a practical guide to evaluate adults with whiplash associated … · 2019-03-27 · definition...
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A practical guide to evaluate adults with Whiplash Associated
Disorder (WAD) I/II in insurance medicine
Peter De Mulder
Disclosure
NO CONFLICT OF INTEREST
NO affiliations or involvement in any organization of entity with an
financial or non-financial interest in the subject matter.
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
Definition
whiplash
is a collection of neck-related symptoms
referring to the flexion-extension trauma
(acceleration-deceleration)
whiplash ≠ disease or condition
= trauma mechanism
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
Classification of patients with whiplash based on the severity of signs and
symptoms
QUEBEC TASK FORCE (1995)Grade 0 no complaints about the neck, no physical signs
Grade 1 neck complaints of pain, stiffness or tenderness only, no physical
signs
Grade 2 neck complaints and musculoskeletal signs (decreased range of
motion and point of tenderness)
Grade 3 neck complaints and neurological signs
Grade 4 neck complaints and fracture or dislocation
Grade 0 no complaints about the neck, no physical signs
Grade 1 neck complaints of pain, stiffness or tenderness only, no physical
signs
Grade 2 neck complaints and musculoskeletal signs (decreased range of
motion and point of tenderness)
Grade 3 neck complaints and neurological signs
Grade 4 neck complaints and fracture or dislocation
Classification of patients with whiplash based on the severity of signs and
symptoms
QUEBEC TASK FORCE (1995)
Epidemiology
variation ...
5 to 60 % evolution to chronification
only WAD II :
95 % whiplash victims
World wide socio-economic burden:
USA: 3,9 B $ / yr
EU: 10 B € / yr
UK: 14 B £ / last 10 yr (only
claims !)
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
Goal
To support daily practice in insurance medicine in Flanders, Belgium.
General objective: guidance
≠ rigid guideline ≠ protocol
anticipate problematic recovery
facilitate > reintegration active employment circuit
> avoid chronification
> prevent prolonged absences of work or disability
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
SEARCH STRATEGY Pubmed MEDLINE
MeSH terms, restricted to last 10 years > 835 hits
”Whiplash injuries”
Boolean search, restricted to last 10 years > 1235 hits
"whiplash injuries"
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
Whiplash trauma ER or GP NO red flags WAD I/II
Sick leave ≥ 1 week
Call ASAP
1st CONTACT:• explanation• reassurance• motivate towards RTW
• RTW unlikely within < 6 weeks ?
• RED ALERT ?
minimalclinical
examinationspecialist
Return to work
RISK analysis:• PCS• TSK• NDI
+ psychological guidance (CBT)+ (occupational health MD)
CHECK UP AFTER 3 WEEKS
NO return to work
+
+
+ Graded exposure(active behavioural physioth)
+
_ _
Sick leave ≥ 1 week
Call ASAP
1st CONTACT:• explanation• reassurance• motivate towards RTW
• RTW unlikely within < 6 weeks ?
• RED ALERT ?
minimalclinical
examinationspecialist
Return to work
RISK analysis:• PCS• TSK• NDI
+ psychological guidance (CBT)+ (occupational health MD)
CHECK UP AFTER 3 WEEKS
NO return to work
+
+
+ Graded exposure(active behavioural physioth)
+
_ _
Whiplash trauma ER or GP NO red flags WAD I/II
Sick leave ≥ 1 week
Call ASAP
1st CONTACT:• explanation• reassurance• motivate towards RTW
• RTW unlikely within < 6 weeks ?
• RED ALERT ?
minimalclinical
examinationspecialist
Return to work
RISK analysis:• PCS• TSK• NDI
+ psychological guidance (CBT)+ (occupational health MD)
CHECK UP AFTER 3 WEEKS
NO return to work
+
+
+ Graded exposure(active behavioural physioth)
+
_ _
Whiplash trauma ER or GP NO red flags WAD I/II
Sick leave ≥ 1 week
Call ASAP
1st CONTACT:• explanation• reassurance• motivate towards RTW
• RTW unlikely within < 6 weeks ?
• RED ALERT ?
minimalclinical
examinationspecialist
Return to work
RISK analysis:• PCS• TSK• NDI
+ psychological guidance (CBT)+ (occupational health MD)
CHECK UP AFTER 3 WEEKS
NO return to work
+
+
+ Graded exposure(active behavioural physioth)
+
_ _
Whiplash trauma ER or GP NO red flags WAD I/II
1st contact: explain en reassure
Motivate to continuation of daily activities
“act as usual”
“keep on working”
Avoid excessive focus on the pain (NO pain diary!)
beware of “medicalisation” !
Medical examinations: explain en reassure
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
Sick leave ≥ 1 week
Call ASAP
1st CONTACT:• explanation• reassurance• motivate towards RTW
• RTW unlikely within < 6 weeks ?
• RED ALERT ?
minimalclinical
examinationspecialist
Return to work
RISK analysis:• PCS• TSK• NDI
+ psychological guidance (CBT)+ (occupational health MD)
CHECK UP AFTER 3 WEEKS
NO return to work
+
+
+ Graded exposure(active behavioural physioth)
+
_ _
Whiplash trauma ER or GP NO red flags WAD I/II
Minimal clinical investigation : WHY ?
WAD I/II
• Diagnosis by exclusion
• No determinable cause
• Accident or trauma
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
Minimal clinical investigation : WHY ?
WAD I/II
• Diagnosis by exclusion
• No determinable cause
• Accident or trauma
> Exclude probable cause that implies urgent
medical care
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
Minimal clinical investigation : WHY ?
WAD I/II
• Diagnosis by exclusion
• No determinable cause
• Accident or trauma
> Exclude probable cause that implies urgent
medical care
• Cervical radiculopathy
• Cervical myelopathy
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
Minimal clinical examination : HOW ?
Visual inspection
Pain assessment (Visual Analogue Scale 0-10)
Hand grip strength in both hands (Jamar dynamometer)
active C-ROM (cervical)
Active and passive S-ROM (shoulders)
Reflexes upper limbs
Cervical radicular syndrome?
Cervical myelopathy?
Repeat hand grip strength (Jamar dynamometer)
consistent?
simulation, aggravation, malingering
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
Minimal clinical examination : HOW ?
Visual inspection
Pain assessment (Visual Analogue Scale 0-10)
Hand grip strength in both hands (Jamar dynamometer)
active C-ROM (cervical)
Active and passive S-ROM (shoulders)
Reflexes upper limbs
Cervical radicular syndrome?
Cervical myelopathy?
Repeat hand grip strength (Jamar dynamometer)
consistent?
simulation, aggravation, malingering
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
Cervical radicular syndrome ?
Combination of:
• Restricted C-ROM
• Sensory changes
• Strength reduction
• Radiating pain in the upper limbs
• SPURLING TEST
Provocation test
Radicular pain
Radiation according the ipsilateral
side
Identify a anatomic injury:
SENS 95 %
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
Cervical myelopathy ?
variable combination of:
• diffuse paresthesia
• Non dermatome-bound
• Variable strenth reduction
• Upper limbs
• Lower limbs
• Gait disorders
• HYPER REFLEXIA
• HOFFMANN REFLEX
• BABINSKI
triade
SENS 92 %
SPEC 88 %
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
Sick leave ≥ 1 week
Call ASAP
1st CONTACT:• explanation• reassurance• motivate towards RTW
• RTW unlikely within < 6 weeks ?
• RED ALERT ?
minimalclinical
examinationspecialist
Return to work
RISK analysis:• PCS• TSK• NDI
+ psychological guidance (CBT)+ (occupational health MD)
CHECK UP AFTER 3 WEEKS
NO return to work
+
+
+ Graded exposure(active behavioural physioth)
+
_ _
Whiplash trauma ER or GP NO red flags WAD I/II
Sick leave ≥ 1 week
Call ASAP
1st CONTACT:• explanation• reassurance• motivate towards RTW
• RTW unlikely within < 6 weeks ?
• RED ALERT ?
minimalclinical
examinationspecialist
Return to work
RISK analysis:• PCS• TSK• NDI
+ psychological guidance (CBT)+ (occupational health MD)
CHECK UP AFTER 3 WEEKS
NO return to work
+
+
+ Graded exposure(active behavioural physioth)
+
_ _
Whiplash trauma ER or GP NO red flags WAD I/II
1st contact : 1st question !!
Will you be back at work/school within 6
weeks?
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
Does the patient expects to be back at work/in school in 6
weeks ?
IF return in 6 weeks seems unlikely =>
RISK for affected working ability after 12 months (OR
3.18)
Clin J Pain, 2015; 31: 14-20.
Sick leave ≥ 1 week
Call ASAP
1st CONTACT:• explanation• reassurance• motivate towards RTW
• RTW unlikely within < 6 weeks ?
• RED ALERT ?
minimalclinical
examinationspecialist
Return to work
RISK analysis:• PCS• TSK• NDI
+ psychological guidance (CBT)+ (occupational health MD)
CHECK UP AFTER 3 WEEKS
NO return to work
+
+
+ Graded exposure(active behavioural physioth)
+
_ _
Whiplash trauma ER or GP NO red flags WAD I/II
RED ALERTs OUTCOME OR (95% CI) Ref
CLINICAL SIGNS:
High neck pain intensity persistent pain 5,61 Walton et al. 2013
Restricted cervical ROM persistent pain 2,56 Walton et al. 2013
(NDI > 15) permanent disability 42,18 Walton et al. 2013
PSYCHOLOGICAL SIGNS
Catastrophizing prolonged recovery 3,77 Walton et al. 2013
Wants referral physio/chiro prolonged recovery 3,03 Myrtveit et al. 2015
Wants medication prolonged recovery 3,53 Myrtveit et al. 2015
WORK RELATED
RTW unlikely after 6 weeks longterm disability 3,18 Gehrt et al. 2015
sickness benefit > 12 weeks decreased income 3,81 Carstensen 2015
before trauma
RED ALERT
Sick leave ≥ 1 week
Call ASAP
1st CONTACT:• explanation• reassurance• motivate towards RTW
• RTW unlikely within < 6 weeks ?
• RED ALERT ?
minimalclinical
examinationspecialist
Return to work
RISK analysis:• PCS• TSK• NDI
+ psychological guidance (CBT)+ (occupational health MD)
CHECK UP AFTER 3 WEEKS
NO return to work
+
+
+ Graded exposure(active behavioural physioth)
+
_ _
Whiplash trauma ER or GP NO red flags WAD I/II
Validated tools to perform risk analysis
PCS: Pain Catastrophizing Scale (0-52)
Exaggerated negative perception to painful stimuli
Screening pts susceptible chronification
Active rumination
Excessive magnification
Helplessness
TSK: Tampa scale for kinesiophobia (17-68)
Pain related fear for movement
Fear > movement > avoiding behaviour
NDI: Neck Disability Index (0-50)
= Oswestry LBP adjusted for neck complaints
Work and not work related items
whiplash = specific target
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
Advantages of these validated tools ?
PCS-DV : Pain Catastrophizing Scale
TSK: Tampa Score voor Kinesiophobia
NDI – DLV: Neck Disability Index
= >
1. Inventory
2. Focus treatment
3. Repeated measures of evolution
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
Sick leave ≥ 1 week
Call ASAP
1st CONTACT:• explanation• reassurance• motivate towards RTW
• RTW unlikely within < 6 weeks ?
• RED ALERT ?
minimalclinical
examinationspecialist
Return to work
RISK analysis:• PCS• TSK• NDI
+ psychological guidance (CBT)+ (occupational health MD)
CHECK UP AFTER 3 WEEKS
NO return to work
+
+
+ Graded exposure(active behavioural physioth)
+
_ _
Whiplash trauma ER or GP NO red flags WAD I/II
Psychological guidance ? target
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
Psychological guidance ? target
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
Psychological guidance ? target
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
Psychological guidance ? target
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
Sick leave ≥ 1 week
Call ASAP
1st CONTACT:• explanation• reassurance• motivate towards RTW
• RTW unlikely within < 6 weeks ?
• RED ALERT ?
minimalclinical
examinationspecialist
Return to work
RISK analysis:• PCS• TSK• NDI
+ psychological guidance (CBT)+ (occupational health MD)
CHECK UP AFTER 3 WEEKS
NO return to work
+
+
+ Graded exposure(active behavioural physioth)
+
_ _
Whiplash trauma ER or GP NO red flags WAD I/II
Een verzekeringsgeneeskundige leidraad voor Whiplash Associated Disorders I/II.
In conclusion
Specific tool: flowchart
accurate and fast classification according QTF
to distinguish alarm signals
problem-driven anamnesis and clinical examination
risk analysis with specific tools and validated tests
refer (via GP) for adapted treatment and return to work
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
Infodemiology i-Epidemiology “health anxiety” “cyberchondria”
Infodemiology i-Epidemiology “health anxiety” “cyberchondria”
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine
A practical guide to evaluate adults with Whiplash Associated Disorder (WAD) I/II in insurance medicine