Recently on the podcast, physiotherapists Andrew Koppejan and Maxi Miciak sat down with Jeff Begg and Simon Cooke to discuss some of the common and not-so-common challenges that clinicians may encounter when treating MVA patients.
Simon is a physiotherapist and clinic owner in Edmonton, Alberta and currently serves as Council President with Physiotherapy Alberta. He was also involved in the working committee in the creation of the Diagnostic & Treatment Protocol Regulation (DTPR) for Alberta. Jeff is a physiotherapist and clinic owner from Edmonton who regularly treats MVA patients, and was also part of the working group involved in the creation of the DTPR.
This article will be covering a few key points from the discussion including:
- What is a WAD diagnosis?
- How to explain a WAD diagnosis to a client.
- How to explain to patients they may not need 21 treatments.
- Getting the diagnosis right.
- What to do when your patient isn’t progressing as expected?
- What to do if the doctor’s diagnosis is not consistent with yours?
WAD Diagnosis: Is it More Than Just the C-Spine?
Prior to the recent updates to the DTPR, injuries to the cervical spine were classified based on the Quebec Task Force on Whiplash Associated Disorders.
Spinal injuries to the thoracic and lumbar spine were previously excluded from the WAD definition. This makes sense as a ‘WAD’ injury relates to a specific mechanism of injury and type of injury sustained by the neck during a motor vehicle accident. However, this led to a gap in treatment of patients who suffered thoracic/lumbar injuries as the treatment caps were much lower for these injuries as compared to a WAD. To help improve access to treatment for these injuries under the regulations, the DTPR was amended to include thoracic and lumbar spine injuries as part of a WAD injury.
But the question arises: Is WAD to the lumbar spine an actual medical diagnosis or is it a diagnosis that was created in Alberta to better assist with patient classification under the DTPR?
Jeff Begg acknowledges that modifying the protocols to incorporate the rest of the spine helps both the practitioner and the insurance adjuster with diagnoses, and the patient get the care that they need.
However, he does admit that this new classification doesn’t help patients understand their diagnosis any better.
“[If] you tell a patient [they] have a WAD II injury of [their] lumbar spine and they Google [the injury], they are not going to find anything because the term ‘WAD’ is ‘whiplash-associated disorder,’ and whiplash is the motion that a neck goes through. The rest of your spine does not go through that motion. So… we have to be careful about [how we communicate the diagnosis to] our patients.\”
It’s possible that patients may end up confused regarding their diagnosis and it’s important to minimize the potential for patient confusion and/or information overload.
Jeff suggests that there may be two separate conversations to be had with patients. One conversation to cover the insurance side of things including the official name of their injury and the number of visits it entitles them to, and another conversation that communicates the physical diagnosis of their injuries.
Simon agrees that how you convey information, especially in the first few sessions, is important. “It sometimes is simple enough to go back to the diagnostic criteria and just say, ‘Your reflexes are normal, you have no key muscle weakness, you have no signs of any nerve injury today, you have loss of movement and you have tenderness when I touch your spine. That means that you have a WAD II injury and that then entitles you to this. It doesn’t limit you to that exclusively, this is a working diagnosis on day one but this is the information that I will then be passing on to the insurer.’”
Simon also notes that it is important to reassure the patient that you are going to communicate with them openly and answer any questions that they might have about their diagnosis going forward. “Patients are still really stuck in the tissue model, they want to know exactly what tissue is hurt, how much it’s hurt, and how long it’s going to take to recover.”
Moving patients beyond this tissue model and educating them about their recovery can help to alleviate anxiety and the added stress that comes along with being involved in a car accident.
How to Explain to Patients They May Not Need 21 Treatments
While patients may be entitled to 21 treatments within the protocols, they may not actually need them. Patients may come for physiotherapy with an expectation they should use their maximum treatment allotment because they paid for this through their car insurance premiums. As therapists it’s important to educate our patients that more treatment can actually hinder their recovery.
Jeff provides an example of how to broach this conversation with a patient. “I might say, ‘You might be entitled to 12 fillings under your insurance by your dentist but do you really want 12? What if you only need two?’ But at the end of the day when someone comes back and says, ‘I know you\’re saying that I\’m doing better but don\’t I still have six visit left?’ [It’s time to] ask: What do you think we need those six visits for? Is there something that you haven\’t returned to yet? Is there a challenge that you haven\’t met yet\”?
If they can [explain to you what is still wrong], fine, but sometimes patients are just saying, ‘Can\’t I just have those last six visits as massage?’, [which means] explaining to them that there\’s a third party involved and it wouldn\’t be right to ask that third party to pay for something that isn’t actually needed.”
Simon likes to use a challenge to motivate his patients to get better faster. “I often use, ‘Let\’s prove them wrong. You\’re going to get better faster than the 21 that they think you\’re going to need… be a super healer and get better in eight, work hard and we can get there!’ [This tactic] depends on the person you\’re interacting with of course, and what types of motivational [tactics] you want to use with them.”
Getting a clear understanding, during the assessment, of a patient’s functional limitations and goals will help guide conversations further along the treatment path. According to Simon, it can be tricky to determine what a patient means if they say they still have issues if you haven’t documented where they started.
“Having a clear list of functional outcome measures can help to determine if additional treatment sessions are needed. You could ask: ‘Based on what you told me on day one, we are there, we\’ve arrived, what am I missing?’ You\’re not accusing them, you\’re just saying ‘I\’m trying to understand [where you are at] based on what you\’ve told me, fill in the gaps for me.’”
Getting the WAD Diagnosis Right
Andrew posed this question to kick-off this part of the conversation; “What do you do if you diagnose a patient off the street with a WAD II and then two or three weeks later you realize they actually have numbness down their arm?”
Simon replied that adjusting a diagnosis following an assessment would have little ramification if it were a private pay situation. However, with car accident rehab, the WAD diagnosis impacts whether a patient falls within the Minor Injury Regulation.
As highlighted in this article, minor injuries under the DTPR have a limit (approximately $5,000) to the amount of money that can be paid out for pain and suffering.
“If you diagnose someone with a WAD II and then three weeks later the funny feeling that they had in their thumb at the time of assessment has become a full-blown C8 radiculopathy, they now have an injury to which the protocols do not apply,” explains Jeff. “Therefore, they technically shouldn\’t have the Minor Injury Regulation applied to them.”
Although, this diagnosis may not change patient treatment planning, it will affect the patient’s options for pain and suffering settlements. In other words, an incorrect diagnosis has potential legal ramifications for the patient.
Once a diagnosis has been made for a patient, it’s important to understand that a change in diagnosis will require an IMC consult. As the practicing therapist, you cannot change the diagnosis.
What To Do When Your Patient Isn’t Progressing As Expected
Although many patients progress as expected, there are occasions when patients are not improving at an acceptable rate or have plateaued in their recovery. Simon highlights that the first step is talking with your patient:
“I would discuss first and foremost with the patient the fact that you think they\’re hitting a bit of a wall or a plateau and then try and see if you can come up with some common ground as to maybe why they\’re not [improving].”
Jeff points out that clinicians should consider changing the treatment plan and looking to the other tools in their treatment toolbox. Simon goes on to highlight that you could also consider using the Injury Management Consultant (IMC) process within the DTPR to get a second opinion for your challenging case.
The IMC process is in place to help you with those cases that are not progressing well, you are wanting a second opinion before making a firm diagnosis, or where a change in diagnosis is required. Learn more about the IMC and the details on how to use it in this article here.
To ensure that you are diagnosing, treating, and communicating with your patients suffering from MVA injuries in the best way possible, it is important to remember a few key points.
- Focus on open and clear communication with both the patient and adjuster. Remember that you can pick up the phone and call the adjuster — a quick phone call to an adjuster can make a significant difference to moving your patient towards recovery.
- Be familiar with and understand MVA regulations. Jeff suggests having the DTPR & AAIB regulations printed and placed in your clinic binder for easy access.
- Remember that you can use an IMC to get a second opinion on diagnosis and/or treatment planning for challenging cases.