BCCA WAD Guidelines

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					                             BRITISH COLUMBIA CHIROPRACTIC ASSOCIATION

                             CLINICAL GUIDELINES FOR THE MANAGEMENT OF
                                   WHIPLASH-ASSOCIATED DISORDERS

                                                  January, 2005


Mission Statement for Whiplash Associated Disorders
The British Columbia Chiropractic Association (BCCA) is committed to delivering appropriate and cost-effective
care towards maximal recovery for injured motorists who sustain whiplash-associated disorders (WAD). The
British Columbia College of Chiropractors recommends the use of these guidelines by practitioners, insurers, and
legal representatives.

General Disclaimer
The purpose of these guidelines is to assist in managing WAD and in measuring patient outcomes. In addition,
guidelines might assist health insurance companies in managing claims and assessing patient outcomes.
However, guidelines do not represent specific or individual case management recommendations, nor
should they be considered standards of care. By scientific necessity, they are flexible and will change as new
information provides better insight into the diagnosis and management of WAD.

Preamble
The “British Columbia Chiropractic Association Clinical Guidelines for the Management of Whiplash Associated
Disorders” has been developed by the BCCA and is recommended by the BCCC for use by member practitioners.

Evidence-based care is the synthesis of clinical experience and judgement with the best scientific research
(evidence) for a given condition (26). These guidelines seek to incorporate the principle of evidenced-based care,
integrating the best scientific evidence with the collective BCCA clinical experience, in the development of
outcomes management for WAD (4).

Introduction
The incidence of WAD in western societies varies widely depending on reporting structures. However, the
magnitude of the problem is significant due to the prevalence of chronic symptoms for patients following a
whiplash (1,6). The WAD related economic, health and social costs to society, the injured patient and to their
families is considerable.

In British Columbia, over 35,000 people suffer each year from WAD due to motor vehicle crashes. The Insurance
Corporation of British Columbia spends approximately 500 million dollars annually (31) to administer claims,
replace income, litigate and lastly, pay for WAD treatment. This figure does not include the cost borne by other
insurers including the Medical Services Plan of British Columbia, Workers Compensation Board or private
insurers such as Pacific Blue Cross. Nor does it include the loss of productivity to employers or financial and
emotional damage to families.

From the perspective of public safety, preventing whiplash-associated disorders through driver education, traffic
safety measures and better vehicle design, is extremely important.

The BCCA Experience
The BCCA accepts the current best evidence in relation to the prevalence of chronic symptoms following a
whiplash injury. Recent scientific reviews and research (6,7,17) indicate that the prevalence of chronic symptoms
of WAD is not as optimistic as suggested by one publication, the Quebec Task Force (QTF) consensus on
WAD(21). The QTF drew unsupported conclusions from the literature regarding the prevalence of chronic
symptoms of WAD (29). In 1997 the BCCA published a Position Statement critiquing the QTF document (20).
Today, the BCCA Position Statement is supported by a growing number of researchers (6,7,29). Presently, the
best scientific estimates indicate that between 14 and 42% of patients will develop recurrent and intrusive
episodes of pain, stiffness and loss of function following a whiplash injury (1,6,8,18,16,22). Approximately 10
percent of patients will develop chronic constant pain (9).
The BCCA whiplash experience is best summarized by Eni in a retrospective study of 805 patients managed by
chiropractic doctors in British Columbia (4). The major findings are:

    •   Chiropractic intervention within 10 days of the accident achieved the highest rate of recovery when
        compared to chiropractic patients seen after a long delay from the date of injury.
    •   The average length of time from the date of injury to the initial chiropractic visit was 2.5 months.
    •   Increased delay for the initial chiropractic visit resulted in higher costs.
    •   A mean of 16 visits were required over an average of 5 months to achieve recovery (59%) or partial
        recovery (19%) in 78 percent of patients.

Chiropractic Scope of Practice
Chiropractic training emphasizes the diagnosis and management of patients with mechanical disorders of the
spine and their related effects on the nervous system (3). Of importance is the compelling evidence that chronic
neck pain and headache following a whiplash injury often arise from the cervical spine facet joints (zygapophyseal
joints)(1,2,14,15). Chiropractic adjustments (manipulation) target mechanical dysfunction of zygapophyseal joints
(13). Of significance, in the treatment of WAD, adjustment is considered a form of patient “activation” along with
exercise and mobilization (21). Accordingly it is not surprising that chiropractic care achieves good results for
many WAD sufferers including patients who do not respond to orthodox medical management (4,12,32).

Additional aspects of chiropractic intervention such as prescribing exercise, lifestyle counseling and occupational
and ergonomic advice also aid in patient recovery (3). If indicated, additional diagnostic tests might be ordered
such as radiographs or patients might also be referred to another health professional.

While spinal adjustments are a common chiropractic approach to treatment there are several other interventions
that do not involve adjustments (3). Further, chiropractors use mobilization and other therapeutics such as
electrotherapy and ultrasound and are thus able to manage and treat patients with non-spine related injuries as
well.

Outcomes Management
The goals of WAD management include:
•   Improving on the natural history of an injury
•   Restoring patients to their normal or pre-accident activity levels
•   Preventing recurrent or chronic symptoms

To attain these goals practitioners must skillfully guide both the patient’s injury(s) as well as the patient through
the various phases of healing that might otherwise be incomplete. Here an important tool to assist the doctor is
outcomes assessment and management.

Outcomes management for WAD is a patient-centred approach to making clinical decisions. It uses patient
generated information, outcomes assessment, to enhance patient care towards a meaningful outcome, to the
patient (10). Following a history, examination, diagnosis (Appendix F) and WAD grading (Appendix A-1),
outcomes assessment provides the doctor with a starting point, a measurement of the impact of the injury on the
patient’s functional status. The chiropractor, in partnership with the patient, is then able to develop a
management/care strategy that involves treatment planning and collecting information (outcomes assessment) on
the patient’s progress in functional status. Outcomes assessment measures whether anticipated improvement is
occurring and if treatment objectives are being met. Insufficient improvement on repeat assessments will alert the
doctor to review or change the management strategy. In addition, outcome assessment will help to establish if
maximum therapeutic benefit has been attained (Management Algorithm-Appendix A-2).

The following outcomes assessment instruments have been found to be valid, reliable and responsive to changes
in pain intensity or functional status of patients with whiplash or low back pain (24,25,29, 32). These include the
Visual Analogue Scale (VAS) for the measurement of pain and the Neck Disability Index (NDI) and the Roland
Morris Questionnaire (RMQ) for the measurement of function (Appendices C, D and E). A test is valid if it
accurately measures what it is intended to measure. A reliable test consistently measures a condition. Lastly, a
test is responsive if with repeated use it can measure change, over time (10). The VAS and these ‘condition-
specific’ measurement tools give meaningful information for WAD management and are therefore recommended
by the BCCA for use in the management of WAD.



                                                        Page 2
The BCCA recommends that outcome assessments be performed on initial visit and thereafter every three weeks
unless, subject to improvement or a trial of care withdrawal, the patient is being followed less often. Assessments
might also be obtained when a patient experiences an acute ‘flare-up’. To objectively measure changes in score
patients should not be advised of their previous scores or be aware of how each instrument is scored. If after two
consecutive assessments (six weeks) a minimal clinically important difference is not attained then other care
options, referral or discharge should be considered (see Appendices C, D and E). For the purposes of these
guidelines the minimal clinically important difference (MCID) may be defined “as the smallest change that is
important to patients” (28).

A pain drawing (Appendix B) is also recommended by the BCCA. Although the pain drawing is not an outcome
measure it pictorially captures the patient’s verbal pain description and records it in the file (33).

Treatment Plan
An important step in achieving successful patient outcomes and improving upon the natural history is to develop
an individualized treatment plan that optimizes the patient’s healing requirements for each phase of the healing
process. Tissue healing normally progresses through three phases, inflammatory, repair and remodeling.
Treatment planning should recognize and support each phase of the patient’s healing process. The treatment
plan sets objectives, helps determine the methods of achieving those objectives as well as estimates the time
required. It follows naturally that in-office care will initially be more frequent to decrease inflammation, hasten
repair and promote tissue remodeling. As the healing progresses, complete repair and remodeling require a
transition to self-care and less frequent in-office care.

Types of Care
The BCCA recognizes three types of clinically necessary care in the management of WAD. These are
therapeutic, supportive and palliative care.
          1.      Therapeutic care refers to care that improves the patient’s health status to the maximum
therapeutic benefit or is necessary to re-establish the maximum therapeutic benefit following acute or intrusive
episodes of symptoms and decreased function.
          2.      Supportive care is defined as care necessary to sustain maximum therapeutic benefit following a
trial of care withdrawal in which a patient’s chronic symptoms and functional status significantly deteriorate.
Supportive care is subsequent to patients complying with appropriate exercise regimens, lifestyle modifications
and home-based self-care. This form of care is inappropriate if it leads to dependence on the practitioner,
somatization, illness behaviour or secondary gain.
          3.      Palliative care relieves chronic symptoms and maintains improvement but does not increase the
patient’s long term functional status and is provided on a ‘pre-requisite necessary’ basis. It is important to
document the type of care needed and communicate this to the patient.

Chiropractic Review Panel
To help practitioners manage more complicated cases the BCCA has appointed a Chiropractic Review Panel.
The purpose of the panel is to act as a resource for doctors to consult with on difficult cases especially for those
who remain off work. Early intervention is extremely important to minimize the risk of chronic problems (see
Appendix G). The BCCA therefore advises practitioners to obtain a patient file review by an independent
Chiropractic Review Panel for patients who remain off work at three weeks post initial chiropractic consultation.
After completing a file review the Panel will make recommendations on further patient management to the
practitioner. In conjunction with the Panel’s recommendations, patients who remain off work at six weeks post
initial chiropractic visit should be considered for a multi-disciplinary evaluation comprised of functional capacity,
orthopedic and psychological tests as well as a workplace assessment. However, appropriate chiropractic care
would continue during file review or other evaluations.

Documenting Whiplash-Associated Disorders and Outcomes
To further assist practitioners in documenting patients’ injuries and clinical course two new report forms have
been developed for use with these guidelines (Appendix H and I). These include a First Report and a Progress
Report. The First Report (Appendix H-1) is a concise record of the patient’s motor vehicle accident history,
examination findings, diagnoses and management plan. It is also designed to capture relevant information
pertaining to the impact of the injury on the patient’s functional status and quality of life. In addition, the First
Report will facilitate communication with insurers such as ICBC or the Chiropractic Review Panel.

The Chiropractor’s Progress Report (Appendix I-1) summarizes improvement in the patient’s pain, functional
status and response to treatment. The “Complicating/Delayed Recovery Factors” section helps practitioners


                                                         Page 3
review important factors for patients whose treatment objectives are not being met within a reasonably estimated
time period.

Summary
The “Clinical Guidelines for the Management of Whiplash-Associated Disorders” serve as a practitioner tool to
improve the patient management and outcomes for motorists who sustain a whiplash-associated disorder. They
will evolve by necessity as newer research increases our understanding of the nature and treatment of these
injuries.*

References
1. Barnsley, L., Lord, S. and Bogduk, N. Clinical review: Whiplash injury. Pain 1994;58:283-307.
2. Barnsley, L. et al. The prevalence of chronic cervical zygapophysial joint pain after whiplash. Spine
   1995;20(1):20-26.
3. Breen, A. The chiropractic treatment of painful conditions: a review of scope and limitation. Pain Reviews
    1996;3:293-305.
4. Eni, G. A retrospective examination of chiropractic treatment of whiplash injury in British Columbia. JCCA:
    Accepted for publication.
5. Fairbank, J., Couper, C., Davies, J. and O’brien, J. The Oswestry Low Back Pain Disability Questionnaire.
    Physiotherapy 1980;66(18):271-273.
6. Freeman, M. et al. A review and methodologic critique of the literature refuting whiplash syndrome. Spine
    1999;24(1):86-96.
7. Freeman, M., Croft A., Rossignol A. “Whiplash Associated Disorders (WAD)-Redefining Whiplash and Its
    Management” by the Quebec Task Force: A Critical Evaluation. Spine 1998;23:1043-9.
8. Gargan, M. and Bannister, G. The rate of recovery following whiplash injury. Eur Spine J 1994;3:162-164.
9. Gargan, M. and Bannister, G. Long-term prognosis of soft-tissue injuries of the neck. J. Bone and Joint Surg.
    Br. 1990;72:901-903.
10. Hansen, D., Mior, S.and Mootz,.R. Why outcomes? Why now? In: The Clinical Application of Outcomes
    Assessment. S. Yeomans, ed. Stamford, Connecticut: Appleton & Lange; 2000:3-14.
11. Hsieh, C-Y., Phillips, R., Adams, A. and Pope, M. Functional Outcomes of Low Back Pain: Comparison of
    Four Treatment Groups in a Randomized Controlled Trial. J Manipulative Physiol Ther 1992;15:4-9.
12. Khan, S., Cook, J., Gargan, M. and Bannister, G. A symptomatic classification of whiplash injury and the
    implications for treatment. The Journal of Orthopaedic Medicine 1999;21(1):22-25.
                                                                          st
13. Kirkaldy-Willis, WH. Manipulation. In: Managing Low Back Pain. 1 ed. New York, NY; Churchill
    Livingstone, 1983:175-183.
14. Lord, S. et al. Third occipital nerve headache: a prevalence study. Journal of Neurology, Neurosurgery, and
    Psychiatry 1994;57:1187-90.
15. Lord, S., Barnsley, L. and Bogduk, N. Cervical zygapophyseal joint pain in whiplash injuries. Spine: State of
    the Art Reviews 1998;12:301-322.
16. Maimaris, C., Barnes, M. and Allen, M. ‘Whiplash injuries’ of the neck: a retrospective study. Injury
    1988;19:393-396.
17. Malanga, G. Cervical Flexion-Extension/Whiplash Injuries. Spine: State of the Art Reviews 1998;12(2):xi.
18. Norris, S. and Watt, I. The prognosis of neck injuries resulting from rear-end vehicle collisions. The Journal
    of Bone and Joint Surgery 1983;65-B(5):608-611.
19. Parker, H., Wood, L. and Main, C. The use of the pain drawing as a screening measure to predict
    psychological distress in chronic low back pain. Spine 1995;20:236-243.
20. Position Statement: The Quebec Task Force Monograph on Whiplash-Associated Disorders (WAD)-
    Redefining “whiplash” and its management. The BCCA 1997, Richmond, British Columbia.
21. Quebec Task Force on Whiplash-Associated Disorders (WAD). Redefining “whiplash” and its management.
    Societe de l’assurance automobile du Quebec. Quebec City, 1995, Chapter 5.3.3:3-4.
22. Radanov, B., Sturzenegger, M. and Giuseppe Di Stefano, M. Long-term Outcome after Whiplash Injury.
    Medicine 1995;74(5):281-297.
23. Riddle, D., Stratford, P. and Binkley, J. Sensitivity to Change of the Roland-Morris Back Pain Questionnaire:
    Part 2. Physical Therapy 1998;78:1197-1207.
24. Roland, M. and Morris, R. A Study of the Natural History of Back Pain. Part I: Development of a Reliable and
    Sensitive Measure of Disability in Low-back Pain. Spine 1983;8:142-144.
25. Roland, M. and Morris, R. A Study of the Natural History of Low-Back Pain. Part II: Development of
    Guidelines for Trials of Treatment in Primary Care. Spine 1983;8:145-150.
26. Sackett, D. Evidence-based medicine. Spine 1998;23(10):1085-1086.
27. Spitzer, W. Scientific Monograph of the Quebec Task Force on Whiplash-Associated Disorders: Redefining
    “Whiplash and Its Management. Spine 1995; Supplement;20(8S):22S-23S.

                                                      Page 4
28. Stratford, P., Binkley, J., Riddle, D., Guyatt, G. Sensitivity to Change of the Roland-Morris Back Pain
    Questionnaire: Part 1. Physical Therapy 1998;78:1186-1196.
29. Teasell, R. and Merskey, H. The Quebec Task Force on whiplash-associated disorders and the British
    Columbia Whiplash Initiative: A study of insurance industry initiatives. Pain Res Manage 1999;4:141-149.
30. Vernon, H. and Mior, S. The Neck Disability Index: A study of reliability and validity. J Manipulative Physiol
    Ther 1991;14:409-415.
31. Weatherston, N. Insurance and disability management. Recovery 1998:9(4):IV-V.
32. Woodward, M., Cook, J., Gargan, M. and Bannister, G. Chiropractic treatment of chronic ‘whiplash’ injuries.
    Injury 1996;27(9):643-645.
33. Yeomans, S. In: The Clinical Application of Outcomes Assessment. Stamford, Connecticut: Appleton &
    Lange; 2000:69-71.

Suggested Reading
1. Cervical Flexion-Extension/Whiplash Injuries. Spine: State of the Art Reviews. Malanga, G., ed.
   Philadelphia, PA.: Hanley & Belfus Inc.; 1998.
2. The Clinical Application of Outcomes Assessment. Yeomans, S. Stamford, Connecticut: Appleton & Lange;
   2000.

*Next revision November 2003.




                                                       Page 5
                                                     Appendix

A. Grading WAD and Management Algorithm
The grading of whiplash-associated disorders is adopted from the QTF consensus document (Appendix A-1) (27).
However, as our understanding of WAD improves the grading system might also be redefined.

Algorithms are a convenient way to illustrate and understand patient management and clinical decision making
(Appendix A-2). The “Algorithm for the Management of WAD” encompasses the outcomes management
pathways discussed in these guidelines.

B. Pain Drawing
The pain drawing is self-administered and consists of a front and back outline of a body (Appendix B-1). Patients
are asked to depict the extent and distribution of their symptoms on the drawing using various symbols to indicate
ache and pain, pins and needles as well as numbness. Research indicates that it is not a useful tool in measuring
patients’ psychological distress and inferences in this regard should be avoided (19).

C. Visual Analogue Scale (VAS)
The Visual Analogue Scale (Appendix C-1) is a one hundred millimeter line with “anchors” at both ends. The left
anchor states “no pain at all” and the right anchor states “pain as bad as it could be”. Patients are asked to draw
a perpendicular mark (not and X or an O) along the line corresponding to their present level of pain. It is quick
and easy to administer and scoring is from the left anchor and measured in millimeters. The percentage of
improvement is the difference between the initial and subsequent(s) measures divided by the initial measure and
multiplied by 100.

Example:

Initial VAS
(No pain at all) 0                                                                   10 (Pain as bad as it could be)

Subsequent VAS
(No pain at all) 0                                                                   10 (Pain as bad as it could be)


Initial – Subsequent (mm) X 100 = Percentage Change
      Initial (mm)

62mm-40mm X 100 = 28%
  62mm

The main purpose of the VAS is to document improvement in the patient’s pain. Presently, there is no minimal
clinically important difference (MCID) for the VAS. It therefore is the patient’s judgement whether or not an
important difference has occurred. Caution must be emphasized against over-interpreting any improvement. For
example, a patient whose original score is 20mm, and subsequent score is 10mm, has technically improved by
50%. However, is this meaningful to the patient?

D. Neck Disability Index (NDI)
The Neck Disability Index (Appendix D-1) consists of ten sections. A point value from 0 to 5 is scored for each of
the 10 sections. Therefore, the maximum total score is 50. If all 10 sections are completed then the percentage
disability is obtained by simply doubling the score. If the patient omits a section then the patient’s score is divided
by the number of sections scored and multiplied by 5. This figure is subsequently multiplied by 100 to arrive at a
percentage disability.

The minimal clinically important difference (MCID) for the NDI has not yet been studied. For the present, the
MCID for the NDI is 10 percent.




                                                        Page 6
Example
Section 2-Personal Care (Washing, Dressing, etc.)                             Point Value
A.   I can look after myself normally without experiencing extra pain.              0
B.    I can look after myself normally but it causes extra pain.                    1
C.    It is painful to look after myself and I am slow and careful.                 2
D.    I need some help but manage most of my personal care.                         3
E.    I need help every day in most aspects of self-care.                           4
F.    I do not get dressed; I wash with difficulty and stay in bed.                 5

       Patient's Score                       x 100 = Percentage Disability
Number of Sections Completed x 5

Score Interpretation*
0%-20%                        Minimal Disability     The patient can cope with most activities of daily living.
20%-40%                       Moderate Disability    The patient experiences more pain and difficulty with activities of
                                                     daily living as well as work.
40%-60%                       Severe Disability      The patient’s pain interferes with work, personal care, social life
and sleep.
60%-80%                       Crippled               Patient’s pain interferes with all aspects of the patient’s life.
80%-100%                                             The patient is either bed-bound or exaggerating their symptoms.
*Adapted from Fairbank et al (5).

E. Roland Morris Questionnaire (RMQ)
The RMQ is a 24-item questionnaire (Appendix E-1) derived from the Sickness Index Profile (136 items)(24). The
evidence suggests that the RMQ is more sensitive to change in sub-acute low back pain patients than the
Oswestry Low Back Pain Disability Questionnaire and is therefore more appropriate for a chiropractic patient
population (11). Patients are asked to mark only the sentences that describe their activities on that day. The sum
of the marked items equals the score with a maximum score of 24.

A MCID has been studied for the RMQ (28). In relation to subsequent assessments the initial RMQ score must
be taken into account (23). Improvement of 4 points or more for patients who initially score 9 to 24 on the RMQ is
considered a minimal clinically important difference. The MCID for patients who score 8 or less on initial visit is 1-
2 points (28).

F. Chiropractic History and Physical Examination
The Chiropractic History and Physical Examination ‘forms’ (Appendix F-1) are included in these guidelines only as
a reference for practitioners. It is recognized that examination tests are determined by the patient’s history. The
minimum requirements for examining and grading a cervical or lumbar spine disorder is spinal range of motion,
neurological examination (sensory, motor and reflexes) as well as palpation findings.

G. Factors Potentially Associated with Chronic Pain
This information is included as reference material (Appendix G-1) to assist the doctor in completing the
Chiropractor’s Progress Report (Complicating/Delayed Recovery Factors).

H. Motor Vehicle Accident-First Report
The BCCA strongly recommends the use of this form for all patients sustaining injuries related to motor vehicle
accidents.

I. Motor Vehicle Accident-Progress Report
The BCCA recommends completing this report every three months or when a significant change in managing the
patient is necessary such as at maximum therapeutic benefit or discharge.




                                                          Page 7
A-1 Grading Whiplash-Associated Disorders*

Clinical Presentation                                                      Grade**
No complaint about the neck
No physical sign(s)                                                          0
Neck complaint of pain, stiffness, or tenderness
No physical sign(s)                                                          I
Neck complaint and musculoskeletal sign(s)
which include decreased range of motion and tenderness                       II

Neck complaint and neurological sign(s)
which include decreased or absent deep tendon
reflexes, weakness and sensory deficits                                      III
Neck complaint and fracture or dislocation                                   IV

*Adapted from Spitzer et al (27).
**Symptoms and disorders such as deafness, dizziness, tinnitus, headache, memory loss, dysphagia, and temporomandibular joint pain may
be present in any grade.




                                                                Page 8
B-1   Pain Drawing
Patient Name:                                               Date:




                     Use letters below to indicate type and location of discomfort
                     A = ACHE                 B = BURNING             C = STABBING
                     N = NUMBING              P = PINS & NEEDLES      O = OTHER




                                                   Page 9
                                       INITIAL VISIT
                               Initial Outcomes Assessments
                              History, Physical Examination,
          A-2                 THE MANAGEMENT OF WAD
                ALG0RITHM FOR Diagnosis and Management Plan



                Grade I-III                                         Grade IV
                  WAD                                                WAD




                 Treatment                                             Refer




                Chiropractor’s
5 DAYS
                 First Report



            Outcomes Assessment
            Every Three Weeks



                                                            Chiropractic Review
21 DAYS          Off Work?                Yes                      Panel



                  Treatment                                    Recommendations



                                                                Multidisciplinary
42 DAYS           Off Work?               Yes                     Evaluation



                 Chiropractor’s
90 DAYS         Progress Report




                                                            Supportive or Palliative Care,
          Maximum Therapeutic Benefit?          Yes             Refer or Discharge



          Continue Therapeutic Care




                                                         Page 10
C-1      Visual Analogue Scale

Patient's Name:                                            Date:



Please place a mark through the line below that most accurately represents the pain you are experiencing at this
moment. Please note the expressions at either end of the line.




(No pain at all) 0                                                               10 (Pain as bad as it could be)




                                                     Page 11
SECTION 1 - PAIN INTENSITY                                                              SECTION 6 – CONCENTRATION
  I have no pain at the moment.                                       0 I can concentrate fully without difficulty.
                              NECK DISABILITY INDEX
  The pain is D-1 mild at the moment.
                  very                                                 1 I can concentrate fully with slight difficulty.
  The pain is moderate at the moment.                                 2 I have a fair degree of difficulty concentrating.
  The pain is THIS QUESTIONNAIRE IS DESIGNED TO HELP US BETTER UNDERSTAND HOW YOUR concentrating.
                  fairly severe at the moment.                         3 I have a lot of difficulty NECK PAIN AFFECTS YOUR ABILITY TO
  The pain is very severe at the moment.                              4 I have a great deal of difficulty concentrating.
                 MANAGE EVERYDAY -LIFE ACTIVITIES. PLEASE MARK IN EACH SECTION THE ONE BOX THAT APPLIES TO YOU. ALTHOUGH
  The painPERSONAL CARE
               is the worst imaginable at the moment.                  5 I can't concentrate at all.
SECTION 2 - YOU MAY CONSIDER THAT TWO OF THE STATEMENTS IN ANY ONE SECTION RELATE TO YOU, PLEASE MARK THE BOX THAT
                                                                       SECTION 7 – SLEEPING
  I can look after myself normally without causing PRESENT -DAY SITUATION.
                 MOST CLOSELY DESCRIBES YOUR
   extra pain.                                                         0 I have no trouble sleeping.
  I can look after myself normally, but it causes                     1 My sleep is slightly disturbed for less than 1 hour.
   extra pain. q                                                       2 My sleep is mildly disturbed for up to 1-2 hours.
  It is painful to look after myself, and I am slow                   3 My sleep is moderately disturbed for up to 2-3 hours.
   and careful.                                                        4 My sleep is greatly disturbed for up to 3-5 hours.
  I need some help but manage most of my personal care.               5 My sleep is completely disturbed for up to 5-7 hours.
  I need help every day in most aspects of self -care.
  I do not get dressed. I wash with difficulty and
   stay in bed.


SECTION 3 – LIFTING                                                                     SECTION 8 – DRIVING
  I can lift heavy weights without causing extra pain.                                 0  I can drive my car without neck pain.
  I can lift heavy weights, but it gives me extra pain.                                1  I can drive as long as I want with slight neck pain.
  Pain prevents me from lifting heavy weights off                                      2  I can drive as long as I want with moderate neck pain.
  the floor but I can manage if items are conveniently                                  3  I can't drive as long as I want because of moderate
  positioned, ie. on a table.                                                              neck pain.
 Pain prevents me from lifting heavy weights, but I                                    4 I can hardly drive at all because of severe neck pain.
  can manage light weights if they are conveniently                                     5 I can't drive my care at all because of neck pain.
  positioned
 I can lift only very light weights.
 I cannot lift or carry anything at all.
                                                                                       SECTION 9 – READING

Section 4 – Work                                                                       0  I can read as much as I want with no neck pain.
                                                                                       1  I can read as much as I want with slight neck pain.
    I can do as much work as I want.                                                  2  I can read as much as I want with moderate neck pain.
    I can only do my usual work, but no more.                                         3  I can't read as much as I want because of moderate
    I can do most of my usual work, but no more.                                         neck pain.
    I can't do my usual work.                                                         4 I can't read as much as I want because of severe
    I can hardly do any work at all.                                                     neck pain.
    I can't do any work at all.                                                       5 I can't read at all.


SECTION 5 – HEADACHES                                                                   Section 10 – Recreation
    I have no headaches at all.                                                        0    I have no neck pain during all recreational activities.
    I have slight headaches that come infrequently.                                    1    I have some neck pain with all recreational activities.
    I have moderate headaches that come infrequently.                                  2    I have some neck pain with a few recreational activities.
    I have moderate headaches that come frequently.                                    3    I have neck pain with most recreational activities.
    I have severe headaches that come frequently.                                      4    I can hardly do recreational activities due to neck pain.
    I have headaches almost all the time.                                              5    I can't do any recreational activities due to neck pain.



                                 Patient Name _______________________________________                         Date _____________

    SCORE      __________ [50]

    Copyright: Vernon H. and Hagino C., 1987. Vernon H, Mior S. The Neck Disability Index: A study of reliability and validity.
    Journal of Manipulative and Physiological Therapeutics 1991; 14:409-415. Copied with permission of the authors.




                                                                                          Page 12
       BACK ROLAND MAY FIND UESTIONNAIRE
  YOURE-1 HURTS YOUMORRIS QIT DIFFICULT TO PERFORM MANY ACTIVITIES THROUGHOUT THE DAY. STATEMENTS
D BELOW HAVE BEEN USED BY PEOPLE TO DESCRIBE THOSE TIMES WHEN THEY ARE EXPERIENCING BACK PAIN. AS YOU READ
                                    DESCRIBE YOUR PAIN TODAY. THEREFORE, PLEASE CHECK Date ___________
  SOME MAY STAND OUT BECAUSE THEYPatient Name ____________________________ THE BOX THAT BEST
 IBES YOUR PAIN TODAY. IF THE SENTENCE DOES NOT FIT, THEN JUST LEAVE IT BLANK AND MOVE ON TO THE NEXT ONE.




              q   I STAY AT HOME MOST OF THE TIME BECAUSE OF MY BACK.
              q   I CHANGE POSITIONS FREQUENTLY TO TRY TO GET MY BACK COMFORTABLE.
              q   I WALK MORE SLOWLY THAN USUAL BECAUSE OF MY BACK.
              q   BECAUSE OF MY BACK, I AM NOT DOING ANY OF THE JOBS THAT I USUALLY DO AROUND THE HOUSE.
              q   BECAUSE OF MY BACK, I USE A HANDRAIL TO WALK UPSTAIRS.
              q   BECAUSE OF MY BACK, I LIE DOWN TO REST MORE OFTEN.
              q   BECAUSE OF MY BACK, I HAVE TO HOLD ON TO SOMETHING TO GET OUT OF MY CHAIR.
              q   BECAUSE OF MY BACK, I TRY TO GET OTHER PEOPLE TO DO THINGS FOR ME.
              q   I GET DRESSED MORE SLOWLY THAN USUAL BECAUSE OF MY BACK.
              q   I ONLY STAND UP FOR SHORT PERIODS OF TIME BECAUSE OF MY BACK.
              q   BECAUSE OF MY BACK, I TRY NOT TO BEND OR KNEEL DOWN.
              q   I FIND IT DIFFICULT TO GET OUT OF A CHAIR BECAUSE OF MY BACK.
              q   MY BACK IS PAINFUL ALMOST ALL THE TIME.
              q   I FIND IT DIFFICULT TO TURN OVER IN BED BECAUSE OF MY BACK.
              q   MY APPETITE IS NOT VERY GOOD BECAUSE OF MY BACK PAIN.
              q   I HAVE TROUBLE PUTTING ON MY SOCKS OR STOCKINGS BECAUSE OF MY BACK .
              q   I ONLY WALK SHORT DISTANCES BECAUSE OF MY BACK PAIN.
              q   I DON'T SLEEP WELL BECAUSE OF MY BACK.
              q   BECAUSE OF MY BACK PAIN, I GET DRESSED WITH HELP FROM SOMEONE ELSE.
              q   I SIT DOWN FOR MOST OF THE DAY BECAUSE OF MY BACK.
              q   I AVOID HEAVY JOBS AROUND THE HOUSE BECAUSE OF MY BACK.
              q   BECAUSE OF MY BACK PAIN, I AM MORE IRRITABLE AND BAD –TEMPERED WITH PEOPLE THAN USUAL.
              q   BECAUSE OF MY BACK PAIN, I WALK UPSTAIRS MORE SLOWLY THAN USUAL.
              q   I STAY IN BED MOST OF THE TIME BECAUSE OF MY BACK.

              score ________ [24]




                                                                 Page 13
F-1     Chiropractic History and Physical Examination

A) History
Includes:
•     history of present accident including mechanism of injury
•     history of previous accidents or injuries
•     history of previous neck – back conditions – length of time for recovery
•     history of work loss due to previous neck – back conditions
•     history of previous treatment
•     general health medical history
•     current complaints
•     pain quality, quantity, radiation severity and timing
•     aggravating and relieving factors
•     effects on ability to work
•     effects on activities of daily living
•     medications

B) Examination
Includes:
•     active range of motion
•     passive range of motion
•     reflexes
•     sensation
•     motor power
•     palpation – vertebral – soft tissue

Might also include:
•     resisted ranged of motion
•     foramen compression tests
•     facet joint compression tests
•     vertebral artery tests
•     brachial plexus stretch tests
•     peripheral joints exam
•     Waddell’s signs

C) X-rays
•     A minimum study of cervical spine consists of an anterior-posterior, open mouth and lateral views. Oblique
      views may be required in cases of suspected neurological deficits. Flexion-extension views may be
      necessary for bio-mechanical instability, dislocation and fractures.

D) Diagnosis
•     Must be consistent with mechanism of injury and history and examination findings.

E) Treatment Plan
•     Includes identifying functional limitations, treatment objectives, methods of achieving objectives, re-
      examination times and overall estimated time to meet objectives. Should include a mix of passive and active
      modalities with patient self-management strategies and an emphasis on early return to work/usual activities.




                                                        Page 14
G-1     Factors Potentially Associated with Chronic Pain

A) Yellow Flags (Psychosocial):

•     presence of a belief that back pain is harmful or potentially disabling
•     fear-avoidance behaviour and reduced activity levels
•     tendency to low mood and withdrawal from social interaction
•     an expectation that passive treatments rather than active participation will help
•     job dissatisfaction
•     multiple different providers previously for same condition

B) Red Flags:

•     sedative/hypnotic use
•     narcotic use
•     multiple caregivers
•     major affective disorders
•     previous significant time loss work




                                                         Page 15
                                   Motor Vehicle Accident - First Report
Claim Number:

Surname of Patient:                                             Given Name:
Address:

Date of Birth (mm/dd/yy):                                       Gender:            Male         Female
Occupation:                                            Adjuster's Name

Date of Accident (mm/dd/yy):                                      Date of this Examination (mm/dd/yy):

Patient was seated: driver's seat, passenger, right rear, left right, other

AS A RESULT OF THE ACCIDENT, THE PATIENT:

Sustained a loss of consciousness:                Yes               No
    If Yes, duration and patient's description:
Complains of neck pain?                           Yes               No
Complains thoracic pain?                          Yes               No
Complains of low back pain?                       Yes               No
Complains of secondary symptoms?                  Yes               No
Was a seat belt used?                             Yes               No

Type:   3-point over shoulder               Lap               Other 

Did any part of their body make contact with the interior of the vehicle?              Yes          No
If Yes, describe contact:

Was the patient looking straight ahead at time of impact?                Yes       No
If No, describe position:

First care was given at:        hospital        this office        other:

Have any X-rays been taken?                No                 Yes
        If Yes, results:

Received any medication?          Yes           No      If yes, list:
What was the patient's pre-accident health status?

Symptoms and other Injuries:

Examination Findings (spinal ranges of motion, upper or lower extremities sensory, motor or reflex changes,
positive orthopaedic tests and palpation findings:




Radiographic/Other Diagnostic Test Findings:




VAS Score:                 NDI Score:               Oswestry Score:                        RMQ Score:



                                                           Page 16
                                     Motor Vehicle Accident - First Report


WAD Classification: (Grade I, II, III or IV)

Cervical Spine:                  Thoracic Spine:                     Lumbar Spine:

Current Pain Frequency Levels and Location:
Constant (76-100%):                                       Frequent (51-75%):

Occasional (26-50%):                                      Intermittent (25% or less):

Current Function

1) Full function without symptoms:             Yes          No

2) Full function with symptoms:                Yes          No

3) Less than full function due to symptoms and/or functional deficit:         Yes         No

4) Significant limitation in function:         Yes          No

Current Work Capacity
In my opinion, the patient is able to:

    Work full duties             Work modified duties           Unable to work at any job

If unable to return to work, state why and expected return or re-assessment date:



Management Plan (circle)
1)    Maintain usual activities.
2)    Limit usual activities. How long?
3)    Treatment frequency per week and for how long?
4)    Exercise - specify:
5)    Prescribed splints/supports - specify:

6)    Referral required?          Yes         No     If yes, practitioner:
7)    Anticipated duration of in-clinic care:
8)    Re-examination date:

Patient Authorization
I hereby authorize the release of this report to the Insurance Corporation of British Columbia and legal
representative in support of my claim.

Signature:                                                         Date:

Chiropractor:
Address:
Phone:                                          Fax:
Signature:                                                         Date:


                                                          Page 17
                                    Motor Vehicle Accident - Progress Report

Date:                                                            Claim Number:

Patient's Name:
Current Clinical Status:
VAS Score:                 NDI Score:               Oswestry Score:                 RMQ Score:

Current Pain Frequency Levels and Location:
Constant (76-100%)                                        Frequent (51-75%):
Occasional (26-50%)                                       Intermittent (25% or less):

Symptoms:




Examination Findings:




Complicating / delayed recovery factors
1)   Symptom flare-up :
2)   Second (new) injury:
3)   Prolonged static posture/activities, home/work:
4)   Significant delay in initiating chiropractic treatment. If so, why?:
5)   Pre-existing health condition(s):

Recovery status Since last report this patient’s condition has:

    Improved          Not improved          Worsened

Patient outcomes (refer to BCCA/ICBC Guidelines page 2):

          Recovered to pre-injury status
          Patient requires further chiropractic care
          Has reached maximum recovery, with persistent symptoms that require supportive or paliative care;
           rehabilition; or multidisciplinary evaluation. (Attach details).
           Referral required       Yes          No     If Yes, to practitioner:

Current Management Plan
Future treatment required:
Expected frequency and duration:
Expected discharge date:

Patient Authorization
I hereby authorize the release of this report to the Insurance Corporation of British Columbia and legal
representative in support of my claim.

Signature:                                                       Date:
Chiropractor:                                                    Date:
Address:                                                     Phone:                         Fax:

                                                          Page 18

				
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