New Guildlines for Whiplash in NSW

Whiplash-Associated Disorders (WAD) is the single most frequently recorded injury amongst Compulsory Third Party (CTP) claimants in NSW. In October 1999 new legislation was enacted governing the operations of the New South Wales Motor Accident Authority (MAA) and the CTP insurance scheme it administers.

One aim of the legislative change under the Motor Accidents Compensation Act 1999 is to improve the capacity of the scheme to ensure that “reasonable and necessary” care is delivered to people with injuries and illness following motor vehicle accidents. Changes made to the scheme are intended to improve the quality of medical assessments and ensure that care provided is consistent with the best available knowledge of appropriate and effective diagnosis, treatment, rehabilitation and ongoing support.

As an interim measure, the MAA accepted a proposal to update the Quebec Task Force (QTF) guidelines. This method offered a practical, cost-effective and immediate way to move ahead on the issue. Looking ahead, the National Musculoskeletal Initiative is expected to deliver more comprehensive evidence-based recommendations for the management of this condition in the future.

Whiplash-Associated Disorders (WAD) have been categorised according to the severity of the signs and symptoms present:

Grade	Symtoms/Signs
WAD Grade I	Neck complaint of pain, stiffness or tenderness only.
WAD Grade II	Neck complaint and musculoskeletal signs
WAD Grade III	Neck complaint and neurological signs
WAD Grade IV	Neck complaint and suspected fracture or dislocation

The guidelines cover the management of WAD Grades I - III in the acute and subacute phases, up to around 3 months from injury.

The guidelines cover diagnosis, prognosis and treatment and acknowledge that there will be individual variations. This article covers only the recommended treatment of WAD as set out by the MAA. Information on diagnosis, prognosis and more detail on treatment is available in the MAA Guidelines document.

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

• Symptoms are a normal reaction to being hurt
• It is important to focus on improvements in function
• Maintaining life activities is an important factor in getting better

Act as usual
“Act as usual” should be used as a treatment for WAD with or without pain relief as per recommendations regarding pharmacology.

Miscellaneous interventions - prescribed work function, work alteration and relaxation techniques
Prescribed function, ie.return to usual activity as soon as possible is recommended. Rehabilitation programs, which may include work alteration and relaxation techniques, may assist recovery depending on symptoms and psychosocial factors.

Manual and physical therapies - exercise
To restore appropriate muscle control and support, range of motion exercise, muscle re-education and low load isometric exercise to the cervical region should be implemented immediately. If necessary, this may occur in combination with intermittent rest when pain is severe. Clinical judgement is crucial if symptoms are aggravated.

Pharmacology
No medication should be prescribed other than simple analgesics for WAD Grade I.

For WAD Grade II and III, non-opioid analgesics and NSAIDs can be used to alleviate pain for the short term, limited to 3 weeks and weighed against possible side effects. Opioid analgesics are not recommended for WAD Grades I and II, but may be prescribed for pain relief in acute severe WAD Grade III for a limited period of time. Generally, muscle relaxants should not be used in acute phase WAD.

Manual and physical therapies
Postural advice
Postural advice can be given in combination with manual and physical therapies and exercise in WAD.

Mobilisation, manipulation, traction and acupuncture
Mobilisation, manipulation and traction can be used for WAD, providing there is evidence of continuing improvement with the treatment. If mobilisation is used it should be commenced early, within the first 7 days. These techniques should be restricted to registered health practitioners trained in the specific methods and according to current professional standards.

Complications from manipulation are rare, but include stroke and death. WAD Grade III (decreased or absent deep tendon reflexes and/or weakness and sensory deficit) is a relative contra-indication for manipulation.

Multimodal
A mulimodal treatment program can be used for WAD that has not settled within 4 to 6 weeks providing there is evidence of continuing improvement with the treatment.

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

In WAD Grade I, PEMT is not recommended because it involves wearing a soft collar for 8 hours per day for 12 weeks. In WAD Grade II, during the first 3 weeks other professionally administered passive modalities/electrotherapies are optional adjuncts to manual and physical therapies and exercise. Emphasis should be placed on return to usual activity as soon as possible.

Immobilisation - prescribed rest
Rest is not recommended for WAD Grade I. Rest for more than 4 days is not recommended for WAD Grades II and III.

Immobilisation - collars
Collars are not recommended for WAD Grade I. If prescribed for WAD Grade II or III, they should not be used for more than 72 hours.

Surgical treatment
There are no indications for surgical intervention in almost all cases of WAD Grades I to III. Surgery should be restricted to the rare WAD Grade III with persistent arm pain that does not respond to conservative management, or with rapidly progressing neurological deficit.

These treatments are not recommended for WAD:

• Immobilisation - cervical pillows
• Manual and physical therapies - spray and stretch
• Injections - steroid injections
• Miscellaneous interventions - magnetic necklaces
• Other interventions - eg. Pilates, Feldenkrais, Alexander Technique, massage and homeopathy

The Guidelines are available on the internet at www.maa.nsw.gov.au or can be obtained in print form by phoning MAA on 1300 137 131.