guidelines for the management of whiplash-associated...

January 2001

Guidelines for the Management ofWhiplash-Associated Disorders

contents

Preface 4

Flow chart of guidelines 6

Notes to accompany flow chart 7

Summary of recommendations for clinical practice 8

Diagnosis 8

Prognosis 10

Treatment 11

Purpose of the guidelines 14

Definition of condition and scope of the guidelines 14

Methodology 16

Recommendations for clinical practice 18

Diagnosis 18

History taking 18

Physical examination 20

Plain radiographs 21

Specialised imaging techniques 22

Specialised examinations 23

Prognosis 24

Symptoms 24

Radiological findings 24

Psychosocial factors 25

Socio-demographic factors 25

Treatment 26

Recommended 26

Reassure 26

Act as usual 26

Miscellaneous interventions - prescribed function, work alteration, acupuncture and relaxation techniques 27

Manual and physical therapies

- exercise 27

Pharmacology 28

Recommended under certaincircumstances 30

Manual and physical therapies - postural advice 30

- mobilisation 30

- manipulation 31

- traction 31

Multimodal 32

Acupuncture 33

Passive modalities/electrotherapies - heat, ice, massage, TENS, PEMT,electrical stimulation, ultrasound,laser, short-wave diathermy 33

Immobilisation - prescribed rest, collars 34

Surgical treatment 35

Not recommended 36

Immobilisation - cervical pillows 36

Manual and physical therapies - spray and stretch 36

Injections - steroid injections 36

Miscellaneous interventions - magnetic necklaces 37

Other interventions - e.g. Pilates, Feldenkrais, Alexander Technique, massage, homeopathy 37

Not relevant to treatment of acute WAD Grades I, II or III 38

Injections - sterile water injections,local anaesthetic or nerve blocks 38

The Working Party 39

Glossary 41

Notes 43

January 2001

Guidelines for the Management ofWhiplash-Associated Disorders

4

Preface

In October 1999 new legislation was enactedgoverning the operations of the New SouthWales Motor Accidents Authority (MAA) and theCompulsory Third Party (CTP) insurancescheme it administers.

One aim of the legislative change under theMotor Accidents Compensation Act 1999 is toimprove the capacity of the scheme to ensurethat “reasonable and necessary” care isdelivered to people with injuries and illnessfollowing motor vehicle accidents.

Changes made to the scheme are intended toimprove the quality of medical assessments andensure that care provided is consistent with thebest available knowledge of appropriate andeffective diagnosis, treatment, rehabilitation andongoing support.

The legislation introduces these changes:

• New procedures for resolving disputes aboutmedical and rehabilitation issues, wherepossible based on the principles of evidence-based medicine.

• Medical assessors from a range of healthbackgrounds to resolve ‘medical’ disputes.

• New guidelines for the assessment ofpermanent impairment.

• New guidelines for the appropriate treatment,rehabilitation and care of injured persons.

Whiplash-Associated Disorders (WAD) is thesingle most frequently recorded injury amongstCTP claimants in NSW. It was a factor in 38.9%of claims and responsible for 25% of costs in1998.

As an interim measure, the MAA accepted aproposal to update the Quebec Task Force(QTF) guidelines. This method offered apractical, cost-effective and immediate way tomove ahead on the issue. Looking ahead, theNational Musculoskeletal Initiative is expected

to deliver more comprehensively evidence-based recommendations for the management ofthis condition in the future.

The Quebec Task Force on Whiplash-AssociatedDisorders1 was convened as a result of theQuebec Automobile Insurance Society requestfor an “in-depth analysis of clinical, publichealth, social and financial determinants of thewhiplash problem”. The QTF focused onclinical issues, specifically risk, diagnosis,treatment and prognosis of whiplash. Duringdevelopment of the guidelines, the QTFreviewed 10,000 publications. In addition, acohort of whiplash subjects from the injuryclaim files of the Quebec Automobile InsuranceSociety was identified and prognostic factors inthe recovery process were examined. The QTFreleased its findings in a scientific monographin April 1995.

In general, the available evidence was found to be sparse and of poor quality. While the QTF would have preferred to base therecommendations on research findings, it wasnecessary to develop the guidelines largely onconsensus and the expert knowledge ofmembers of the QTF who were drawn frommany clinical fields. Despite uncovering somenew evidence, the same problem has faced theWorking Party preparing these guidelines fiveyears later.

In these guidelines, changes to therecommendations of the QTF have been basedon available new evidence published since theQTF literature review. Where publishedevidence is lacking or inconsistent, a consensusof the Working Party (i.e. majority view of allmembers) is given. When making itsrecommendations, the Working Party also tookinto account comment received during abroader consultation and reviews by threeexperts.

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.

1 See Notes, page 43

5

The MAA is aware that the work of the QTF hasbeen criticised,2 with major criticisms being:

• the work is largely consensus based ratherthan evidence based (due to lack ofevidence)

• selection criteria for the literature review werenot clear and some evidence, which indicatedthat studies demonstrating WAD to be otherthan a self-limiting condition of temporarydiscomfort and no permanent harm, wasexcluded (i.e. selection bias).

The criticism of a bias towards viewing WAD asa self-limiting condition was noted and does notaffect the recommendations on diagnosis andtreatment which form the substance of theseguidelines. The guidelines recognise that thenatural course of the condition can go beyondthe acute phase addressed here.

While acknowledging these criticisms, the MAAaccepted that other experts in this area view theQTF guidelines as “the first ever systematic

review of the world literature on whiplash”which “established the baseline scientificknowledge in this subject area and created thefirst evidence-based patient care guidelines”.3

Clinical utility has been uppermost in the mindsof the team working on this project. The MAAhopes that the guidelines will be useful toprimary care practitioners, consumers and theinsurance industry.

These guidelines are to cover the first 12 weeksfollowing the motor vehicle accident.

Of course, these guidelines only offer a startingpoint. It is important to encourage practitionersto consult the guidelines and to ask for theirfeedback. Rather than perfecting the guidelinesin theory, the MAA has planned a strategy topublish, distribute and test these guidelines inNew South Wales.

2, 3 See Notes, page 43

6

12 w

eeks

6 we

eks

Guidelines for early management of Whiplash-Associated Disorders

History Physical examination

initia

l visit

7 days

3 we

eks

Return to usual activity.

Reassure, encourage activity.Manage pain.

If not resolving, reassess and consider manual and

physical therapies.

If not resolving, seek Specialist advice*.

If not resolving,multi-disciplinary painteam or rehabilitationprovider evaluation.

Reassurance and encouragement to return to usual activities.If not resolving, reassess and consider manual and physical therapies.

If not resolving, reassess.

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.

NO YES Immediate referral toA&E or specialist surgeon.

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.

WAD Grade Ineck complaint

WAD Grade IIneck complaint and musculoskeletal signs

WAD Grade IIIneck complaint and neurological signs

WAD Grade IVneck complaint and suspected

fracture or dislocation

Positive for fracture/dislocation.

7

These are guidelines only.There will be individual variations.GPs should reassess patients regularly, at leastat the intervals on the flow chart.

Consultations should include an assessment asto whether patients are gaining improvementfrom therapy programs, including those beingdelivered elsewhere, e.g. physical or manualtherapy. If improvement is not evident, GPsshould consider liaising with the therapist orcurtailing that treatment.

Usually, referral for physical therapy or manualtherapy is not required for the first few days,but if required, should commence within sevendays.

Whole person treatment includes managing anyaccompanying anxiety and/or depression thatmay be associated with WAD or with otherstressful life events.

WAD Grade I has been considered separatelyfrom WAD Grades II and III as more expedientresolution is expected. Also, referral isrecommended earlier for unresolving cases,especially if psychosocial factors appear to bedelaying recovery.

If the patient presents with any known adverseprognostic indicators (yellow flags), the

potential for more intensive treatment and/orreferral should be considered.

An ever-present problem in managingWhiplash-Associated Disorders as recommendedin this flow chart is possible delay between thetime of requesting an appointment with aspecialist, multi-disciplinary pain orrehabilitation team and the subsequent date ofthe appointment. One solution, especially forcases with adverse prognostic indicators (yellowflags), would be to make a provisionalappointment before the need is urgent. GPs andspecialists could negotiate an arrangement thatenables the appointment to be cancelled if notrequired.

These guidelines cover the management ofWAD Grades I to III in the acute and sub-acutephases, up to around three months from injury.The exit points from here are indicated in theflow chart by a dark blue box. These are:

• referral to a multi-disciplinary pain team orrehabilitation provider for WAD Grade I for acase which is not resolving after six weeks

• referral to a multi-disciplinary pain team orrehabilitation provider for WAD Grades II and III for a case which is not resolving at 12 weeks

• referral to A&E or a specialist surgeon forWAD Grade IV.

Yellow Flags4

If one or more of the following adverse prognosticindicators are present, more intensive treatmentand/or earlier referral may be required.

Severity of neck symptoms and radicularirritation

Presence of specific symptoms such as headache;muscle pain; pain or numbness radiating fromneck to arms, hands or shoulders

More initial subjective complaints and concernregarding long-term prognosis

Multiple initial symptoms

Older age

Female gender

Not in full-time employment

Having dependants

Presence of osteoarthritis on X-ray

Notes to accompany flow chart


8

History taking

History taking is important during all visits forthe treatment of WAD patients of all grades.

The history should include information about:

• date of birth, gender, occupation, number ofdependants, marital status

• prior history of neck problems includingprevious whiplash injury

• prior history of psychological disturbance

• prior history of long-term problems inadjusting to symptoms of an injury or illness

• current psychosocial problems, e.g. family,job-related, financial problems

• symptoms including pain, stiffness, numbness,weakness and associated extracervicalsymptoms – localisation, time of onset andprofile of onset should be recorded for allsymptoms

• circumstances of injury (sport, motorvehicle…); mechanism of injury, e.g. if thehead moved forwards, backwards, sidewaysor all of these; how the accident occurred;the position of the person in the car, i.e.passenger or driver; body position; type ofvehicle involved

• results of assessments conducted using toolsto measure general psychological state andpain and disability outcomes, e.g., theGeneral Health Questionnaire (GHQ), a visualanalogue pain scale or a neck disability index – examples of these are available fromthe MAA.

History details should be recorded. A standardform may be used.

Physical examination

A focused physical examination is necessary for all patient visits. The physical examinationshould include at least:

• inspection

• palpation for tender points

• ROM in flexion-extension, rotation and lateralflexion

• neurological examination to assesssensorimotor function and tendon reflexes ofupper and lower limbs

• assessment of associated injuries

• assessment of general medical condition asneeded, including mood, affect andpsychological state.

A universal goniometer can be used to measureneck ROM, and/or a hand-held dynamometercan be used to measure strength.

Both positive and negative findings should berecorded. A standardised form may be used.

Plain radiographs

WAD Grade IWAD Grade I patients do not require a plainradiograph on presentation if they:

• are conscious

• show no signs of alcohol-related impairment

• are not obtunded by narcotics or other drugs

• show no physical signs on examination, havenot been involved in a high speed or highimpact injury, or in a collision where anotheroccupant has been killed.

Diagnosis of Whiplash-Associated Disorders

Summary of recommendations for clinical practice

This section summarises the recommendations for clinical practice.For information about how these recommendations were made, see Methodology,page 16, and Recommendations for Clinical Practice, page 18.

9

WAD Grade IIIn patients presenting as WAD Grade II, plainX-rays of the cervical spine should be taken if:

• the severity of the signs on examinationsuggest the possibility of a bony injury

• their level of consciousness or pain sensationis impaired by brain injury or alcohol or otherdrugs

• they have been involved in high speed orhigh impact injury, or in a collision whereanother occupant has been killed.

Flexion and extension views may occasionallybe indicated.

WAD Grade IIIAll patients who present with WAD Grade IIIshould have baseline radiological investigationof the cervical spine including anterior-posterior, lateral and open-mouthed views. Allseven cervical vertebral and the C7-T1 discshould be well visualised. Flexion-extensionviews may occasionally be indicated.

Specialised imaging techniques

WAD Grades I and II There is no role for specialised imagingtechniques (e.g. tomography, CAT scan, MRI,myelography, discography etc.) in WAD GradesI and II.

WAD Grade IIISpecialised imaging techniques might be usedin selected WAD Grade III patients, e.g. nerveroot compression or suspected spinal cordinjury, on the advice of a medical or surgicalspecialist.

Specialised examinations

Specialised examinations were considered bythe Working Party as not relevant tomanagement of WAD Grades I to III. Examplesinclude EEG, EMG and specialised peripheralneural tests.

10

Symptoms

Poor outcome has been associated with:

• severity of neck symptoms and radicularirritation at initial assessment

• presence of specific symptoms such asheadache; muscle pain; pain or numbnessradiating from neck to arms, hands orshoulders

• history of pre-traumatic headaches

• previous history of head injury

• initial injury reaction (sleep disturbance,nervousness)

• more initial subjective complaints andconcern regarding long-term prognosis

• pre-existing osteoarthritis

• head rotated or inclined at time of impact;occupancy in truck/bus; being in head-on orperpendicular collision.

Identification of these yellow flag factors should alert thepractitioner to the potential need for more intensive treatment or earlier referral.

Radiological findings

Poor outcome may be associated with pre-existing osteoarthritis on the initial cervicalradiograph.

This yellow flag factor should alert the practitioner to thepotential need for more intensive treatment or earlier referral.

Psychosocial factors

Poor outcome may be associated with:

• prior history of psychological disturbance –these disturbances may be indicative of aproneness to emotional/affective problemsand somatisation reactions, which arefrequently based on affective disorders;somatisation reaction in the course of WADmay establish a basis for symptomaugmentation; without early identification andproper treatment, this condition may lead todelayed recovery

• prior history of long-term problems inadjusting to symptoms of an injury or illness,e.g. coping mechanisms

• current psychosocial problems, e.g. family,job-related, financial problems.

These yellow flag factors should alert the practitioner to thepotential need for more intensive treatment or earlier referral.

Socio-demographic factors

In addition to the fact that management of thiscondition, by definition, is taking place in thecontext of compensation (recognised as anadverse prognostic indicator), other socio-demographic indicators associated with pooroutcome are:

• older age

• female gender

• not in full-time employment

• having dependants.


Prognosis of Whiplash-Associated Disorders

Summary of recommendations (continued)

11

Treatment of Whiplash-Associated Disorders

Reassure

The practitioner should reassure the patient –by acknowledging that the patient is hurt andhas symptoms, and advising that:

• symptoms are a normal reaction to being hurt

• it is important to focus on improvements infunction

• maintaining life activities is an importantfactor in getting better.

Act as usual

Act as usual – should be used as a treatment forWAD with or without pain relief as perrecommendations regarding pharmacology.

Miscellaneous interventions -prescribed function, work alterationand relaxation techniques

Prescribed function, i.e. return to usual activityas soon as possible, is recommended.Rehabilitation programs which may includework alteration and relaxation techniques, mayassist recovery depending on symptoms (e.g.pain, ability to concentrate) and psychosocialfactors.

Manual and physical therapies - exercise

ROM exercises, muscle re-education and lowload isometric exercise to restore appropriatemuscle control and support to the cervicalregion should be implemented immediately, ifnecessary in combination with intermittent restwhen pain is severe. Clinical judgment is crucialif symptoms are aggravated.

Pharmacology

WAD Grade I No medication should be prescribed other thansimple analgesics.

WAD Grades II and III Non-opioid analgesics and NSAIDs can be usedto alleviate pain for the short term. Their useshould be limited to three weeks and weighedagainst possible side effects.

Opioid analgesics are not recommended forWAD Grades I and II. They may be prescribedfor pain relief in acute severe WAD Grade IIIfor a limited period of time.

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, oras an adjunct to activating interventions in theacute phase (less than three months’ duration).

Use of high dose IV methylprednisoloneinfusion for acute management of WAD GradesII and III is not recommended.

Recommended

Summary of recommendations (continued)

12

Manual and physical therapies - postural advice

Postural advice can be given in combinationwith manual and physical therapies andexercise in WAD.

- mobilisation

Mobilisation can be used for WAD, providingthere is evidence of continuing improvementwith the treatment. If mobilisation is used itshould be commenced early, within the firstseven days. This technique should be restrictedto registered health practitioners5 trained in thespecific methods and according to currentprofessional standards.

- manipulation

A regime of manipulation can be used for WAD,providing there is evidence of continuingimprovement with the treatment. This techniqueshould be restricted to registered healthpractitioners trained in the specific methods andaccording to current professional standards.5

Complications from manipulation are rare, butinclude stroke and death. WAD Grade III(decreased or absent deep tendon reflexesand/or weakness and sensory deficit) is arelative contra-indication for manipulation.

- traction

A regime of traction can be used incombination with other mobilising modalities inWAD providing there is evidence of continuingimprovement with the treatment.

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.

Acupuncture

A regime for acupuncture can be used in WADproviding there is evidence of continuingimprovement with the treatment.

Passive modalities/electrotherapies - heat, ice, massage, TENS, PEMT,electrical stimulation, ultrasound, laser,short-wave diathermy

WAD Grade IAlthough active PEMT in a soft collar is betterthan sham PEMT in a soft collar, PEMT is notrecommended because it involves wearing asoft collar eight hours/day for 12 weeks.

WAD Grades II and III During the first three weeks, otherprofessionally administered passivemodalities/electrotherapies are optional adjunctsto manual and physical therapies and exercise.Emphasis should be placed on return to usualactivity as soon as possible.

Immobilisation - prescribed rest

WAD Grade IRest is not recommended for WAD Grade I.

WAD Grades II and IIIRest for more than four days is notrecommended for WAD Grades II and III.

Immobilisation - collars

WAD Grade I Collars are not recommended for WAD Grade I.

WAD Grades II and IIIIf prescribed for WAD Grade II or III, theyshould not be used for more than 72 hours.

Recommended under certain circumstances


13

Injections - sterile water injections

Not included. Not relevant to management ofacute WAD Grades I to III.

Injections - local anaesthetic nerveblocks

Not included. Not relevant to management ofacute WAD Grades I to III.

Surgical treatment

There are no indications for surgicalintervention in almost all cases of WAD GradesI to III. Surgery should be restricted to the rare

WAD Grade III with persistent arm pain thatdoes not respond to conservative management,or with rapidly progressing neurological deficit,e.g. cervical radiculopathy supported byappropriate investigations.

Immobilisation - cervical pillows

Cervical pillows are not recommended.

Manual and physical therapies - spray and stretch

Spray and stretch is not recommended.

Injections - steroid injections

Intra-articular steroid injections can not berecommended for WAD. Epidural steroidinjections are not recommended for WAD Grade I or WAD Grade II. Occasionally, WAD Grade III with unresolved radicular painof more than one month might benefit fromepidural steroid injections.

There is no indication for steroid trigger pointinjection in the ‘acute’ phase (less than threeweeks). Because harmful side effects of

repeated steroid use have been reported,steroid trigger point injections should not beused unless their benefit in WAD is shown invalid RCTs. Intrathecal steroid injections carrysuch risk of serious morbidity that they shouldbe avoided in all grades of WAD.

Miscellaneous interventions - magnetic necklaces

Magnetic necklaces are not recommended.

Other interventions - e.g. Pilates,Feldenkrais, Alexander Technique,massage and homeopathy

Pilates, Feldenkrais, Alexander Technique,massage and homeopathy are notrecommended.

Not recommended

Not relevant to acute WAD Grades I, II or III

14

Purpose of the guidelines

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 of condition and scope of the guidelines

Definition

The QTF6 definition of Whiplash-AssociatedDisorders (WAD) has been adopted as thedefinition of acute or sub-acute simple neckpain for the purposes of these guidelines.

Whiplash is an acceleration-decelerationmechanism of energy transfer to the neck. It may result from “...motor vehiclecollisions...” The impact may result in bonyor soft tissue injuries,7 which in turn maylead to a variety of clinical manifestations(Whiplash-Associated Disorders).

Scope

The scope of the guidelines covers WAD GradesI, II and III following a motor vehicle collision.

These guidelines are applicable in the firsttwelve weeks when WAD is the only injury orwhen it has occurred concurrently with otherinjuries.

Grades of WAD

The following clinical classification provided bythe QTF is noted.

Symptoms and disorders that can be manifest inall grades include deafness, dizziness, tinnitus,headache, memory loss, dysphagia andtemporomandibular joint pain.

Grade Classification

0 No complaint about the neck.No physical sign(s).

I Neck complaint of pain, stiffness ortenderness only.No physical sign(s).

II Neck complaint ANDmusculoskeletal sign(s).Musculoskeletal signs includedecreased range of motion and pointtenderness.

III Neck complaint AND neurologicalsign(s). Neurological signs include decreasedor absent deep tendon reflexes,weakness and sensory deficits.8

IV Neck complaint ANDfracture or dislocation.

6, 7, 8 See Notes, page 43

15

When to consult the guidelines

An example of appropriate use of theguidelines is a situation in which an adult whois experiencing neck pain after a recent motorvehicle collision consults his or her generalpractitioner. The guidelines would be relevantduring the period when the doctor:

• takes a history

• conducts an examination

• determines what, if any, investigations arerequired, and

• treats or refers for treatment from other healthprofessionals such as physiotherapists andchiropractors.

In many cases, recovery from WAD occursquickly; however, it is recognised that somepeople with WAD will require treatment andsupport beyond 12 weeks.

To deal with more complex cases the guidelinesoffer ways to take action, by:

• alerting primary health care professionals toadverse prognostic indicators (yellow flags)which may indicate the need for moreintensive treatment or early referral.

• confirming that the diagnosis of a fracture ordislocation warrants immediate referral to anAccident and Emergency Department or aspecialist surgeon.

• providing indications of durations whenreferral to specialists or multi-disciplinary painteam or rehabilitation providers should beconsidered.

Target audience and products

The primary target audience for the clinicalpractice guidelines is general practitioners inNew South Wales. The guidelines will berelevant to other health professionals involvedin primary care in New South Wales, e.g.physiotherapists, chiropractors and osteopaths.

Companion documents have also beendeveloped for consumers, and for claimsofficers in the compulsory third party insuranceindustry in New South Wales.

A technical report containing the tables ofevidence and a detailed description of themethodology used to adapt the QTF guidelinesfor use in New South Wales has also beenprepared.

Titles of the five documents are as follows:

• Guidelines for the Management of Whiplash-Associated Disorders – for health professionals.

• SUMMARY Guidelines for the Management ofWhiplash-Associated Disorders.

• Your Guide to Whiplash Recovery – forconsumers.

• Compulsory Third Party Claims Guide to theManagement of Whiplash-AssociatedDisorders – for the compulsory third partyinsurance industry.

• TECHNICAL REPORT Update of QTFGuidelines for the Management of Whiplash-Associated Disorders.

Copies are available from the Motor AccidentsAuthority.

16

The methodology was guided by NationalHealth and Medical Research Councilrecommendations9 for the development ofclinical practice guidelines. The followingapproach was taken:

• Recommendations contained in the guidelinesdeveloped by the QTF and published in 1995were taken as the starting point.

• A literature review was undertaken to collectinformation on additional evidence whichwas both relevant to the scope of theseguidelines and which had been publishedafter the evidence was collected by the QTF(i.e. after 1993). The NHMRCrecommendations for the review of evidenceare summarised on the next page.

• Tables of evidence were prepared which:

– summarise the literature identified, and

– rate the new evidence provided by thereview: from I, the highest quality, to IV,the lowest quality. In rating the evidencethe Working Party was guided by NHMRCrecommendations, summarised on the next page.

• QTF recommendations were reviewed in thelight of this evidence, and in the absence ofany further evidence, the opinion of theTechnical Group, a sub-set of the WorkingParty. Criteria taken into account in makingthese recommendations were: opinion onefficacy and safety.

• The draft developed by the Technical Groupwas reviewed by the broader Working Party.

• The draft clinical guidelines were then sentout to a range of medical and healthorganisations and individuals for comment.

• Consultations on the draft clinical guidelineswere undertaken with industry representativesand consumers in order to developcompanion documents for claims managers inthe compulsory third party insurance industryand for consumers.

• The clinical guidelines were substantiallyreworked in the light of public comment.Changes included:

– providing more information about thestanding of the QTF guidelines, includingcriticisms

– providing more information on the basisfor changes made to the QTFrecommendations

– improving the layout of the document tomake it easier for primary health carepractitioners to use

– modifying some recommendations.

• The four documents were then sent to threeexperts for review – two reviewers overseasand one in Australia.

• Overall the comments of the reviewers werepositive. Further changes made to incorporatereviewers’ comments were:

– providing more information about thelimitations of the QTF guidelines

– adding a recommendation that patientsshould be reassured as part of theirtreatment

– recommending that psychological andpsychosocial factors should be recorded aspart of history taking and added asprognostic indicators

– recommending rehabilitation programs forthose unable to return immediately to theirusual activities.

Methodology

A detailed account of the process by which these consensus guidelines weredeveloped is described separately in Technical Report: Update of Quebec TaskForce Guidelines for the Management of Whiplash-Associated Disorders.


17

Key characteristics of this approach:

• Clearly stated title and objectives for thereview.

• Comprehensive strategy to search for studiesthat address the objectives of the review(relevant studies) to include unpublished aswell as published studies.

• Explicit and justified criteria for theinclusion or exclusion of any study.

• Comprehensive list of all studies identified.

• Clear presentation of the characteristics ofeach study included and an analysis ofmethodological quality.

• Comprehensive list of all studies excludedand justification for exclusion.

• Clear analysis of the results of the eligiblestudies using statistical synthesis of data(meta-analysis), if appropriate and possible.

• Sensitivity analyses of the synthesised data ifappropriate and possible.

• Structured report of the review clearlystating the aims, describing the methods andmaterials and reporting the results.

NHMRC methodology for review of evidence

Grade IEvidence obtained from a systematic reviewof all relevant randomised controlled trials.

Grade IIEvidence obtained from at least one properlydesigned randomised controlled trial.

Grade III-1Evidence obtained from well-designedpseudo-randomised controlled trials.

Grade III-2Evidence obtained from comparative studieswith concurrent controls and whereallocation is not randomised (cohort studies),case-control studies, or interrupted timeseries with a control group.

Grade III-3Evidence obtained from comparative studieswith historical control, two or more single-arm studies, or interrupted time serieswithout a parallel control group.

Grade IVEvidence obtained from a case series, eitherpost-test or pre-test and post-test.

NHMRC rating scale for quality of evidence

• The four documents were then sent as finaldrafts to the MAA Advisory Council forapproval.

• During the period of public comment andexpert review an implementation andevaluation strategy was developed.

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History taking

Recommendations for clinical practice

The Working Party recommendations for clinical practice are presented by subject,with the original Quebec Task Force recommendation, its basis, and an explanationof any change to that recommendation.

Additional evidence located by the literaturereview covering 1993 to 1999 in relation to thissubject is then summarised and the level ofevidence provided by this research is rated.

The Technical Report, also published by theMAA, provides titles and further details of these studies.

Finally there is a justification for any changesmade to the QTF recommendation.

Diagnosis of Whiplash-Associated Disorders

History taking is important during all visits for thetreatment of WAD patients of all Grades.


• date of birth, gender, occupation, number of dependants, marital status

• prior history of neck problems including previouswhiplash

• prior history of psychological disturbance

• prior history of long-term problems in adjusting to symptoms

• current psychosocial problems, e.g. family, job-related, financial problems

• symptoms including pain, stiffness, numbness,weakness and associated extracervical symptoms –localisation, time of onset and profile of onsetshould be recorded for all symptoms

Working Party recommendationsfor clinical practice

• circumstances of injury (sport, motor vehicle); mech-anism of injury, e.g. if the head moved forwards, backwards, sideways or all of these; howthe accident occurred; the position of the person inthe car, i.e. passenger or driver; body position; typeof vehicle involved

• results of assessments conducted using tools tomeasure general psychological state and pain anddisability outcomes, e.g. the General HealthQuestionnaire (GHQ), a visual analogue pain scaleor a neck disability index; examples of these are available from the MAA.

History details should be recorded. A standard formmay be used.

Quebec Task Force (QTF) recommendations forclinical practiceHistory taking is important during all visits forthe treatment of WAD patients of all Grades.

19


• date of birth, gender, occupation, number ofdependants and marital status

• prior history of neck problems, includingprevious whiplash

• symptoms including pain, stiffness, numbness,weakness and associated extracervicalsymptoms

• circumstances of injury (e.g. sport, motorvehicle) and

• mechanism of injury.

This minimal history should be recorded on astandard form.

Basis of QTF recommendationsTwenty studies dealing with aspects of thepatient history in diagnosis of WAD werereviewed. No accepted study dealt with thevalue of history taking for the positive diagnosisof WAD.

These recommendations are based on theconsensus of the Task Force.

Additional evidence No additional study was identified that dealtwith the value of history taking for positivediagnosis of WAD.

There are cohort studies considering prognosticindicators of WAD that are relevant to historytaking (see below for details of studies). Pooroutcome/delayed recovery has been associatedwith several variables including:

• severity of neck symptoms and radicularirritation at initial assessment (Radanov BP,1994 and 1995)

• presence of specific symptoms such asheadache; muscle pain; pain or numbnessradiating from neck to arms, hands orshoulders (Radanov BP, 1994)

• history of pre-traumatic headaches or pasthead injury (Radanov BP, 1994 and 1995)

• initial injury reaction (sleep disturbance,nervousness) (Radanov BP, 1994)

• more initial subjective complaints andconcern regarding long-term prognosis(Radanov BP, 1995)

• pre-existing osteoarthritis (Radanov BP, 1995)

• older age (Harden S et al., 1998; Hartling L etal., 1999; Smed A, 1997; Radanov BP, 1994and 1995)

• female gender (Harden S et al., 1998; SmedA, 1997)

• not in full-time employment (Harden S et al.,1998)

• having dependants (Harden S et al., 1998)

• insurance/compensation – presence of; typeof system (Cassidy D et al., 1999)10

• head rotated or inclined at time of impact(Radanov BP, 1995; Haden S et al., 1998);occupancy in truck/bus; being in head-on orperpendicular collision (Radanov BP 1995)

• pre-traumatic headaches (Radanov B P, 1994and 1995)

• previous history of head injury (Radanov BP,1994).

Evidence of psychosocial factors was conflicting(Radanov BP 1994 and 1995; Karlsbourg et al.,1997; Heikkila H et al., 1998). Cassidy (1999)found that the incidence rate of claims was lessin a no fault scheme compared to a tort scheme.

Rating of additional evidence: III–2 for adverseprognostic indicators.

Noted that for research on prognosis a well-designed cohort study is the highest possiblelevel of evidence.

Basis for changes to QTF recommendationsBy consensus of the Working Party, reference tovalidated tools for measuring pain and neckdisability was added in response to publiccomment. By consensus of the Working Partypychosocial factors (prior history ofpsychological disturbance, prior history of long-term problems in adjusting to symptoms andcurrent psychosocial problems, e.g. family, job-related, financial problems) and examples ofmechanism of injury were included in responseto comment from an expert reviewer. As well itwas stated that a standardised form “may be”used rather than “should be” used.


20

Physical examination

QTF recommendations for clinical practiceA focused physical examination is necessaryduring all patient visits. The physicalexamination should include at least:

• inspection


• assessment of range of motion in flexion-extension, rotation and lateral flexion

• neurological examination to assesssensorimotor function and tendon reflexes ofupper and lower limbs


• assessment of general medical condition, asneeded.

Results of the minimal physical examinationshould be recorded on a standard form.

Basis of QTF recommendationsEighteen studies dealing with aspects ofphysical examination of WAD patients werereviewed. No accepted study dealt with thevalue of physical examination for the positivediagnosis of WAD.

These recommendations are based on theconsensus of the Task Force.

Additional evidence No accepted additional study was identified thatdealt with the value of physical examination forthe positive diagnosis of WAD.

There are cohort studies considering prognosticindicators of WAD that are relevant to physicalexamination. One cohort study of 50 patientspresenting to an accident and emergencydepartment found that a diminished range ofneck movements and poor psychological state,as measured by the General HealthQuestionnaire (GHQ 28), at three months waspredictive of intrusive or disability symptoms attwo years (Gargan M et al., 1997). In oneseven-year cohort study of 2,627 subjects,authors concluded that patients presenting withseveral specific musculoskeletal (neck pain onpalpation) and neurological signs andsymptoms may have a longer recovery period(Suissa S, 1999).

Rating of additional evidence: IV for tendernessto palpation, neurological signs, ROM andpsychological state.

Basis for changes to QTF recommendations“Mood, affect and psychological state” wasadded to physical examination on the basis oflevel IV evidence. In response to publiccomment the Working Party agreed to includereference to the use of goniometers anddynamometers. As well it was stated that astandard form “may be” used rather than“should be” used.

The addition of the phrase “both positive andnegative findings” before “should be recorded”was based on the comments of an externalreviewer and Working Party consensus.

A focused physical examination is necessary for allpatient visits. The physical examination should includeat least:• inspection


• ROM in flexion-extension, rotation and lateral flexion

• neurological examination to assess sensorimotor func-tion and tendon reflexes of upper and lower limbs


• assessment of general medical condition as needed,including mood, affect and psychological state.

• a universal goniometer can be used to measureneck ROM, and/or a hand-held dynamometer canbe used to measure strength.

Both positive and negative findings should berecorded. A standard form may be used.


Recommendations for clinical practice (continued)

21

Plain radiographs

QTF recommendations for clinical practiceAll patients who present with WAD Grades IIand III should have baseline radiologicalexamination of the cervical spine. Thisexamination should include anteroposterior,lateral and open-mouth views. All sevencervical verterbral and the C7-T1 disc spaceshould be well visualised.

In patients with WAD Grades II or III, flexion-extension views may occasionally be indicated.

WAD Grade I patients who are conscious, showno evidence of alcohol-related impairment, arenot obtunded by narcotics or other drugs, andwho show no physical signs on examination,require no plain radiographs on presentation.

Basis of QTF recommendationsSixty-one studies dealing with plain radiographsin WAD patients were reviewed. No acceptedstudy dealt with the value of plain radiographsfor the diagnosis of WAD.

Plain radiographs are not useful for thediagnosis of WAD Grades I, II and III.Radiographs are needed to diagnose bonylesions of WAD Grade IV. There is suggestion inthe literature that patients with WAD Grade Iand no other injury, with no midline cervicalpain, with normal alertness and attention, andwho are not obtunded by narcotics, alcohol, orother drugs, may not need radiographs. Thesmall sample size of these studies and theresulting uncertainty around estimates of falsenegative and positive rates made it impossibleto make recommendations about plainradiographs on the basis of scientific data.

Recommendations regarding plain radiographsin diagnosis of WAD are based on theconsensus of the Task Force.

Additional evidenceNo accepted additional study was identified thatdealt with the value of plain radiographs for thepositive diagnosis of WAD.

With regard to usefulness of plain radiographs,there was one observational study of 669subjects where authors concluded that in theabsence of very high force/speed impacts,clinicians should feel safe in assessing patientsinvolved in rear-end MVCs without the use of X-rays (Brison R et al., 1999). A cohort study of117 subjects identified that poor outcome wasassociated with more signs of pre-existingcervical spine osteoarthritis on initial X-ray(Radanov BP 1995). In another cohort study of100 subjects authors concluded that kyphoticangle seen on functional views does not indicatesoft tissue injury (Ronnen HR et al., 1996).

WAD Grade IWAD Grade I patients who are conscious, show nosigns of alcohol-related impairment, are not obtundedby narcotics or other drugs, who show no physicalsigns on examination, have not been involved in ahigh speed or high impact injury, or in a collisionwhere another occupant has been killed, require noplain radiograph on presentation.

WAD Grade IIIn patients presenting as WAD Grade II, plain X-raysof the cervical spine should be taken if the severityof the signs on examination suggest the possibility ofa bony injury, or if their level of consciousness, orpain sensation is impaired by brain injury or alcoholor other drugs, or if they have been involved in highspeed or high impact injury, or in a collision whereanother occupant has been killed. Flexion andextension views may occasionally be indicated.

WAD Grade IIIAll patients who present with WAD Grade III shouldhave baseline radiological investigation of the cervicalspine including anterior-posterior, lateral and open-mouthed views. All seven cervical vertebral and theC7-T1 disc should be well visualised. Flexion-extensionviews may occasionally be indicated.



22

Plain radiographs (continued)

Rating of additional evidence: IV for aconservative approach to radiologicalinvestigation.

Basis for changes to QTF recommendationsThe recommendation was re-organised forclarity. The requirement for plain X-rays of thecervical spine for WAD Grade II wasdowngraded to specifying the circumstances inwhich this would be required. The basis for thiswas level IV evidence. The requirements forradiological investigation for high speed, highimpact collisions, or those where anotheroccupant has been killed, were added forconsistency with the Royal Australasian Collegeof Surgeons guidelines for trauma management.

Specialised imaging techniques

QTF recommendations for clinical practiceThere is no role for specialised imagingtechniques (tomography, CT scan, MRI,myelography, discography, scinigraphy,angiography…) in WAD Grades I and IIpatients. Specialised imaging techniques mightbe used in selected WAD Grade III patientsbased on the advice of an accredited medical orsurgical specialist.

Basis of QTF recommendationsOne study dealing with tomograms, 10 studiesof CT scan, five studies of MRI, one study ofmyelography, one study of discography, threestudies of scintigraphy, and no studies ofaniography were reviewed.

No accepted studies dealt with CT scans in WADpatients; one study dealt with MRI, but did notprovide any evidence that this technique mightbe useful for the diagnosis of WAD.

Specialised imaging techniques are not useful forthe positive diagnosis of WAD Grades I to III.

Specialised imaging techniques might benecessary, in some instances, to make thepositive diagnosis of WAD Grade IV.

Therefore, these recommendations are based onTask Force consensus.

Additional evidence One two-year cohort study of 52 subjectssuggested no benefit in using MRI for commonneck hyperextension-flexion injuries(Borchgrevink GE et al.,1995). A cohort study of43 subjects over seven months reportedcorrelation between MRI and clinical findingswas poor (Karlsborg et al., 1997). In anobservational study of 39 subjects authorsconcluded that relationship between MRIfindings and the clinical symptoms and signs ispoor (Pettersson K et al., 1998). Anobservational study of 100 acute whiplash injurypatients suggested that there is no role for MRIin routine work-up of acute whiplash injurywhen patients have normal radiographs and/orno evidence of a neurological deficit (RonnenHR et al., 1996).

In conclusion there is evidence (Level IV) toindicate that MRIs are not useful in predictingoutcomes in WAD Grades I to III.

Rating of additional evidence: IV

WAD Grades I and II There is no role for specialised imaging techniques(e.g. tomography, CAT scan, MRI, myelography,discography etc.) in WAD Grades I and II.

WAD Grade IIISpecialised imaging techniques might be used inselected WAD Grade III patients, e.g. nerve rootcompression or suspected spinal cord injury, on theadvice of a medical or surgical specialist.


23

Basis for changes to QTF recommendationsThe recommendations were reorganised forclarity. Additional information was provided onwhen special imaging techniques might beappropriate to improve usefulness to clinicians.Examples given were based on consensus ofthe Working Party.

Specialised examinations

QTF recommendations for clinical practiceIndications for evoked potentials (SSEP) in WADGrade III patients should be based on theadvice of an accredited medical or surgicalspecialist.

Indications for selective nerve root blocks andof EMG in WAD Grades II and III patientsshould be based on the advice of a medical orsurgical specialist.

Indications for other specialised examinations inWAD patients should be based on the advice ofan accredited medical or surgical specialist.

Basis of QTF recommendationsThe QTF examined one study dealing withevoked potentials (SSEP). No accepted studydealt with evoked potential in WAD.

The QTF examined four studies of selectivenerve root blocks and two studies of EMG.There were no accepted studies of theseexaminations in WAD patients.

The QTF examined five studies ofneurobehavioural tests, six studies of EEG, onestudy of ENG, two studies of other specialaudiology or visual examinations. There wereno accepted studies of any of these specialexaminations in patients with WAD.

Therefore all recommendations regarding thesespecialised examinations are based on theconsensus of the Task Force.

Additional evidenceNot included. Not relevant to management ofWAD Grades I–III.

Basis for changes to QTF recommendationsConsidered by Working Party as not relevant tomanagement of WAD Grades I–III. It wasagreed to provide examples of specialisedexaminations – EEG, EMG, and specialisedperipheral neural tests.

Considered by Working Party as not relevant to management of WAD Grades I to III. Examples includeEEG, EMG and specialised peripheral neural tests.



24

Symptoms

QTF findings Three accepted studies provide information onsymptoms that are useful for predictingrecovery. These studies did not cover similarsymptoms and outcome measures. Similarly,only one accepted study provided usefulinformation about signs of prognostic value.Therefore, the QTF recommendations are basedon both evidence and the Task Force consensus.

Additional evidenceSee ‘History taking’ page 18.

Basis for changes to QTF recommendationLevel III-2 evidence for adverse prognosticindicators (yellow flags). Working Partyconsensus was the basis for adding actionfollowing identification of yellow flag/s.

Radiological findings

QTF findings Although several accepted studies addressedradiological findings, none of the results aredefinitive.

Additional evidenceOne study showed that presence of pre-existingosteoarthritis on the initial cervical radiograph wasa poor prognostic indicator (Radanov BP, 1995).

Rating of additional evidence: IV

Basis for changes to QTF recommendationsLevel IV evidence for adverse prognosticindicator (yellow flag). Consensus of WorkingParty for action following identification ofyellow flag.

Prognosis of Whiplash-Associated Disorders

Poor outcome has been associated with:

• severity of neck symptoms and radicular irritationat initial assessment

• presence of specific symptoms such as headache;muscle pain; pain or numbness radiating from neckto arms, hands or shoulders

• history of pre-traumatic headaches

• previous history of head injury

• initial injury reaction (sleep disturbance,nervousness)

• more initial subjective complaints and concernregarding long-term prognosis

• pre-existing osteoarthritis

• head rotated or inclined at time of impact;occupancy in truck/bus; being in head-on or perpendicular collision.



Poor outcome may be associated with pre-existingosteoarthritis on the initial cervical radiograph.

This yellow flag factor should alert the practitioner to thepotential need for more intensive treatment or earlier referral.


25

Psychosocial factors

QTF recommendations for clinical practiceNot included.

Basis of QTF recommendationsNot included.

Additional evidence No additional evidence was found concerningthe independent effect of reassurance on WAD.

Basis for changes to QTF recommendationsConsensus of the Working Party members basedon comments of expert reviewer.

Socio-demographic factors

QTF findings Of the 11 studies accepted, two provided dataon potential predictive factors.

QTF recommendation is based on both evidenceand the Task Force consensus.

Additional evidenceSee ‘History taking’ page 18.

Basis for changes to QTF recommendationsLevel III-2 evidence for adverse prognosticindicators (yellow flags). Consensus by WorkingParty for action following identification ofyellow flag/s.

In addition to the fact that management of thiscondition, by definition, is taking place in the contextof compensation (recognised as an adverse prognosticindicator), other socio-demographic indicatorsassociated with poor outcome are:

• older age

• female gender

• not in full-time employment

• having dependants



Poor outcome may be associated with:

• prior history of psychological disturbance – thesedisturbances may be indicative of a proneness toemotional/affective problems and somatisationreactions, which are frequently based on affectivedisorders. Somatisation reaction in the course ofWAD may establish a basis for symptomaugmentation, if not identified early, this isfrequently not treated properly and may lead todelayed recovery

• prior history of long-term problems in adjusting tosymptoms of an injury or illness, e.g. copingmechanisms

• current psychosocial problems, e.g. family, job-related, financial problems.




26


Reassure



Additional evidence No additional evidence was found concerningthe independent effect of reassurance on WAD.

Basis for changes to QTF recommendationsConsensus of the Working Party members.

Act as usual



Additional evidenceOne RCT of 201 WAD subjects suggested asignificantly better outcome for the ‘act as usualgroup’ (self-training and a five-day prescriptionfor NSAIDs) in terms of subjective symptoms incomparison to the other group who wore acollar and were put on sick leave for 14 days(Borchgrevink GE et al., 1995).

Rating of additional evidence: II for act as usualadvice plus self-training and NSAIDS.

Basis for changes to QTF recommendationsLevel II evidence.

The practitioner should reassure the patient – byacknowledging that the patient is hurt and hassymptoms, and advising that:

• symptoms are a normal reaction to being hurt,

• it is important to focus on improvements infunction, and

• maintaining life activities is an important factorin getting better.


Act as usual – should be used as a treatment forWAD with or without pain relief as perrecommendations regarding pharmacology – see page 28.


Recommended

27

Miscellaneous interventions - prescribed function, work alteration,

acupuncture and relaxation techniques

QTF recommendations for clinical practiceConsensus basis:

• WAD Grade I – prescribed function, i.e.immediate return to usual activity, isrecommended. Neck school, work alteration,acupuncture and relaxation techniques arenot indicated for Grade I.

• WAD Grades II and III – prescribed function,i.e. return to usual activity, is encouraged assoon as possible. Neck school, temporarywork alteration, acupuncture and relaxationtechniques are optional adjuncts for symptomduration more than three weeks.

Basis of QTF recommendationsNo additional evidence was found concerningthese treatments.

Additional evidence No additional evidence was found regardinguse of these treatments in acute WAD.

One expert reviewer referred to a study ofpatients with minor head injuries (many ofwhom have similar problems to whiplashpatients)11 which describes the importance ofgradual return to regular activities. The strategydescribed in the study was ‘individually tailored’and mainly considered the patients’ effectivelevel of functioning. It showed considerableadvantages in long-term outcome whencompared to arbitrary schemes.

Basis for changes to QTF recommendationsConsensus of the Working Party members wasbased on comments of expert reviewer.Acupuncture is addressed in separaterecommendation on page 32.

Manual and physical therapies - exercise

QTF recommendations for clinical practiceEvidence based – there is insufficient evidenceassessing the independent contribution ofexercise.

Consensus based – ROM exercises should beimplemented immediately, in combination ifnecessary with intermittent rest, when pain issevere. Clinical judgment is crucial if symptomsare aggravated.

Basis of QTF recommendationsNo evidence was found regarding independentbenefit of exercise in WAD.

Prescription of home exercise combined withactivation advice, was found to have short- andlong-term benefit for WAD presenting withinfour days of injury.

Additional evidence No additional evidence was found regardingindependent benefit of exercise in WAD.

ROM (range of movement) exercises, muscle re-education and low load isometric exercise torestore appropriate muscle control and support to thecervical region, should be implemented immediately, ifnecessary in combination with intermittent rest whenpain is severe. Clinical judgment is crucial ifsymptoms are aggravated.



Prescribed function, i.e. return to usual activity assoon as possible, is recommended. Rehabilitationprograms, which may include work alteration andrelaxation techniques, may assist recovery dependingon symptoms (e.g. pain, ability to concentrate) andpsychosocial factors.



28

Manual and physical therapies - exercise (continued)

A Cochrane Review (1998) on physicalmedicine modalities for management ofmechanical neck disorders concluded there waslack of scientific evidence to determine theefficacy of exercise (Gross AR et al., 1998).

Basis for changes to QTF recommendations“Muscle re-education and low load isometricexercise” were added to the QTFrecommendation relating to ROM exercise byconsensus of the Working Party.

Pharmacology

QTF recommendations for clinical practiceConsensus based – no medications should beprescribed for WAD Grade I. Non-narcoticanalgesics and NSAIDs can be used to alleviatepain for the short term in WAD Grades II andIII. Their use should not be continued for morethan three weeks, and should be weighedagainst possible side effects. Narcotic analgesicsshould not be prescribed for WAD Grades I andII. Occasionally they may be prescribed for painrelief in acute severe WAD Grade III, but onlyfor a limited period of time. Although commonlyprescribed, muscle relaxants should notgenerally be used in the acute phase of WAD.

The psychopharmacologic drugs are notrecommended for use on a general basis inWAD of any duration or Grade, but they maybe used occasionally for symptoms such asinsomnia or tension, as an adjunct to activatinginterventions in the acute phase (less than threemonths duration).

For chronic pain in WAD (more than threemonths’ duration), the minor tranquillisers andantidepressants may be used.

Basis of QTF recommendationsNo evidence was found regarding the benefit ofnarcotic analgesics or psychopharmacologics inWAD. No studies were accepted regarding thebenefit of muscle relaxants in WAD.

Analgesics or NSAIDs in combination with othertreatment modalities were found to be of short-term benefit in WAD Grades I and II presentingwithin three days of injury (see activation,passive modalities).

Additional evidenceA RCT of WAD Grades I and II givenTenoxicam 20 mg within 72 hours of injury hadbetter ROM and less pain at 15 days comparedto control (Gunzburg R, 1999).

A small RCT of WAD Grades II and III subjectssuggested those treated with high dose 24-hourmethylprednisolone infusion (as per acutespinal cord trauma protocol) had less sick leavecompared to controls (Pettersson K & ToolanenG, 1998).

Rating of additional evidence: II for use ofTenoxicam and for methylprednisilone infusion.

WAD Grade I No medication other than simple analgesics should beprescribed.

WAD Grades II and III Non-opioid analgesics and NSAIDs can be used toalleviate pain for the short term. Their use should belimited to three weeks and should be weighedagainst possible side effects.

Opioid analgesics are not recommended for WADGrades I and II. They may be prescribed for painrelief in acute severe WAD Grade III for a limitedperiod of time.

Muscle relaxants should not generally be used inacute phase WAD.

Psychopharmacologic drugs are not recommended inWAD of any duration or grade; however, they may beused occasionally for symptoms such as insomnia ortension or as an adjunct to activating interventionsin the acute phase (less than three months’ duration).

Use of high dose IV methylprednisolone infusion foracute management of WAD Grades II and III is notrecommended.


29

Basis for changes to QTF recommendationsWAD Grade I – prescription of simpleanalgesics was included by consensus of theWorking Party.

WAD Grades II and III – unchanged butreorganised. Working Party preferred the term“opioid” to “narcotic”.

“Occasionally” was deleted for consistency withNHMRC Guidelines for the management of pain.12

The Working Party did not consider the use ofhigh dose IV methylprednisilone infusion, giventhe potential adverse effects, could be justifiedon the basis of a small RCT.

Recommendations regarding thepharmacological management of chronic painare not included as this is outside the scope ofthe guidelines.



30


Recommended under certain circumstances

Manual and physical therapies - postural advice

QTF recommendations for clinical practiceConsensus based – postural advice can be givenin combination with activation in WAD.

Basis of QTF recommendationsNo evidence was found concerning theindependent therapeutic effect of posturalalignment in WAD.

Advice on posture, combined with advice onactivation for WAD presenting within four daysof injury, has short- and long-term benefit.When combined with physiotherapy, soft collarand analgesics, there was only short-termbenefit.

Additional evidenceNo additional evidence was found concerningthe independent therapeutic effect of posturalalignment in WAD.

In one RCT, Mealy et al., divided subjects intothree groups:

• Group 1 = analgesics plus rest;

• Group 2 = analgesics plus physical modalities,ROM exercises and mobilisation;

• Group 3 = analgesics plus collar plusphysiotherapy advice on mobilisation, postureand ROM exercises.

At two years, Group 3 had fewer symptoms. Attwo years, Group 3 had less pain than Groups 1and 2 (in Hurwitz ET et al., 1996).

Rating of additional evidence: II for the effect ofphysical modalities, ROM exercise, mobilisation;and physiotherapist advice on posture and ROM exercise.

Basis for changes to QTF recommendationsRecommendation unchanged other thanreplacing the term “activation” with “manualand physical therapies and exercise”.

Manual and physical therapies - mobilisation

QTF recommendations for clinical practiceEvidence based – there is weak cumulativeevidence to support their combined use in WAD.

Consensus based – a regimen of mobilisationcan be used for WAD.

Basis of QTF recommendationsNo evidence was found concerning theindependent effect of mobilisation on WAD.

Manual mobilisation combined with otherphysiotherapeutic interventions in WADpresenting within four days of injury and inneck pain syndromes of indeterminate duration,was shown to have short-term benefit; long-term results are no better than those forcombined collar, rest and analgesics.

Postural advice can be given in combination withmanual and physical therapies and exercise in WAD.


Mobilisation can be used for WAD, providing there isevidence of continuing improvement with thetreatment. If mobilisation is used it should becommenced early, within the first seven days. Thistechnique should be restricted to registered healthpractitioners trained in the specific methods andaccording to current professional standards.


31

Additional evidenceNo additional evidence was found concerningthe independent effect of mobilisation on WAD.

A major systematic review of manipulation andmobilisation of cervical spine for treatment ofmechanical neck pain and headache publishedin 1996 concluded that these modalities provideshort-term benefit and that more high qualityresearch is required (Hurwitz ET et al., 1996).Three RCTs reviewed found that mobilisationfor acute neck pain provided short-term benefit(McKinney LA, 1989; McKinney LA et al., 1989;Mealy K et al., 1986).

Mealy K et al., divided subjects into threegroups:

• Group 1 = analgesics plus rest;

• Group 2 = analgesics plus physical modalities,ROM exercises and mobilisation;

• Group 3 = analgesics plus collar plusphysiotherapy advice on mobilisation, postureand ROM exercises.

At two years, Group 3 had fewer symptoms. Attwo years, Group 3 had less pain than Groups 1and 2.

Rating of additional evidence: II for short-termbenefit of mobilisation.

Basis for changes to QTF recommendationsLevel II evidence to support short-term benefitof mobilisation for acute neck pain.

- manipulation

QTF recommendations for clinical practiceConsensus based – a short-term regime ofmanipulation can be used for WAD. Thistechnique should be restricted to registeredhealth practitioners trained in the specificmethods and according to current professionalstandards.

Basis of QTF recommendationsNo evidence was found addressing the short- orlong-term benefits of a complete course ofmanipulative therapy on WAD.

The immediate effect on pain and ROM of asingle manipulation is similar to that of a singlemobilisation in neck pain of varying duration.There is insufficient evidence assessing theindependent contribution of this technique.

Additional evidenceNo additional evidence was found concerningthe independent effect of manipulation onWAD.

A major systematic review of manipulation andmobilisation of cervical spine for treatment ofmechanical neck pain and headache publishedin 1996 concluded that these modalities provideshort-term benefit and that more high qualityresearch is required (Hurwitz ET et al., 1996).No RCTs were found examining manipulationfor acute neck pain.

Basis for changes to QTF recommendationsConsensus of Working Party members.

- traction

A regime of manipulation can be used for WAD,providing there is evidence of continuing improvementwith the treatment. This technique should berestricted to registered health practitioners trained inthe specific methods and according to currentprofessional standards. Complications frommanipulation are rare, but include stroke and death.WAD Grade III (decreased or absent deep tendonreflexes and/or weakness and sensory deficit) is arelative contra-indication for manipulation.


A regime of traction can be used in combinationwith other mobilising modalities in WAD providingthere is evidence of continuing improvement with thetreatment.



32

- traction (continued)

QTF recommendations for clinical practiceEvidence based – there is weak evidence thattraction is of short-term benefit.

Consensus based – a regime of traction can beused in combination with other mobilisinginterventions in WAD.

Basis of QTF recommendationsNo evidence was found addressing independenteffects of traction in WAD.

Traction in combination with otherphysiotherapeutic interventions was found to beof short-term benefit in WAD presenting withinfour days of injury, and in neck pain syndromesof indeterminate duration; there was no long-term (two year) benefit for WAD presentingwithin four days of injury.

In a small RCT, there were no statisticallysignificant differences between static,intermittent and manual traction in combinationwith other physiotherapeutic interventions inneck pain syndromes of indeterminate duration.

Additional evidence No additional evidence was found addressingindependent effects of traction in WAD.

A Cochrane Review (1998) on physicalmedicine modalities for mechanical neckdisorders concluded that lack of scientifictesting prevented determination of efficacy oftraction (Gross AR et al., 1998). An earliersystematic review on traction for neck and backpain reported there was no conclusive evidencethat traction was an effective therapy formechanical neck and back pain (Van derHeijden et al., 1995).

Basis for changes to QTF recommendationsGiven the lack of evidence on the effectivenessof traction, by consensus the Working Partyagreed that evidence of improvement inindividual cases would be required to justifyongoing use of traction.

Multimodal



Additional evidenceOne RCT of 60 WAD patients suggestedimproved pain, disability and return to work formultimodal treatment group compared tocontrol group that received physical modalitiesalone (Provenciali L et al., 1996).

Rating of additional evidence: II for multimodaltreatment.

Basis for changes to QTF recommendationsLevel II evidence to support use of thistreatment. Recommendations regardingappropriate time to commence and the need formonitoring were based on Working Partyconsensus.

A multimodal treatment program can be used forWAD which has not settled within four to six weeksproviding there is evidence of continuing improvementwith the treatment.


33

Acupuncture

QTF recommendations for clinical practice

WAD Grade I Acupuncture is not recommended for WADGrade I (see also page 27 Miscellaneousinterventions).

WAD Grade II and IIIPrescribed function, i.e. return to usual activity,is encouraged as soon as possible, temporarywork alteration, relaxation techniques andacupuncture are optional adjuncts forsymptom duration greater than three weeks.

Basis of QTF recommendationsOne accepted RCT was found for chronic neckpain (daily neck pain with or without radiationmore than six months). The study suggestedthat acupuncture and NSAIDs or analgesicswere not better than sham TENS with NSAIDsor analgesics for relief of pain.

Additional evidence No additional evidence was foundindependently examining use of acupuncture inacute WAD.

A Cochrane Review (1998) on use ofacupuncture in neck disorders concluded therewas insufficient quality research to comment oneffectiveness of acupuncture (Gross AR et al.,1998).

Basis for changes to QTF recommendations Given the lack of evidence on the effectivenessof acupuncture for WAD, by consensus theWorking Party agreed that acupuncture shouldonly be continued if there was evidence ofimprovement in individual cases.

Passive modalities/electrotherapies - heat, ice, massage, TENS, PEMT,

electrical stimulation, ultrasound,laser, short-wave diathermy

QTF recommendations for clinical practiceConsensus based:

• WAD Grade I: although active PEMT in a softcollar was better than sham PEMT in a softcollar, PEMT is not recommended because itinvolves wearing a soft collar eight hours aday for 12 weeks.

• WAD Grades II and III: the otherprofessionally administered passivemodalities/electrotherapies are optionaladjuncts during the first three weeks toactivating interventions with emphasis onreturn as soon as possible to usual activity.

Basis of QTF recommendationsThere were virtually no accepted studiesaddressing the benefit of these modalities.

Two small RCTs in WAD Grades I and IIpresenting less than 72 hours, and in neck painnot related to WAD more than eight weeks’duration, suggest a benefit from PEMTcompared with sham PEMT in pain control

A regime for acupuncture can be used in WADproviding there is evidence of continuing improvementwith the treatment.


WAD Grade IAlthough active PEMT in a soft collar was better thansham PEMT in a soft collar, PEMT is notrecommended because it involves wearing a softcollar eight hours a day for 12 weeks.

WAD Grades II and III During the first three weeks the other professionallyadministered passive modalities/electrotherapies areoptional adjuncts to manual and physical therapiesand exercise with emphasis on return to usualactivity as soon as possible.



34

Passive modalities/electrotherapies(continued)

when combined with NSAIDs, activating adviceand soft collar.

All modalities except laser were possible adjunctsto mobilising interventions, which had short-termbenefit equivalent to activation advice.

There were no accepted studies in which thebenefits of laser were addressed.

Additional evidenceNo additional accepted studies independentlyassessing the use of these modalities in acuteWAD Grade I to III were found.

Basis for changes to QTF recommendationsThe only change is the use of the terms“manual and physical therapies and exercise”instead of “activating interventions”.

Immobilisation - prescribed rest

QTF recommendations for clinical practiceEvidence based – there is weak cumulativeevidence to restrict prescribed rest to shortperiods of time.

Consensus based – rest should not beprescribed for WAD Grade I. Rest for more thanfour days should not be prescribed for WADGrades II and III.

Basis of QTF recommendationsNo evidence was found concerningindependent benefit of prescribed rest in WAD.

Prescribed rest for 10 to 14 days in combinationwith soft collars and analgesia in WAD wasassociated with delayed recovery.

Additional evidenceIn a RCT of 201 acute whiplash subjects it wasdemonstrated that an ‘act as usual’ group hadbetter outcomes in terms of subjectivesymptoms compared to subjects managed with14 days’ sick leave and immobilisation with softneck collar (Borchgrevink GE, 1998).

Rating of additional evidence: II

Basis for changes to QTF recommendationsRecommendation unchanged.

Comment: the additional evidence referred toabove would suggest that for many cases “actas usual” should be recommended, andtherefore an additional recommendation hasbeen added to this effect, see page 26.

- collars

QTF recommendations for clinical practiceEvidence based – there is weak cumulativeevidence to restrict their use to short periods oftime.

Consensus based – collars should not beprescribed for WAD Grade I. If prescribed forWAD Grades II or III, they should be restrictedto no more than 72 hours.

WAD Grade I Collars should not be prescribed.

WAD Grades II and IIIIf prescribed for WAD Grades II or III, they shouldnot be used for more than 72 hours.


WAD Grade IRest should not be prescribed for WAD Grade I.

WAD Grades II and IIIRest for more than four days should not beprescribed for WAD Grades II and III.


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Basis of QTF recommendationsNo evidence was found addressing independentbenefit of collars in WAD.

Soft collars in combination with prescribed restand analgesics are associated with delayedrecovery (pain and ROM) in WAD presentingwithin four days of injury.

Soft collars do not restrict ROM in non-injuredsubjects.

Additional evidenceA RCT of 196 acute whiplash subjects indicatedthat use of soft collars did not alter the durationor pain in whiplash patients (Gennis P et al.,1996).

In a RCT of 201 acute whiplash subjects it wasdemonstrated that an ‘act as usual’ group hadbetter outcomes in terms of subjectivesymptoms compared to subjects managed with14 days’ sick leave and immobilisation with softneck collar (Borchgrevink GE, 1998). A RCT of220 acute whiplash subjects suggested thatsubjects immobilised in collar for four weeksfollowed up by a defined exercise period didbetter than controls and better than a groupmanaged with early defined exercise(Gurumoorthy D, 1999).

Rating of additional evidence: II


Surgical treatment

QTF recommendations for clinical practiceConsensus based – There are no indications forsurgical intervention in WAD Grades I and II.Surgery is to be restricted to the rare WADGrade III with persistent arm pain that does notrespond to conservative management or withrapidly progressing neurologic deficit.

Basis of QTF recommendationsNo studies were accepted concerning thebenefit of disc surgery, nerve block or rhizolysisfor any Grade or duration in WAD.

Additional evidence No additional accepted study was identifiedregarding the benefits of surgery, nerve blockor rhizolysis in acute management of WADGrades I to III.

Basis for changes to QTF recommendationsThe recommendation has been changed byproviding an example of a case which maybenefit from surgery.

There are no indications for surgical intervention inalmost all cases of WAD Grades I to III. Surgeryshould be restricted to the rare WAD Grade III withpersistent arm pain that does not respond toconservative management or with rapidly progressingneurological deficit, e.g. cervical radiculopathysupported by appropriate investigations.



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Immobilisation - cervical pillows

QTF recommendations for clinical practiceConsensus based – cervical pillows are notrequired.

Basis of QTF recommendationsNo evidence was found addressing thetherapeutic effects of cervical pillows in WAD.

Additional evidence No additional evidence was found.


Manual and physical therapies - spray and stretch

QTF recommendations for clinical practiceConsensus based – Spray and stretch is notrecommended.

Basis of QTF recommendationsNo evidence was found concerning theindependent therapeutic effect of spray andstretch in WAD.

Additional evidenceNo additional evidence was found concerningthe independent therapeutic effect of spray andstretch in WAD.


Injections - steroid injections

QTF recommendations for clinical practiceConsensus based – intra-articular steroidinjections are not recommended for WAD.Epidural steroid injections are notrecommended for WAD Grades I or II.Occasionally, WAD Grade III with unresolvedradicular pain of more than one month mightbenefit from epidural steroid injections.


Not recommended

Cervical pillows are not recommended.


Spray and stretch is not recommended.


Intra-articular steroid injection cannot berecommended for WAD. Epidural steroid injectionsshould not be used for WAD Grades I or II.Occasionally, WAD Grade III with unresolved radicularpain of more than one month might benefit fromepidural steroid injections.

There is no indication for steroid trigger pointinjection in the ‘acute’ phase (less than three weeks).Because harmful side effects of repeated steroid usehave been reported, steroid trigger point injectionsshould not be used unless their benefit in WAD isshown in valid RCTs. Intrathecal steroid injectionscarry such risk of serious morbidity that they shouldbe avoided in all grades of WAD.


37

There is no indication for steroid trigger pointinjection in the ‘acute’ phase (less than threeweeks). Because harmful side effects ofrepeated steroid use have been reported,steroid trigger point injections should not beused unless their benefit in WAD is shown invalid RCTs. Intrathecal steroid injections carrysuch risk of serious morbidity that they shouldbe avoided in all Grades of WAD.

Basis of QTF recommendationsOne accepted study showed no benefit of intra-articular steroid injections in WAD greater thanthree months.

No accepted studies were found concerning thebenefit of epidural or intrathecal steroidinjections in WAD. No additional evidence wasfound concerning trigger point steroid injectionsin WAD.

Additional evidenceNo accepted studies were found concerning theacute treatment of WAD Grades I to III withepidural or intrathecal steroid injections orconcerning injection of trigger points.

Basis for changes to QTF recommendations Recommendation unchanged.

Miscellaneous interventions - magnetic necklaces

QTF recommendations for clinical practiceConsensus based – magnetic necklaces are notrecommended.

Basis of QTF recommendationsAn accepted RCT indicated that the magneticnecklace is no better than placebo for neckpain of duration greater than one year. No other

evidence was found concerning theeffectiveness of the magnetic necklace.

Additional evidenceNo additional evidence assessing the use ofmagnetic necklaces in treatment of acute WADGrades I to III was identified.


Other interventions – e.g. Pilates,Feldenkrais, Alexander Technique,massage and homeopathy

QTF recommendations for clinical practiceConsensus based – there is no reason for apractitioner to prescribe any of these treatments.

Basis of QTF recommendationsNo evidence was found concerning thesetreatments.

Additional evidence No additional evidence independently assessinguse of any of these modalities in acute WADwas identified.

Basis for changes to QTF recommendationsThe wording of the recommendation waschanged for consistency. The Working Partycould not justify recommending any of these inthe treatment of acute WAD.

Magnetic necklaces are not recommended.


Pilates, Feldenkrais, Alexander Technique, massage andhomeopathy are not recommended.



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Injections - sterile water injections

QTF recommendations for clinical practiceConsensus based – sterile water subcutaneoustrigger point injections can be used for WADGrade II where trigger points are present as anoptional adjunct to activating interventions withemphasis on return to usual activities.

Basis of QTF recommendationsThis recommendation was based on oneaccepted RCT from a WAD Grade II patientwith neck and shoulder pain four to six yearsafter injury that suggested a sustained smallbenefit of subcutaneous sterile water injections.

Additional evidenceNot included. Not relevant to management ofacute WAD Grades I to III.

Basis for changes to QTF recommendations Not included. Not relevant to management ofacute WAD Grade I to III.

Injections - local anaesthetic nerve blocks



Additional evidenceNot included. Not relevant to management ofacute WAD Grades I to III.

Basis of change to QTF recommendations Not included. Not relevant to management ofacute WAD Grades I to III.


Considered not relevant to treatment of acute WAD Grades I, II or III

Not included. Not relevant to management of acuteWAD Grades I to III.


Not included. Not relevant to management of acuteWAD Grades I to III.


39

In establishing this Working Party the MAA wasaware that primary care health professionals,especially general practitioners, physiotherapists

and chiropractors, manage much of the healthburden from Whiplash-Associated Disorders.

Name Occupation Association

Tina Bidese Senior Rehabilitation Advisor Allianz General InsuranceInsurance Council of Australia

Dr Stephen Buckley (Chair) Rehabilitation Physician Australasian Faculty of Rehabilitation Medicine Motor Accidents Council

A/Prof. Dr Ian Cameron* Rehabilitation Physician Faculty of Medicine, University of Sydney

Dr Louise Crowle*/ Researcher/Consultant NE&A Pty Ltd/PWC Sarah Evans

Dr Michael Eagleton General Surgeon Australasian Association of Surgeons

Dr Niki Ellis* Occupational and NE&A Pty Ltd/PWC Public Health Physician

Dr John Frith* General Practitioner School of Community Medicine, University of NSW, nominee of theRoyal Australian College of General Practitioners (NSW Faculty)

Mary Hawkins/Anna Bray Workplace Injury WorkCover Authority NSWManagement Branch

John Heazlewood Lawyer Law Society of New South Wales

David Husband* Chiropractor Chiropractors’ Association of Australia (NSW)

A/Prof. Gwendolen Jull* Specialist Manipulative Faculty of Health Sciences, The Physiotherapist University of Queensland, nominee

of the Motor Accidents Insurance Commission (Qld)

Andrew Leaver Manipulative Physiotherapist Australian Physiotherapy Association (NSW Branch)

Suzanne Lulham Principal Advisor, Rehabilitation Motor Accidents Authority

Shayne O’Reilly Manager, Strategic Planning NRMA Insurance Council of Australia

The Working Party

Thanks go the Working Party who guided this project.

40

Name Occupation Association

Trudy Rebbeck* Manipulative Physiotherapist Australian Physiotherapy Association (NSW Branch)

Maz Thompson Consumer Representative Consumer Representative(one meeting only)

Dr Simon Willcock General Practitioner Department of General Practice, University of Sydney, nominee of the Royal Australian College of General Practitioners (NSW Faculty)

Dr Conrad Winer* Consultant Physician in Royal Prince Alfred Hospital, Rehabilitation and nominee of the Australian Medical Musculoskeletal medicine Associationand Registered Osteopath (UK)

* Also member of the Technical Group

The MAA is also grateful to those who providedcomment on the draft guidelines, some ofwhich was quite critical, and led to a significantre-working of the clinical guidelines. The organisations and individuals from whomcomment was received are listed in theTechnical Report.

Thanks also to three expert reviewers whomade final comments.

Marc WhiteCentre for the Study of Curriculum and InstructionFaculty of EducationUniversity of British ColumbiaVancouverBritish Columbia

Professor Bogdan RadanovDepartment of PsychiatryUniversity of BerneBerneSwitzerland

Professor Peter BrooksRheumatologistExecutive Dean of Health SciencesUniversity of QueenslandAustralia

The Working Party (continued)

41

Glossary

Adverse prognostic indicatorsFactors that have been associated withadverse outcomes.

Cervical pillowsCommercially made contoured pillows.

ConsensusMajority view of all members of the WorkingParty. The basis for recommendations in theabsence of evidence.

ExerciseMay be either a direction to increase activityor a prescription for a specific set ofexercises.

ImmobilisationTo prevent motion of the neck usually byapplication of a cervical collar.

ManipulationA technique of treatment applied to joints forthe relief of pain and improvement of motion.It is a single high velocity, low amplitudemovement applied passively to the jointtowards the limit of its available range.

Manual and physical therapiesMethods of treatment (e.g. manipulative andexercise therapy) used in the rehabilitation ofpersons with musculoskeletal disorders. Theyare non-invasive, non-pharmaceutical methodsof treatment.

Miscellaneous interventions nototherwise defined

A set of complementary health treatmentsidentified in the QTF guidelines not addressedseparately.

MobilisationA technique of treatment applied to joints forthe relief of pain and improvement of motion.Mobilisation is the passive application ofrepetitive, rhythmical, low velocity, smallamplitude movements to the joint within or atthe end of range.

Multi-disciplinary pain team A group of health care providers capable ofassessing and treating the physical,psychosocial, medical, vocational and socialaspects of patients with chronic pain. Thehealth care team should hold regular meetingsconcerning individual treatment outcomes andevaluate overall program effectiveness.

Multimodal treatmentManagement that includes simultaneousapplication of treatment modalities includingrelaxation training, manual and physicaltherapies, exercise, postural training andpsychological support.

MVAMotor vehicle accident.

MVCMotor vehicle collision.

NSAIDsNon-steroidal anti-inflammatory drug(s).

Passive modalitiesThose electrotherapeutic agents that areapplied for such purposes as the relief of painand assisting the resolution of theinflammatory response. They are administeredpassively to the patient.

PEMT Pulsed electromagnetic treatment.

Postural advice Specific instructions on posture.

Prescribed functionRecommendation of specific activity, e.g.walking.

Prescribed restRecommendation of ‘rest’ that may includeavoidance of some activites of daily living.

QTFQuebec Task Force.

Glossary (continued)

42

Radicular irritationSymptoms caused by irritation of the nerve root.

RCTRandomised controlled trial.

Relaxation Techniques used to reduce muscle tensionand anxiety.

ROMRange of movement.

Soft collarsFoam neck supports.

Specialised examinationsSpecialised tests that are not routinelyperformed as part of physical examinationand that often require specialised testingequipment.

Specialised imaging techniquesAll radiological techniques except plain filmradiology.

Spray and stretchTechniques where a coolant spray is appliedto a painful area as a precursor to stretching.

TENSTranscutaneous 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.

TractionA passive, longitudinal force of a vertebralsegment that can be applied manually ormechanically with the aim of inducing subtlevertebral distraction for duration of theprocedure.

Whiplash-Associated Disorders (WAD)Whiplash is an acceleration-decelerationmechanism of energy transfer to the neck.It may result from “...motor vehiclecollisions...” The impact may result in bony orsoft tissue injuries, which in turn may lead toa variety of clinical manifestations.

Work alterationModification of work duties and/orenvironment to accommodate an injuredworker.

Yellow flagsCondition in which adverse prognosticindicators have been identified. ‘Yellow flags’is a term developed in the area ofmusculoskeletal medicine to describe adverseprognostic indicators. The presence of yellowflag factors indicates the potential need formore complex management.

43

1 Scientific Monograph of the QTF on Whiplash-Associated Disorders, Redefining “Whiplash” andIts Management, Spine, 1995, Supplement Vol 20 Num 85.

2 See for example Teasall, RW et al., Limitations of the QTF on Whiplash-Associated Disorders,AAPM&R 61st Annual Assembly and 13th World Congress of the International Federation ofPhysical Medicine and Rehabilitation, November 1999; and Freeman M, Croft A, and Rossignol A,“Whiplash-associated Disorders: Redefining whiplash and its management” by the QTF. Spine;1998, 23(9): 1043–1049.

3 See for example Cassidy, D et al., The QTF on Whiplash-Associated Disorders – Impact andUpdate, AAPM&R 61st Annual Assembly and 13th World Congress of the International Federationof Physical Medicine and Rehabilitation, November 1999.

4 ‘Yellow flags’ is a term developed in the area of musculoskeletal medicine to describe adverseprognostic indicators. The identification of yellow flags indicates the potential need for morecomplex management.

5 To find out more about practitioner registration visit the NSW Department of Health web site:http://www.health.nsw.gov.au.

6 Scientific Monograph of the QTF on Whiplash-Associated Disorders, Redefining “Whiplash” andIts Management, Spine, 1995, Supplement Vol 20 Num 85.

7 Although the term ‘whiplash injury’ was included in the QTF definition, this has been excludedas it is not concise and confuses cause and effect.

8 Arm pain on its own is not sufficient for a diagnosis of WAD Grade III.

9 National Health and Medical Research Council, A guide to the development, implementation andevaluation of clinical practice guidelines, Ausinfo, Canberra, 1999.

10 Now published: Cassidy DJ et al., Effect of Eliminating Compensation for Pain and Suffering onthe Outcomes of Insurance Claims for Whiplash Injury, New England Journal of Medicine, April20, 2000, Vol. 342, No 16, p 1179–1186.

11 Wrightson P, Gronwall D, Time off work and symptoms after minor head injury, Injury 1981;12:445–54.

12 NHMRC, Acute pain Management: information for general practitioners, Commonwealth ofAustralia, 1999.

Notes

For more informationIf you have queries or need copies of this publication, contact:Motor Accidents AuthorityLevel 22580 George Street, Sydney NSW 2000Phone: 1300 137 131 Fax: 1300 137 707Web site: www.maa.nsw.gov.aue-mail: [email protected]

Claims Advisory Service 1300 656 919

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