Compulsory Third Party Claims Guide for the Management of Acute Whiplash-Associated Disorders An Insurer s Guide 2nd Edition 2007
Contents Introduction...........................................................................1 Flowchart for early management of Whiplash-Associated Disorders................................................2 Notes to the flowchart............................................................3 Investigations........................................................................4 Indicators of poor prognosis....................................................5 Treatment.............................................................................6 Applying these guidelines........................................................ 7 Case studies......................................................................... 9 Canadian C-Spine Rule.......................................................... 17 Outcome measures...............................................................18 Glossary............................................................................. 20 Acknowledgments Other publications Where to find more information
Introduction Purpose of this guide This guide has been designed as a reference for claims consultants who manage compulsory third party claims involving Whiplash-Associated Disorders (WAD). It is based on the Guidelines for the Management of Acute Whiplash-Associated Disorders for Health Professionals 2nd Edition 2007 used in clinical practice. A copy of the Guidelines can be downloaded from www.maa.nsw.gov.au. Please refer to it for more detailed information. Definition The Quebec Task Force (QTF) 1 definition of WAD has been adopted for the purposes of these guidelines. Whiplash is an acceleration-deceleration mechanism of energy transfer to the neck. It may result from...motor vehicle collisions... The impact may result in bony or soft tissue injuries (whiplash injury), which in turn may lead to a variety of clinical manifestations (Whiplash- Associated Disorders). Scope The scope of the guidelines covers WAD Grades I, II and III following a motor vehicle collision. Grade IV is only considered to the extent of diagnosis of the condition and immediate referral to an Emergency Department or appropriate medical specialist. These guidelines are applicable in the first 12 weeks from date of injury when WAD is the only injury or when it has occurred concurrently with other injuries. These guidelines do not cover persistent pain or a chronic pain syndrome or where there is a fracture or dislocation (WAD Grade IV). Although the scope of these guidelines does not extend beyond the acute and sub-acute phase of WAD, it is recognised that some people with WAD will require treatment and support beyond this phase. Also, patients with WAD may have psychological symptoms that may require treatment. Grades of WAD The following clinical classification provided by the QTF is shown in the table below. Symptoms and disorders that can be manifest in all grades include deafness, dizziness, tinnitus, headache, memory loss, dysphagia and temporomandibular joint pain. Quebec Task Force Classification of Grades of WAD Grade Classification 0 No complaint about the neck. No physical sign(s). I II III IV Complaint of neck pain, stiffness or tenderness only. No physical sign(s). Neck complaint AND musculoskeletal sign(s). Musculoskeletal signs include decreased range of movement and point tenderness. Neck complaint AND neurological sign(s). Neurological signs include decreased or absent tendon reflexes, weakness and sensory deficits. Neck complaint AND fracture or dislocation. 1. Scientific Monograph of the Quebec Task Force on Whiplash-Associated Disorders, Redefining Whiplash and its Management, Spine 1995 Supplement vol 20 No.85. 1
Early management flowchart Early management of Whiplash-Associated Disorders ASSESSMENT History & Physical Examination 1 NO Is an X-ray needed? Apply Canadian C-Spine Rule (see page 17) YES INITIAL VISIT Assess Classify WAD grade Pain Visual Analogue Scale (VAS) and Disability Neck Disability Index (NDI) Define WAD grade WAD I WAD II WAD III Apply recommended treatments Educate, act as usual Exercise Prescribed Function Pharmacology X-ray - ve + ve WAD Grade IV Immediate referral to Emergency Department or Specialist 2 Reassess (Should include VAS and NDI) 7 DAYS Improving Continue recommended treatments Not Improving (VAS and NDI still high) Consider more concerted treatment. Other treatments not routinely recommended (e.g., manual and physical therapies) may be considered 3 Reassess (Should include VAS and NDI, may include a psychological measure (for e.g., IES) 3 WKS Improving Continue recommended treatments Resolved* cease treatment Not Improving (e.g., VAS and NDI still high/unchanged) Refer to Specialist Specialist exam should include specialised physical examination 4 Reassess (Should include VAS and NDI, may include IES) 6 WKS Resolving Reduce treatment Resolved* cease treatment Not Resolving (e.g., VAS and NDI still high/unchanged) Refer to Specialist Specialist exam should include specialised physical examination and/or psychological examination 5 6 Resolution expected Not Resolving Discharge from care in a Follow recommendation from specialist and percentage of cases or ensure coordinated care (and follow chronic intermittent review WAD guidelines when available) 3 MTHS 2 *Resolution is defined as VAS < = 3/10 and NDI < 8/50
Notes to the flowchart Notes to the flowchart The flowchart provides a structure for the assessment and treatment of people with WAD during the first 12 weeks following injury. It provides a summary of the guideline recommendations. It is a guide only and there will always be individual variations. Initial assessment Classify the WAD grade according to the QTF definition. Although higher WAD grades indicate greater severity, poor prognosis is most likely to be associated with a high Visual Analogue Scale (VAS) pain score (> 7/10) or high Neck Disability Index (NDI) score (> 20/50). It is recommended assessing the VAS scale and the NDI at the initial assessment (preferred) or at the seven day review (see below) to identify WAD patients at risk of nonrecovery. Apply recommended treatments. Review Primary care practitioners should review patients regularly, at least at the following intervals: seven days, three weeks, six weeks and three months. Reviews should include reassessment of the VAS and the NDI. Improvement is considered at least a 10% change on these scales. Seven day reassessment Reassess, including the VAS and NDI. If the VAS and NDI are high or unchanged, treatment type and intensity should be reviewed. Other treatments listed in this guide as not routinely recommended may be considered. This may involve referral for physical or manual therapy. The effectiveness of such treatments should be closely monitored and only continued if there is evidence of benefit (at least 10% change in VAS and NDI) from the previous assessment. Three week reassessment Reassess, including the VAS and NDI. If the VAS and NDI are unchanged, a more complex assessment may need to be considered and treatment type and intensity should again be reviewed. The Impact of Event Scale (IES) may be used as a baseline for psychological assessment. However, other recommended scales in these guidelines can be used. If the VAS and NDI are unchanged, consider referral to a specialist in WAD. A specialist is considered to be a practitioner with specialised expertise in the management of WAD. 1 2 3 These may include rehabilitation physicians, pain medicine specialists and occupational physicians who specialise in WAD. Equally, specialist physiotherapists or musculoskeletal medicine practitioners who specialise in WAD can be considered. Amongst other things, if the VAS and NDI are unchanged, the specialist should undertake a more complex physical and/or psychological examination. They should direct more appropriate care and liaise with the treating practitioner to ensure this is implemented. If the symptoms are resolving treatment should be reduced. Six week reassessment Reassess again at this point. In at least 40% of cases resolution should be occurring, and the process of reducing treatment in these cases should commence or continue. If resolution is not occurring and the VAS and NDI have not changed by at least 10% from the last review, specialist care should still be followed, or a specialist should be referred to if this has not already been done. At this point, referral to a clinical psychologist should also be considered if the psychological assessment data are markedly below norms (for IES this means a score of > 26 at the six week reassessment interval). Three month reassessment Resolution should have occurred in at least 40% of cases. In these cases treatment should be ceased. If the patient is still improving, continue treatment; however, independence should be promoted (e.g., focus on active exercise). In these resolving cases, the patient should be reviewed intermittently over the next six to 12 months until resolution, to ensure home programs are maintaining improvement. Coordinated care Patients whose VAS and/or NDI scores are not improving at this point are likely to require coordinated care that is multidisciplinary. It is likely that a combination of physical, psychological and medical care is required. The primary practitioner should facilitate this process. 4 5 6 3
Investigations Investigations for Acute WAD in the first 12 weeks after injury The following investigations can be recommended after injury. It is important to understand the circumstances when investigations are appropriate. Investigation Plain radiographs (X-ray) Considerations Treating practitioners should use the Canadian C-Spine Rule (see Page 17) to decide whether X-ray of the cervical spine is required. This clinical assessment tool has been validated since the 2001 WAD guidelines were developed. Specialised imaging techniques: e.g., tomography, computed scan (CT), magnetic resonance imaging (MRI), myelography, discography etc. There is no role for specialised imaging techniques in WAD Grades I and II. They may be used in selected patients with WAD Grade III; e.g., nerve root compression or suspected spinal cord injury, on the advice of a medical or surgical specialist. Specialised examinations: e.g., electroencephalography (EEG), electromyographic (EMG), or specialised peripheral neurological tests There is no role for specialised examinations in WAD Grades I and II. They may be used in selected patients with WAD Grade III; e.g., nerve root compression or suspected spinal cord injury, on the advice of a medical or surgical specialist. Summary Investigation WAD I WAD II WAD III X-Ray C-Spine Rule C-Spine Rule C-Spine Rule Tomography, CT, MRI, discography no no for selected patients only EEG, EMG, specialised peripheral no no for selected neurological tests patients only 4
Indicators of poor prognosis Indicators of poor prognosis There is strong evidence that poor outcomes, that is, ongoing pain symptoms or ongoing disability following whiplash ARE associated with high initial: pain intensity (e.g., pain > 7/10 on VAS scale); and disability (e.g., Neck Disability Index > 20/50). If either of these two factors are present, the injured person with WAD may need more intensive treatment or earlier referral to a specialist in WAD. There is strong evidence that the following factors are NOT associated with ongoing pain following whiplash: degenerative changes shown on X-ray age up to 65 years sex marital status There is strong evidence that poor outcomes, that is, ongoing disability is associated with: limited educational level Further information about the quality of evidence of other factors may be found in the Guidelines for the Management of Acute Whiplash-Associated Disorders for Health Professionals 2nd Edition 2007. 5
Treatment for Acute WAD Treatment for Acute WAD in the first 12 weeks after injury Claims consultants should be aware that this information is to assist your decision making about treatment. It will also help you decide if a file should be referred to your rehabilitation advisor for further advice. Recommended treatment Education - encouragement to act as usual Prescribed functional exercises - return to normal activities, work alteration Exercise - range of movement exercises, muscle re-education Pharmacology - simple analgesics Treatments not routinely recommended Evidence of the effectiveness of these treatments is limited or does not exist. If the treatments below are being used, their effectiveness should be closely monitored in each case. Treatment not routinely recommended should only be continued if there is evidence of benefit (at least 10% change on VAS and NDI from the last review). Postural advice Passive joint mobilisation Manipulation Traction Acupuncture Multimodal treatment Passive modalities / electrotherapies Surgical treatment Non-opioid analgesics & Nonsteroidal antiinflammatory drug(s) (NSAIDs) can be used short-term (up to three weeks for WAD II-III) Opioid analgesics can be prescribed for pain relief for limited periods for WAD II-III Not recommended Cervical pillows Immobilisation rest for more than four days, neck collars for more than 48 hours Spray and stretch technology Injections Magnetic necklaces Other interventions e.g., Pilates, Feldenkrais, Alexander technique, massage and homeopathy Opioid analgesics for WAD I Muscle relaxants should not be used in acute phase WAD Psychopharmacologic drugs are not recommended in acute and sub-acute WAD but can be used as a supplementary treatment or for symptoms such as insomnia or tension 6
Applying these guidelines Example One When providing information to claimants It is important that all injured claimants with WAD are provided with the self help guide Your Guide to Whiplash Recovery in the first 12 weeks after the accident 2nd Edition 2007 as soon as possible. You should check that the claimant has this guide the first time you speak with them. Copies are available for insurers from the MAA and can be downloaded from the MAA website www.maa.nsw.gov.au In your initial conversations with the claimant it is also important to reinforce the following principles whenever possible: symptoms are a normal reaction to being hurt maintaining life activities is an important factor in getting better voluntary restriction of activity may cause delayed recovery it is important to focus on improvements in function staying active is important in the recovery process Example Two When specialised investigations are requested If a request for an inappropriate investigation is made, for example, the practitioner requests an MRI scan for WAD Grade I or II, you should: clarify the WAD Grade consider approving appropriate investigations based on guidelines refer the practitioner to the Guidelines for the Management of Acute Whiplash-Associated Disorders for Health Professionals 2nd Edition 2007 discuss the request with the rehabilitation advisor Example Three When discussing treatment with the provider If the initial treatment does not include recommended treatments, for example, if the practitioner recommends the claimant wear a collar for more than 48 hours instead of staying active, you should: check the provider is aware of the Guidelines for the Management of Acute Whiplash-Associated Disorders for Health Professionals 2nd Edition 2007. Direct the provider to publications on the MAA website note other treatments being recommended closely monitor progress e.g., request a report/review that includes outcome measures in pain and function levels 7
Applying these guidelines (CONTINUED) Example Four When the provider recommends treatments that the guidelines do not recommend You should: clarify the goals of treatment if improving, consider approving not routinely recommended treatments check for indicators for poor prognosis closely monitor progress; e.g., request a report /review that includes outcome measures in pain and function levels consult the rehabilitation advisor Example Five When you are uncertain whether there are indicators for poor prognosis Check the information that you have on the file, for example, the details of the accident and the Ambulance and Emergency Department records if available. In particular, look for VAS pain score > 7/10 or a NDI score > 20/50. If indicators for poor prognosis are present you should: consider regular claims management review request regular clinical review and regular reporting using outcome measures discuss with the rehabilitation advisor referral to a specialist in WAD, e.g., specialist physiotherapist, rehabilitation physician or referral to a clinical psychologist consider approving early intervention to address poor prognostic factors Example Six When the claimant s condition is not resolving If at six weeks after injury the claimant s symptoms have not changed by at least 10% on the NDI or VAS, it means the claimant s condition is not resolving. In these circumstances you should: contact the provider to discuss progress check for indicators for poor prognosis consult the rehabilitation advisor consider supporting referral to a specialist in WAD, e.g., specialist physiotherapist, rehabilitation physician and/or a clinical psychologist for further management 8
Case studies These case studies are designed to assist claims consultants by providing examples of what information to consider when making decisions about: requesting additional information approving treatment monitoring progress checking outcome factors for indicators for recovery/non-recovery. These studies are examples only and it should be remembered that every case will need to be considered individually. Case Study One Case Study One Background Information Female passenger aged 35 years Works part-time as a shop assistant, has 2 children Rear end MVA, car stationary at the time, low speed No ambulance or police to the scene Considerations Check all the available information (Claim form, ANF, medical certificate, NOC Form) for indicators of prognosis. In particular, look at what factors are associated with a strong level of evidence for a poor prognosis, e.g., high initial disability, reduced cervical range of movement (ROM), limited education. In this case there does not appear to be strong evidence of factors associated with a poor prognosis. Initial Presentation Attended GP the day of the accident Medical certificate states whiplash injury to neck Diagnosis Non-specific neck pain No WAD grade given Check the medical certificate and NOC Form for the WAD grade. Refer to the QTF grades of WAD. Request additional information about the WAD grade from the GP or chiropractor. In this case, the diagnosis is WAD grade II (decreased cervical ROM, no neurological signs). 9
Case studies (CONTINUED) Case Study One (CONTINUED) Investigations Management Week 1 Background Information Plain X-ray requested Referral for chiropractic care (see NOC Form) Considerations Check the medical certificate and/or NOC Form. Use Canadian C-spine rule to help you decide whether to approve an X-ray. Direct the GP to the WAD publications on the MAA website. Week 4 Chiropractic Care Review Form received Some improvement on VAS and PSFS scores Ongoing treatment for 2 weeks upgrading to exercise program only by 6 weeks Anxiety increasing when driving, GP review requested Continue to monitor for indicators of poor prognosis. The ongoing symptoms of anxiety could affect the prognosis for recovery. Consider approving the GP review. Consider requesting use of a standardised outcome measure to assess psychological status e.g., IES. Week 6 GP review Requests approval for psychologist referral Psychology review Diagnosis of PTSD Requests 4 sessions of Cognitive Behavioural Therapy (CBT) Upgrade chiropractic care to exercise program Physical symptoms are resolving but not psychological symptoms. Consider approval for a psychology assessment based on flowchart in guidelines. Request the psychologist uses a standardised outcome measure to assess current psychological status and progress e.g., IES. 3 months No further ongoing physical treatment. Mild symptoms of PTSD remaining but psychologist reports patient has responded well to CBT and will discharge after the next session. Psychologist s report states the IES score < 26. 10
Check to see if there are any related preexisting conditions that might impact on recovery and treatment. Personal and accident history, neck movements and no neurological signs indicate X-ray is not required. The outcome measure should match the functional limitation and goal. The outcome should be measurable. Look for goals that are activity or outcome focused, and have measurable timeframes. Check to see if the proposed treatments are recommended according to the guidelines. Consider approving treatments not routinely recommended if the functional limitations, goals and outcomes are clearly defined and measurable i.e. evidence of benefit can be determined on the Chiropractic Care Review Form. Education and exercise is recommended. Manual therapy and acupuncture is not routinely recommended. Consider approving as goals and outcomes are clearly defined. Could consider requesting that the NDI is administered to monitor the benefit of manual therapy and acupuncture. Factors and strategies listed in this section may indicate areas where the insurer could: request further information; closely monitor the claim; approve a review to assess the need for further treatment; and approve diagnostic tests. Consider closely monitoring the claim due to the reported anxiety. *Patient Specific Functional Scale. See A chiropractor s guide to providing treatment in the NSW Motor Accidents Scheme 2006. 11
Case studies (CONTINUED) Check to see if functional/work status has improved or not. Review whether goals have been achieved and if new goals have been set. Are the new goals a progression from the previous ones? If not, why not? Is there objective evidence of improvement with changes in outcome measures? Is the proposed treatment recommended according to the guidelines is there evidence that treatment is reducing due to the reduction of physical symptoms? Anxiety appears to be increasing. Consider approving GP review. Check if physiotherapist has contacted the GP and an appointment has been made. *Patient Specific Functional Scale. See A chiropractor s guide to providing treatment in the NSW Motor Accidents Scheme 2006. 12
Case Study Two Case Study Two Background Information Male driver aged 67 years Retired, lives alone High speed accident at an intersection Police to the scene Considerations Check all the available information (ANF, Claim form, medical certificate, NOC Form) for indicators of prognosis. In particular look at what factors are associated with a strong level of evidence e.g., high initial disability and pain, reduced cervical ROM. In this case there does appear to be strong evidence of factors associated with a poor prognosis. Initial Presentation Attended A & E the day of the accident, plain X-ray taken, GP follow-up 2 days later Medical certificate states whiplash injury to neck Diagnosis Neck pain with reported numbness in right arm No WAD grade given Check the medical certificate and NOC Form for the WAD grade. Request additional information from the GP or physiotherapist about the neurological signs and WAD grade. In this case the diagnosis could be a WAD grade II or III (if there are positive neurological signs on physical examination it is a WAD grade III). Phone call to GP reveals numbness in the distribution of C6 dermatome and an absent C5 biceps reflex. GP also reports injured person is having difficulty managing at home with cooking, personal care and is unable to sleep due to severe neck pain. The diagnosis is WAD grade III. The high levels of pain and disability reported could indicate a poor prognosis. Consider closely monitoring the claim and requesting the use of standardised outcome measures to assess disability and pain e.g., NDI. Investigations MRI and additional plain X-rays requested from GP due to neurological signs. Consider approval for MRI scan. In addition, the MVA was at high speed, a fracture could have been missed in the initial plain X-ray. 13
Case studies (CONTINUED) Case Study Two (CONTINUED) Background Information Considerations MRI Scan Results show degenerative changes but no evidence of nerve root compression Management Week 1 Week 4 GP requests referral for physiotherapy (see NOC Form), prescribes pain relief medication GP review Week 6 Alters pain relief medication Reports neurological findings are normal Rescheduled further appointment for 2 weeks to review new medication Physiotherapy Review Form received Minimal improvement VAS/NDI Ongoing treatment requested for 12 weeks, goals are poorly defined, predominately relating to pain reduction. Long timeframes are given. Physiotherapist has requested specialist review There is limited evidence of benefit of physiotherapy. Consider approval for specialist review; this could be a specialist physiotherapist or doctor. Consider whether or not further physiotherapy should be approved with this physiotherapist and/or request additional information from physiotherapist. Consider discussing the case with the rehabilitation advisor. 10 weeks Ongoing management by specialist physiotherapist. No manual therapy Progressive exercise program Clearly defined goals and measurable outcomes in a set timeframe Requests 1 session every 2 weeks for the next 6 weeks to progress exercises Plan to discharge in 6 weeks GP review No longer requires medication Consider approval of further specialist physiotherapy treatment. 14
Accident history and objective findings indicate this is a grade WAD III and further investigations could be required. Reduced cervical ROM, high pain and disability levels are potential indicators of poor prognosis. Plus injured person lives alone and is having difficulty with personal care and driving. Consider closely monitoring the claim and discussing with the rehabilitation advisor. Look for goals that are activity or outcome focused, and have measurable timeframes. The outcome measure should match the functional limitation and goal. The outcome should be measurable. The physiotherapist has indicated treatment is likely to be completed at 6 weeks. This may not be realistic. There are indicators of poor prognosis that may need to be monitored either by the physiotherapist and/or GP. Check to see if the proposed treatments are recommended according to the guidelines. Consider approving treatments not routinely recommended if the functional limitations, goals and outcomes are measurable i.e. evidence of benefit can be determined on the Physiotherapy Review Form. The physiotherapist has alerted the claims consultant of high pain levels and difficulty with pain management. Consider if requested approval for GP review and altered medication. 15
Case studies (CONTINUED) The original goals on the NOC Form have not really been achieved. The new goals are similar to the initial goals but poorly defined. The outcomes given are poorly defined in comparison with initial outcomes. The treatment plan has not progressed. In conjunction with the goal setting, could consider not approving further physiotherapy treatment or contacting the physiotherapist for additional information. Consider discussing the case with the rehabilitation advisor. A significant number of treatments have been requested over a long timeframe. Consider approval of specialist review. It would appear there is not objective evidence of benefit from physiotherapy. 16
Canadian C-Spine Rule The Canadian C-Spine Rule The Canadian C-Spine Rule should be used by treating practitioners to decide whether X-ray of the cervical spine is required. It has been validated since the issue of the previous WAD Guidelines in 2001. For alert (GCS score = 15) and stable trauma patients when cervical spine injury is a concern. 1. Any high-risk factor that mandates radiography? Age 65 yr or Dangerous mechanism* or Paresthesias in extremities NO YES Key * Dangerous mechanism Fall from elevation 91.5cm /5 stairs Axial load to head, e.g., diving 2. Any low-risk factor that allows safe assessment of range of movement? Simple rear-end MVC or Sitting position in ED or Ambulatory at any time or Delayed onset of neck pain or Absence of midline cervical spine tenderness NO UNABLE Radiography MVC (Motor Vehicle Collision) high speed (> 100 km/h), rollover, ejection Motorised recreational vehicles Bicycle crash Simple rear-end MVC excludes Pushed into oncoming traffic Hit by bus/large truck Rollover YES Hit by high-speed vehicle 3. Able to actively rotate neck? 45 degrees left and right Delayed i.e., not immediate onset of neck pain ABLE No radiography 17
Outcome measures An outcome measure is a measure of change, the difference from one point in time (usually before an intervention) to another point in time (usually following an intervention). The results obtained can be used to evaluate the impact of an intervention, or treatment; provide information to the injured person, to other practitioners and to the insurer. The following outcome measures are referred to in the flowchart for early management of WAD. More information on outcome measures and a complete copy of the questionnaires may be found in the Guidelines for the Management of Acute Whiplash-Associated Disorders for Health Professionals 2nd Edition 2007. Pain Visual Analogue Scale (VAS) Scott J, Huskisson E, Graphic Representation of Pain. Pain 1976; 2: 175 184 The VAS consists of a 10cm line with two endpoints representing no pain and pain as bad as it could possibly be. Patients are asked to rate their pain by placing a mark on the line corresponding to their current level of pain. The distance along the line from the no pain marker is then measured with a ruler giving a pain score out of 10. No pain Pain as bad as it could possibly be The Neck Disability Index (NDI) Vernon H, Mior S, The Neck Disability Index: A Study of Reliability and Validity. J. Manip. and Physiological Therapeutics 1991; 14: 409-415 The NDI is designed to measure neck-specific disability and is based on the Oswestry Disability questionnaire. The questionnaire has 10 items concerning pain and activities of daily living including personal care, lifting, reading, headaches, concentration, work status, driving, sleeping and recreation. Each item is scored out of 5 (with the no disability response given a score of 0), giving a total score for the questionnaire out of 50. Higher scores represent greater disability. The result can be expressed as a percentage or as raw scores (out of 50). Here is an extract from the questionnaire. Section 1 - Pain Intensity I have no pain at the moment. The pain is very mild at the moment. The pain is moderate at the moment. The pain is fairly severe at the moment. The pain is very severe at the moment. The pain is the worst imaginable at the moment. Section 7 - Work I can do as much work as I want to. I can only do my usual work, but no more. I can do most of my usual work, but no more. I cannot do my usual work. I can hardly do any work at all. I cannot do any work at all. 18