exercise
The practitioner should reassure the patient byacknowledging that the patient is hurt and has ROM exercises, muscle re-education and low load isometric exercise to restore appropriate • symptoms are a normal reaction to being hurt muscle control and support to the cervical • it is important to focus on improvements in region should be implemented immediately, if necessary in combination with intermittent restwhen pain is severe. Clinical judgment is crucial • maintaining life activities is an important Act as usual
Pharmacology
Act as usual – should be used as a treatment for WAD with or without pain relief as perrecommendations regarding pharmacology.
No medication should be prescribed other thansimple analgesics. Miscellaneous interventions
- prescribed function, work alteration,
Non-opioid analgesics and NSAIDs can be used and relaxation techniques
to alleviate pain for the short-term. Their use Prescribed function, i.e. return to usual activity should be limited to three weeks and weighed as soon as possible, is recommended.
Rehabilitation programs which may include Opioid analgesics are not recommended for work alteration and relaxation techniques, may WAD Grades I and II. They may be prescribed assist recovery depending on symptoms (e.g.
for pain relief in acute severe WAD Grade III pain, ability to concentrate) and psychosocial Generally, muscle relaxants should not be usedin acute phase WAD. Psychopharmacologic drugs are notrecommended in WAD of any duration orgrade; however, they may be used occasionallyfor symptoms such as insomnia or tension, or as an adjunct to activating interventions in the acute phase (less than three months’ duration).
infusion for acute management of WAD GradesII and III is not recommended.
Manual and physical therapies
Acupuncture
- postural advice
A regime for acupuncture can be used in WAD Postural advice can be given in combination providing there is evidence of continuing Passive modalities/electrotherapies
- mobilisation
- heat, ice, massage, TENS, PEMT,
electrical stimulation, ultrasound, laser,
Mobilisation can be used for WAD, providingthere is evidence of continuing improvement short-wave diathermy
with the treatment. If mobilisation is used itshould be commenced early, within the first seven days. This technique should be restricted Although active PEMT in a soft collar is better to registered health practitioners trained in the than sham PEMT in a soft collar, PEMT is not specific methods and according to current recommended because it involves wearing a - manipulation
A regime of manipulation can be used for WAD, providing there is evidence of continuing improvement with the treatment. This technique modalities/electrotherapies are optional adjuncts should be restricted to registered health to manual and physical therapies and exercise.
practitioners trained in the specific methods and Emphasis should be placed on return to usual according to current professional standards.
Complications from manipulation are rare, butinclude stroke and death. WAD Grade III Immobilisation - prescribed rest
(decreased or absent deep tendon reflexesand/or weakness and sensory deficit) is a relative contra-indication for manipulation.
Rest is not recommended for WAD Grade I.
- traction
A regime of traction can be used incombination with other mobilising modalities in Rest for more than four days should not be WAD providing there is evidence of continuing prescribed for WAD Grades II and III.
Multimodal
A multimodal treatment program can be usedfor WAD that has not settled within four to sixweeks providing there is evidence of continuingimprovement with the treatment. Immobilisation - collars
Surgical treatment
intervention in almost all cases of WAD Grades I to III. Surgery should be restricted to the rareWAD Grade III with persistent arm pain that does not respond to conservative management,or with rapidly progressing neurological deficit, If prescribed for WAD Grades II or III, they should not be used for more than 72 hours.
Immobilisation - cervical pillows
weeks). Because harmful side effects ofrepeated steroid use have been reported, steroid trigger point injections should not beused unless their benefit in WAD is shown in Manual and physical therapies
valid RCTs. Intrathecal steroid injections carry - spray and stretch
such risk of serious morbidity that they shouldbe avoided in all grades of WAD.
Spray and stretch is not recommended.
Miscellaneous interventions
Injections - steroid injections
- magnetic necklaces
Intra-articular steroid injections can not be Magnetic necklaces are not recommended.
recommended for WAD. Epidural steroidinjections should not be used for WAD Grade Ior WAD Grade II. Occasionally, WAD Grade III Other interventions
with unresolved radicular pain of more than - e.g. Pilates, Feldenkrais, Alexander
one month might benefit from epidural steroid Technique, massage and homeopathy
Pilates, Feldenkrais, Alexander Technique, There is no indication for steroid trigger point injection in the ‘acute’ phase (less than three Not relevant to acute WAD Grades I, II or III Injections - sterile water injections
Injections - local anaesthetic nerve
blocks
Not included. Not relevant to management ofacute WAD Grades I to III.
Not included. Not relevant to management ofacute WAD Grades I to III.
Adverse prognostic indicators
Multi-disciplinary pain team
A group of health care providers capable of assessing and treating the physical,psychosocial, medical, vocational and social Cervical pillows
aspects of patients with chronic pain. The Commercially made contoured pillows.
health care team should hold regular meetingsconcerning individual treatment outcomes and Consensus
evaluate overall program effectiveness.
Majority view of all members of the Working Multimodal treatment
Party. The basis for recommendations in theabsence of evidence.
Management that includes simultaneousapplication of treatment modalities including Exercise
relaxation training, manual and physicaltherapies, exercise, postural training and May be either a direction to increase activity or a prescription for a specific set ofexercises.
Immobilisation
Manipulation
A technique of treatment applied to joints forthe relief of pain and improvement of motion.
Non-steroidal anti-inflammatory drug(s).
It is a single high velocity, low amplitude Passive modalities
movement applied passively to the jointtowards the limit of its available range.
Those electrotherapeutic agents that areapplied for such purposes as the relief of pain Manual and physical therapies
Methods of treatment (e.g. manipulative and inflammatory response. They are administered exercise therapy) used in the rehabilitation of persons with musculoskeletal disorders. They are non-invasive, non-pharmaceutical methodsof treatment. Miscellaneous interventions not
Postural advice
otherwise defined
Prescribed function
identified in the QTF guidelines not addressedseparately.
Recommendation of specific activity, e.g.
walking.
Mobilisation
Prescribed rest
A technique of treatment applied to joints forthe relief of pain and improvement of motion.
Recommendation of ‘rest’ that may include Mobilisation is the passive application of avoidance of some activities of daily living.
repetitive, rhythmical, low velocity, smallamplitude movements to the joint within or at Radicular irritation
Traction
A passive, longitudinal force of a vertebral segment that can be applied manually ormechanically with the aim of inducing subtle vertebral distraction for duration of the Relaxation
Whiplash-Associated Disorders (WAD)
mechanism of energy transfer to the neck. It may result from “.motor vehicle collisions.”. The impact may result in bonyor soft tissue injuries, which in turn may lead to a variety of clinical manifestations.
Soft collars
Work alteration
Specialised examinations
environment to accommodate an injuredworker.
Specialised tests that are not routinelyperformed as part of physical examination Yellow flags
and that often require specialised testing indicators have been identified. ‘Yellow flags’ Specialised imaging techniques
is a term developed in the area of musculo-skeletal medicine to describe adverse All radiological techniques except plain film prognostic indicators. The presence of yellow flag factors indicates the potential need for Spray and stretch
Techniques where a coolant spray is appliedto a painful area as a precursor to stretching.
Transcutaneous electrical nerve stimulation isa non-invasive low frequency electricalstimulation, which is applied through the skinwith the aim of introducing an afferentbarrage to decrease the perception of pain.
• Guidelines for the Management of • Compulsory Third Party Insurance Whiplash-Associated Disorders – for Claims Guide for the Management of health professionals involved in clinical Whiplash-Associated Disorders – for the compulsory third party insurance industry • Your Guide to Whiplash Recovery – for people injured in motor vehicle accidents • TECHNICAL REPORT Update of Quebec Task Force Guidelines for theManagement of Whiplash-AssociatedDisorders – for health professionalsinvolved in the treatment of WAD If you have queries or need copies of this publication, contact:

Source: http://www.kandelphysio.ch/Wissen/images/WAD2.pdf