Summary of Submissions - Draft Australian Clinical Guidelines for Health Professionals Managing People with Whiplash-Associated Disorders

• Abbreviations and jargon need to be removed so the chart is accessible for non-specialists, including nurses and Aboriginal and Torres Strait Islander Health Practitioners.
• Removing visual analogue scale and its association and expectation that pain level can be zero is even more important in chronic pain.

The flow charts give a timeline of management over a 12-month period. Management continues for much longer than this.

The Canadian C spine rule has been included in the Diagnosis Section of the Guidelines.
Clarity has been added to ensure the rule is followed to refer for imaging (which in turn diagnoses fracture) rather than to just classify WAD.
Amended text:

• "A positive result is an indication to refer for imaging to determine possible cervical fracture.”
• “Subgroup of WAD IV is determined by imaging if positive for cervical fracture.”
• “If a cervical fracture is confirmed by imaging there should be urgent referral to a Hospital Emergency Department or immediate surgical consultation.”

There appears to be selective literature bias and a disregard of a substantial body of literature on the application of medial branch blocks and RFN for WAD. There is strong evidence and comparative data supporting RFN, yet a recommendation against it has been made. The only trial that was considered was a single study by Lord et al. in 1996, which was incorrectly described as a small pilot trial. The study followed a prior pilot trial and was adequately powered to detect a statistically significant difference in the clinical setting where there is a large difference in outcomes between the control and the intervention group.
There is extensive literature and many publications that support RFN in facetogenic pain which have not been mentioned. These include:

• Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP)
• Guidelines Facet Joint Interventions 2020 Guidelines
• Consensus practice guidelines on interventions for cervical spine (facet) joint pain in Regional Anaesthesia and Pain Medicine in 2022 by a multispecialty international working group.
• Landmark studies by Lord et al in 1996, 1999 and 2003.
• Review by Eseonu and colleagues looking at the utility of facet joint injections in whiplash associated spinal pain.
• Study by Manchikanti L and colleagues on therapeutic cervical medial branch blocks administered for proven cervical facetogenic pain.
• Rydman and colleagues’ longitudinal study regarding cervical degeneration.
• Malik 2021 literature review and Yang and colleagues 2010 study on cervical facet joint pain.

Multiple clinical trials have provided compelling evidence that a highly effective treatment exists that significantly reduces or eliminates pain by targeting the known pain generators. Based on the most rigorous studies using appropriate diagnostic techniques to select patients and using optimal treatment techniques of on cervical medial branch thermal RFN (CMBTRFN):

• Over 60% of patients treated with CMBTRFN can expect to be pain-free at 1 year with restoration of activities of daily living and no need for other health care for neck pain.
• In the event of a recurrence of pain, complete relief can be reinstated by repeating the treatment.
  No literature refutes any of these conclusions. SIRA should continue supporting practices that achieves such outcomes and ensure they remain available to patients.

The recommendation against evidence-based medial branch blocks and RFN treatment should be rescinded.

• Without the branch blocks I would not be able to do my role as a Clinician.
• As a patient who has obtained immediate relief as a result of these procedures, I am distressed to hear that your group is seeking to discontinue the procedure.

• “Refer for imaging to determine probable diagnosis of cervical radiculopathy” implies there is no indication to refer for imaging in other circumstances. This will lead to injuries being missed.
  There are many other indications for imaging in acute whiplash. Multiple anatomical areas and structures need to be considered even without radicular pain e.g., the cranio-cervical joint [CCJ] complex, bones, ligaments and facet joint capsules. Relevant pain syndromes that occur may include the upper cervical spine (cervico-encephalic syndrome) or lower cervical spine (lower cervical syndrome).
  Imaging should be considered if there is any concern about fracture or instability. Other aspects to consider imaging include;
• Any alteration in level of consciousness.
• Any evidence of trauma to the head or neck (“trauma above the clavicles”).
• Any evidence of intoxication.
• Any distracting painful injury elsewhere.
• Age greater than 65 years.
• High-speed rear-end motor vehicle collision.
• Focal neurologic symptoms or signs.

Clinical judgement is still the overriding principle and radiography must be carried out while ensuring mobilisation of the cervical spine.

• We have developed a list of other medical interventions that were proposed during the public consultation period and are listed in the guidelines without specific recommendations. These interventions were not identified in our systematic review of RCTs of people with WAD and were not prioritised as clinical questions in these Guidelines. These interventions, for acute WAD included:
• Alexander technique
• Antidepressant medication – specific types e.g., duloxetine
• Anticonvulsant medication – including gabapentinoids (with exception of pregabalin in acute WAD)
• Cannabis – medicinal products
• Cervical pillows
• Electrical nerve stimulation
• Heat
• Homeopathy
• Ice
• Injection techniques – other e.g., transforaminal epidural steroid injection
• Feldenkrais
• Ketamine infusion
• Lidocaine infusion
• Magnetic necklaces
• Pilates
• Shortwave diathermy
• Traction

A similar (but not identical) list was developed for chronic WAD.

Amended treatment recommendation title for amitriptyline (acute and chronic) to “Antidepressants” to be consistent with the secondary evidence that was reviewed and implementation considerations that were outlined for a broader range of antidepressant medications.
Pregabalin was left as a recommendation for acute WAD given that a small RCT was included. Short term use for pregabalin was noted due to known side effects associated with their use, particularly with long-term use. Further, a planned clinical trial will be carried out in Australia for pregabalin use for the management of acute WAD.
The draft pregabalin recommendation was removed from the chronic WAD section due to insufficient evidence.
Antiepileptics including gabapentinoids were added to the list of treatment interventions not considered in these guidelines (see previous response).
A neutral recommendation classification for simple analgesics means that it could be used in some instances provided there is clinical benefit. Lack of efficacy of this medication in chronic pain management was considered in the implementation points:
“If a person with chronic WAD is already using simple analgesia (e.g., paracetamol) for pain management, HCPs should review the prescribing and consider the following actions:

• Explain the lack of evidence for these medicines for managing chronic pain.
• Develop a shared plan in conjunction with the injured person for usage of simple analgesia if there are clinically meaningful benefits at a safe dosage.
• Explain the risks of continuing if they report little benefit or adverse effects and encourage and support them to reduce and stop the medicine if possible.”

Comments in relation to sections of the Technical Report Chapter 4: Treatment
T.9.2, page 169 – Undesirable effects

• Fernandez des la Pen 2004 – Assume cause and effect here – limited evidence for that.

T.9.3, page 172 - Recommendation

• There is no real evidence for or against. The recommendation should be that, not biased against manipulation.
• Inclusive study – 1 study with poor control. Full spine approach then recommendations based on parts of the study – inappropriate bias.
• Technique variances
• Inconclusive

T.9.4, page 174

• All assumptions, no evidence
• Relates to risk factors in diagnostics like dizziness and anterior neck pain
• Qualify recommendations to how protocol and evidence within the cited study. Why apply this bias here within the physio and manual therapy literature. The opposite is true for the CBT literature as well as the harmful medications.
• Do not provide sweeping conclusions based on one flawed study.
• Conclusions should be neither for or against the intervention.

T.18.2, page 283

• Contrast these findings with manipulation. No evidence and yet supported.
• Side effect similar to placebo

T.20, page 294

• Bias towards medication

T.20.1, page 299 – Recommendation

• Here there are no trials and the recommendation is “conditional recommendation for either the intervention or the comparison”. A similar recommendation should occur for manipulation in the absence of evidence to the contrary.

T.21.3, page 309

• Biased source
• Strong side effects, inappropriate and soft recommendation (unlike manipulation).

T.22.2, page 317

• Regarding opioids – under reporting of side effects

T.23.6, page 337 – Recommendations

• Compare these recommendations to HVLA recommendations

T.25.2, page 352

• Compare this outcome with HVLA manipulation
• Risk of surgery understated
• Bias

T.9 (HVLA manipulation recommendations):
We agree that there is inconclusive evidence (lack of high-quality studies) for manipulation techniques for the management of people with WAD. This is highlighted in the evidence summary for acute WAD where the trial is not consistent with care in an Australian context and that there was very low certainty in the evidence. The decision to make two recommendations regarding manipulation in acute WAD was made considering the evidence-to-decision framework where risks and benefits were considered. The “conditional against” recommendations do not rule out use of the procedure for individual patients, but we suggest that it should not be used for most people with whiplash. This has been clarified in the HVLA manipulation recommendations with the addition of “most”. Regarding comments on the other interventions (e.g., medications such as opioids); they should not be applied for most people with WAD and the implementation considerations for their use are stringent.

T.18 (simple analgesics):
We agree that there is no high-quality evidence for simple analgesics for the management of WAD. However, paracetamol is a first line analgesic that is widely available in an Australian context and is known to be an effective analgesic for some types of acute pain and has fewer side effects than NSAIDs.

T.20 (antidepressants recommendation):
This recommendation considered acute and chronic pain guidelines and efficacy of these medications in other pain types. Similar to the response with opioids above, subgroup considerations and indications for their use are outlined “People with suspected neuropathic/nociplastic pain and/or psychological distress who have not shown benefit with simple analgesics and NSAIDs.”

T.21 (pregabalin):
Small pilot randomised placebo-controlled trial (very low certainty in the evidence) showing clinically significant benefits of pregabalin in a specific subgroup with stringent indications for short-term use: “People who have high initial pain intensity (NRS≥5) early after whiplash injury (e.g., 48 hours post) and are suspected to have neuropathic pain.” This treatment has an upcoming planned clinical trial in Australia to evaluate its efficacy in people with WAD.

T.22 (opioid analgesics):
We do not believe we have underreported side effects “Clinically meaningful adverse effects (nausea, vomiting) of opioids are dose-related and in high doses opioids can induce hyperalgesia and/or acute tolerance.” We have also detailed additional considerations that include screening for history of drug misuse and ongoing monitoring, and contraindications for opioid use.

T.23 (multidisciplinary care):
While there is limited high quality evidence for multidisciplinary care in the context of WAD, multidisciplinary care is common practice for people who are medium/high risk of poor prognosis following whiplash injury in Australia. “Recommended treatments for managing acute WAD in these guidelines are delivered by several healthcare professions, and people with acute WAD are likely to receive multi-profession care in practice.” The risk stratified approach outlined in the whiplash injury care flowcharts in the Guidelines can be used to determine those who may benefit from multidisciplinary care, as it should not be applied to all people with acute WAD.

T.25.2 (Spinal surgery for chronic WAD and cervical radiculopathy). Risks outlined “Known significant adverse risks with cervical surgery (e.g., infection, vascular/neural damage).” The recommendation differs in this context as this is applicable to a small subgroup of people with chronic WAD and radiculopathy, rather than most people with WAD like in the HVLA recommendation.

Implementation – How to measure and interpret

• It is important to note that the PCL-5 tool, or any other self-report measure, should not be used as the primary measure for diagnosis of PTSD.
• The Primary Care PTSD Screen (PC-PTSD) is also a well-validated screening tool for PTSD to be used by psychologists and should be included in the guidelines.
• There appears to be some variability within the Guidelines for the cut-off score for a provisional diagnosis of PTSD with the PCL-5 (e.g., on pages 70 and 141). Other research specifies 38 as a raw cut-off score for a provisional diagnosis, which has high sensitivity (.78) and specificity (.98). We recommend due consideration when using the PCL-5 to screen for PTSD. It would be beneficial to thoroughly review the research around the PCL-5 cut-off points to ensure there is a strong rationale within the Guidelines for these suggestions, along with consistent statements about the cut-off points throughout the Guidelines to minimise confusion.
• It is also important to note that while a raw cut-off score is one method for determining a provisional PTSD diagnosis when using the PCL-5, the other method is to examine items rated as 2="Moderately" or higher as an endorsed symptom, then following the DSM-5-TR diagnostic rule which requires at least: 1 B item (questions 1-5), 1 C item (questions 6-7), 2 D items (questions 8-14), 2 E items (questions 15-20).
• Further, if the PCL-5 is being used to monitor symptom change over time, a minimum 10-point change represents clinically significance.

Implementation – Indications

• We agree with the position within the Guidelines that psychologists do not need to be immediately involved following a potentially traumatic experience. We recommend that people are offered practical and emotional support and encouraged to use their existing personal resources and social supports.

Implementation – What to do

• However, it is critical for psychologists to become involved with individuals who are very distressed or do not start to return to their usual functioning within the first- or second-week post trauma. We recommend reconsidering the position within the Guidelines to wait until 6 weeks to refer if PTS symptoms are not improving.
• This is particularly relevant given the ongoing and systemic workforce issues that have led to a chronic undersupply of psychologists nation-wide. Waiting until 6 weeks to make a referral to a psychologist may result in the patient waiting even longer to receive the treatment they need, thereby delaying recovery.

Implementation – Indications
We have added to the specific education information recommendations that educational information in the acute phase can include:
“Practical and emotional support for people with WAD to use their existing personal resources and social supports.”

Implementation – What to do
We agree and have amended the acute whiplash injury care flowchart and the prognosis section (PTSS) to consider assessment of PTSS and referral for psychological assessment in weeks 2-4 following injury.
For TF-CBT indications we have outlined for “People with diagnostic criteria for MVC-related PTSD.” and noted “The intervention could be provided earlier than three months, based on persons levels of distress and loss of function.”
We have removed any reference to length of time for diagnostic criteria for MVC related PTSD. See response above in relation to following recommended guidelines for diagnosing PTSD.

Implementation – How to measure and interpret

• In addition to the using the DASS-21 to measure symptoms, the DASS-42 is also recommended and can be useful to yield meaningful discrimination between symptoms.
• The in-text reference of “Guest et al., 2018” does not appear to be in the reference list of the Guidelines and hence we are unclear about the statement that a score on the DASS -21 greater than or equal to 15 out of 63 indicates a probable MDD. We assume the statement is referring to an interpretation of the raw score on the depression subscale only (i.e., out of 21), rather than a total raw score across the three subscales combined.
• Further, the statement that a DASS -21 score greater than or equal to 15 out of 63 indicates a probable MDD may be misleading, particularly as the DASS is based on a dimensional rather than a categorical conception of psychological disorders, and scores emphasise the degree to which someone is experiencing symptoms rather than having specific diagnostic cut off points.

• It is important to note that there are a variety of treatments which commonly fall under the umbrella term of trauma-focused cognitive-behavioural therapy. These interventions commonly include:
  • Trauma-focused cognitive therapy (CT-PTSD)
  • Prolonged exposure (PE)
  • Eye movement desensitisation and reprocessing (EDMR), and
  • Cognitive processing therapy (CPT)
• There is scope for the Guidelines to be more specific and expand on the well-established and evidence based recommended psychological treatments for PTSD.
  Implementation – Indications
• We are unclear about the rationale for specifying that full diagnostic criteria for MVC related PTSD cannot be met until at least six months after the trauma. The DSM-5-TR criteria specifies that PTSD can be diagnosed when the “Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month”. We therefore recommend that the Guidelines be amended from specifying “at least six months” to “more than one month” to align with the DSM-5-TR criteria for a PTSD diagnosis.
• Why is the full diagnostic criteria not met until at least six months after the trauma (when PTSD can be diagnosed one month post trauma)?
• There is an opportunity to better recognise Acute Stress Disorder (ASD) - ASD and PTSD share the same physiological and stress symptoms. However, ASD is only differentiated from PTSD by its limited duration, with symptoms present for more than three days, but less than one month. Where symptoms persist beyond a month, a diagnosis of PTSD should be considered.
  Implementation – Considerations
• A structured clinical interview to assist with making a clinical diagnosis of PTSD according to DSM-5-TR criteria is recommended.
• The following interview tools are recommended for use in the diagnosis of PTSD:
  • Clinician Administered PTSD Scale (CAPS)
  • PTSD Symptom Scale - Interview Version (PSS-I), and
  • Structured Interview for PTSD (SI-PTSD).
• It is also important to note that while self-report measures can also provide useful information at the screening stage, these should not be used as a primary tool for diagnosis as they do not routinely provide an accurate picture of a client's symptoms or their severity
• Recommend updating the Guidelines to ensure all references to the “DSM-5” are amended to refer to the most recent version, the DSM-5-TR.

Implementation

• We are unclear about the rationale to include ‘sleep quality’ within the category of jaw symptoms and upper limb disabilities. Sleep is an essential pillar of good health and while sleep disturbances may initially appear as a symptom of another disorder (e.g., depression, PTSD) or injury, this is not always the case.
• It is important to acknowledge that sleep disturbance can be an independent problem that should be assessed or treated by appropriately experienced medical practitioners, sleep physicians or psychologists.
• Note: other scales commonly used by psychologists to assess sleep disturbance include the Epworth Sleepiness Scale (ESS), STOP-BANG Sleep Apnea Questionnaire, and the Dysfunctional Beliefs and Attitudes about Sleep (DBAS).

The role of the whiplash specialist is detailed in My Whiplash Navigator and can be amended in the implementation phase.

The actions below could assist in raising awareness of the Guidelines amongst stakeholders:

• Education sessions for emergency staff as well as primary care providers with a focus on the importance of clinical assessment.
• Documentation of WAD level diagnosis and the recommended care pathways for each level of WAD.
• Updated information in SIRA’s online Treatment Advice Centre.

To assist in the application of these recommendations, it is proposed that:

• A register of whiplash specialists is developed that includes the location and qualifications of each specialist.
• The guidelines include a summary of expected timeframes for recovery pathways based on the WAD classifications.
• Consideration for the whiplash specialists to be used as a resource to provide guidance and recommendations to treating providers.

Injured people should have the appropriate supports when using prognostic tools such as WhipPredict and SF-Orebro that provide a risk stratification to the user. As these tools can be self-administered online, injured people may obtain information indicating (in Week 1) that they have a poor prognosis. This may have a detrimental psychological effect that negatively impacts recovery.
In addition, it may be beneficial if the guidelines placed a stronger emphasis on positive messaging by practitioners to encourage positive recovery strategies that may not be provided via a prognostic tool used in isolation.
icare notes that the Dissemination and Implementation Plan includes the development of CTP insurer bespoke/specific guidelines and welcomes the opportunity to take part in any consultation relating to these.