The moral hazard of whiplash

A whole edition of Spine was recently dedicated to whiplash associated disorders (WAD) (Vol 36 Number 25S). One paper by Cote and Soklaridis (1) caught my attention. They warn that health professionals should be aware of the danger of iatrogenesis during the early stages of WAD. According to Wikipedia the term iatrogenesis means brought forth by a healer (from the Greek iatros, healer). In this case, it refers to the development of iatrogenic disability through the promotion of illness behaviour. This paper discusses how whiplash has been medicalised, transforming it from a benign problem to a medical condition with significant societal costs.

A recent article by the Chartered Society of Physiotherapy (UK) called for greater involvement by physiotherapists in the management of acute WAD (2). However, this paper presents evidence that “too much too early after whiplash injury can delay recovery”(1). The Neck Pain Task Force also came to this conclusion in 2008 suggesting that “less is more” in acute WAD (3).  The provision of intensive treatment in the early phase post injury may be harming patients. Whiplash injuries are complex, complicated by societal and compensation influences, however, it made me consider the role of health professionals in managing acute WAD. Cote and Soklaridis suggest this is a moral hazard. They suggest that health professionals should no longer provide clinical interventions but need to be prevention managers. We need to educate, reassure and promote the return to activities early on after whiplash injury. We need to think carefully about the treatments we provide, avoiding treatments for which there is little evidence of benefit (even if that means providing less treatment) or passive treatments that encourage patient dependence. My experience of working on a large clinical trial evaluating treatments for acute WAD is that many health professionals view acute injuries through a   biomedical lens. If you don’t believe me then have a look at this:

httpvh://www.youtube.com/watch?v=Ap4sAqVnG5s

The biomedical approach, embedded with medical jargon and descriptions of tissue damage, has most likely contributed to the medicalisation of WAD. Health professionals need consider the information provided to patients and how the language used can impact on patients’ conceptualisation of their injury and resulting symptoms. It is clear that social and psychological factors impact on outcome in WAD. These factors need to be considered right from the start which is essentially the conclusion by Cote and Soklaridis. So what is the way forward with the early management of WAD? For a start, as health professionals we need to view WAD through a biopsychosocial lens, providing patients with information aimed at promoting wellness behaviours rather than illness behaviours. Unfortunately, the best way to achieve this is still not clear but there are some excellent suggestions in the final discussion paper in that special edition of Spine (4).

About Esther Williamson

grey The moral hazard of whiplash  Esther is originally from Brisbane, Australia where she did her physiotherapy degree at the University of Queensland. Esther has lived in the UK for the past 15 years and recently completed her PhD at the University of Warwick where she worked part-time as a research fellow in the Clinical Trials Unit. Esther’s main research interest is finding out ways that physiotherapists can improve the management of acute injuries and prevent long term disability. Her other job is looking after her two kids, Fraser and Annie.

References

1. Côté P, & Soklaridis S (2011). Does early management of whiplash-associated disorders assist or impede recovery? Spine, 36 (25 Suppl) PMID: 22101750

2. CSP: ‘Give physios a bigger role in assessing whiplash injuries‘. 12 January 2012.

3. Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, Peloso PM, Holm LW, Côté P, Hogg-Johnson S, Cassidy JD, Haldeman S, & Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (2008). Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine, 33 (4 Suppl) PMID: 18204386

4. Jull G, Söderlund A, Stemper B, Kenardy J, Gross A, Côté P, Treleaven J, Bogduk N, Sterling M, & Curatolo M (2011). Towards Optimal Early Management After Whiplash Injury to Lessen the Rate of Transition to Chronicity: Discussion paper 5. Spine PMID: 22020602

Comments

  1. Nice article. Dr Rettner scares the willies out of me. I hope I don’t get whiplash and need reconstructive chiropractic care.

  2. Alice Fung says:

    I left a message a while back to clarify WAD grade III treatment. The therapist that I have liaised have highlighted to me that the patient would need to come to see her for a very long time given her WAD being grade III. She said that she is unlikely to get better and she would need at least 3-4 times a week of treatment for at least 6-12 months. She told the patient the same thing. No wonder my patient doesn’t even want to contemplate on the idea of normal activity or movement. She has been pretty much advised that she is quite stuffed. I think regardless whether it is WAD or chronic back pain , what we tell our patients make a hugh difference to their attitude of healing and getting better. Don’t insert wrong ideas in their head. Don’t be a bad mentalist!

  3. Neil O'Connell says:

    Great stuff Esther thanks, and what a video!

    I would recommend anyone with an interest to read Andrew Malleson’s “whiplash and other useful illnesses”. Malleson wears his bias on his sleeve and pulls no punches in indicting clinicians, researchers and insurers in manufacturing a chronic illness epidemic with very real victims. There are serious oddities within the whiplash data that at best we usually ignore and he covers them all.

    One paper by Pape in 2009 really intrigues me. We already knew that more treatment (mostly chiropractic) increased the risk of a poor outcome: http://www.ncbi.nlm.nih.gov/pubmed/17530688

    But Pape found that even enlightened guideline-led MDT care was not just inneffective but increased the risk of chronicity: http://www.ncbi.nlm.nih.gov/pubmed/19181548

    As clinicians we may be damned if we do, even if we try to be up-to-date and less structurally obsessed.

    ian stevens Reply:

    Esther , excellent post and I think your research will have obvious relevance to clinical practice. I am interested in why lip service is paid to thinking and acting along these lines –probably historical and cultural in rehabilitation or an attitude that interventions that are not ‘manual’ are less skilled?

    Neil, Jack Straw M.P is interested in this subject –he knows about the Malleson book (his researcher who wrote back told me!). He made some funny remarks about why is it that people in Dumfries have ‘stronger’ necks than in Carlisle …The variations are surely related to genetics?
    It is a huge integrated industry .I received two texts last week informing me that I am able to claim for my accident(which I never had).
    As Dr Iatrogenesis on the video quite rightly states, huge amounts of damage can occur at 5mph when you collide into another trolley in Tesco’s. Such violent collisions obviously overwhelm the recruitment of your deep neck flexors and can lead to a reduction in your clubpoints. Funny enough stockcar racers who choose to drive into each other don’t get disabled.
    Geoff,I don’t know how you ‘operationalise’ the BPS model -surely a lot of the knowledge behind pain neurophysiology/stress/societal interactions should be common and accepted practice in all stages of presentation. Currently , even in many pain clinics structuralism and linear models/thinking are the norm . Iain McGilchrist’s animated RSA video details why this may be so (but that is my interpretation of how it applies here ).

    Esther Reply:

    I haven’t managed to get hold of the Pape paper but that sounds slightly depressing. I see it was a multidisciplinary approach – maybe that was too much much and it needed to be balanced with the “less is more” approach.

    Neil O'Connell Reply:

    Hi Esther,

    The Pape study basically applied Quebec Taskforce guided care. Quoting them “The intervention consisted of a thorough clinical examination by a general practitioner, who had special training and experience with WAD, and comprehensive testing by physiotherapists specialized in manual therapy. This examination lasted approximately 2 1/2 h. In addition, 50% were examined by a rehabilitation physician and 30% by a neurologist. Results from the different investigations were reviewed by the general practitioner and summarized into a report, which also included advice on treatment and self-management, and a prognostic evaluation. All reports were sent to the patient and the patient’s primary physician. When the conclusion was WAD I or II, the report comprised reassurance that the prognosis was good and a recommendation of an early return to normal physical activity and for 27% of the patients no additional therapy was recommended. Additional manual therapy was recommended for 36%, ordinary physiotherapy and exercises for 27% and 10% were referred for further investigations or therapy outside the framework of our research study.”

    So this is pretty hands off on the whole and emphasises return to normal and good prognosis. So it is bir concerning that the intervention was found to be a unique risk factor for poor outcome.

    Esther Reply:

    Thanks Neil. Do you think a 2 1/2 hour assessment was enough to make people think that this must be pretty serious or they wouldn’t be doing such an extensive assessment? Maybe the answer is even less input. Should we just be making sure patients have good pain relief and then leaving them to get on with it?

    neil o'connell Reply:

    Hi Esther,

    I wonder what the mechanism was for worsening? I reckon it is plausible that the full and thorough assessment had a medicalizing effect in that study. Could the risk be avoided with a much more cursory approach to triage followed by discharge with advice?

  4. Nice post Esther! I agree that we often conceptualize acute pain almost entirely through a biomedical lens and this potetnially gets some people into trouble. When pain persists, all of a sudden a new biopsychosocial frameworks is needed. Often, messages learned in the acute stage of an injury need undoing later on.
    Psychosocial factors seem neglected early after injury, while biological factors are viewed skeptically in persistent pain states. Neither of which is biopsychosocialism. While the biopsychosocial model has received a lot of attention, it mystifies me that it is not really well operationalized. For example, what does a biopsychosocial approach to the assessment of acute WAD actually look like? Taken from this point of view, the BPS model isn’t really a model insofar as models are testable. I’m all for the BPS approach, but I’m afraid it will not integrate into practice without an operational definition (kind of like beliefs – we all know what they are, until you have to define them!).

    Geoff

    Esther Reply:

    Hey Geoff. I agree. How exactly do we conceptualise this BPS? I have some ideas of my own but this is definitely an area that needs more work. I find it hard to define exactly where the bio starts and ends. Where does ensuring patients have good pain relief fit in? Is that part of the bio management? Surely that has to be a part of early management to limit the amount of nocioceptive input into the nervous system along with lots of positive messages and understanding of how they can help themselves.

  5. Steve Kamper says:

    Thanks for the post Esther.

    I was lucky enough to go along to the symposium which spawned the Spine whiplash issue. One of the really interesting discussions surrounded the ideas put forward by Dr Cote in this paper and those by Dr Connelly (see Spearing and Connelly in the same issue). This largely surrounded the issue of how we should interpret the evidence supporting the effect of the compensatory system on the course of whiplash, more specifically it’s impact on poor prognosis. In this case we could view the compensatory system as more or less as a proxy measure of societal influence.

    Basically, Dr Connelly questioned whether the epidemiological evidence was strong enough to establish a causal influence of compensation of whiplash prognosis. I don’t want to re-hash his arguments but much of this had to do with study methodology. In particular he highlights the probability that people with worse prognosis are more likely to pursue compensation, rather than the other way around i.e. reverse causality. Dr Cote obviously argues that the weight of evidence and designs are robust such that causality is likely.

    I think the danger here is to interpret Dr Cote’s position as to contend that there is NO anatomical basis for whiplash injuries (see Discussion paper 1 for more on this), and that the other side of the argument holds that there is NO societal influence. I don’t think this is the true. I never asked directly but I would reckon both would contend a biopsychosocial conception of the condition is appropriate (notwithstanding Geoff’s very reasonable concern regarding operationalisation of the BPS model).

    Which leads (sorry to take so long) to the question of treatment. To my mind the Conclusion section of the paper by Cote and Soklaridis sets out a very reasonable position.

    “Health care providers can assist recovery by providing effective modalities…However, they can also impede recovery and promote chronicity by providing ineffective interventions and overtreating patients.”

    I don’t think there is anything too controversial here neither do I think this statement applies uniquely to whiplash injuries.

    Maybe the moral hazard applies to all conditions.

    Esther Reply:

    Hi Steve, I hadn’t taken the Cote paper to mean there is no anatomical basis for WAD but just that health professionals need to take care with the type of treatments they are providing as it is possible that some of these can do more harm than good. I definately think there is a tissue element to whiplash in the early stages as in any acute injury which needs to be considered along side psychological and social factors. You would expect that the early days after injury is when the body has the greatest capacity to heal so maybe our roles as physios is to try and maximise this natural healing process rather than apply treatments as such. How exactly we do this is very challenging and I think will continue to be debated until we have some more robust evidence. I agree, this is an issue for the management of all acute injuries and maybe where we need to start is as Geoff suggested trying to operationalise what is meant by a BPS assessement or approach for acute injuries.
    I agree that studying the impact of compensation is difficult – unless we can find some patients that would be happy to be randomised to making a compensation claim or not – I think it will remain a contensious issue. You are right, if you are more seriously injured you are more likely to claim. In our study we had hoped to look at this but of the 599 randomised to have physiotherapy treatments only 5% had not claimed making it impossible to draw any conclusions.

  6. Sara Brentnall says:

    Thanks Esther!
    Words of warning indeed – Peter O’Sullivan also suggests that there are a significant number of our patients (with back pain) who actually have worse outcomes if they recieve more treatment. Scary stuff for clinicians!

  7. Dave Nolan says:

    It does lead to a very challenging professional debate and internal thought process. Hopefully with the exposure of sites like this and the growing knowledge of pain and pain neurophysiology we can start to produce some quality evidence that we are mildly useful… some of the time!

    Lynn Brice Rosen Reply:

    Hi Dave: “mildly useful some of the time”!! Perfect. My own whiplash story occurred while sliding a [US-] Thanksgiving turkey into the oven. My spine went kkkkkkrnch but I had no symptoms until 24 hours later—unable to rotate cervical spine or raise arms. Was living abroad at the time & hadn’t sorted out the health care system but went to an Alexander Technique teacher. [as a former dancer I was familiar with certain types of injuries &…easily ruled out the need for medical help] The short story is that after 6 weeks I was without any pain. And had begun learning how to attend to mySelf in new ways.

    As others have written, I believe that most patients benefit from a multi-disciplinary approach which includes learning how to attend to and refine their sensing abilities. It’s simply not enough to urge [warn?] pts to avoid particular movements when they lack the awareness or experience of noting them. Habits are…habits. So familiar that they’re not noticed. Thus pain easily continues, much to the disappointment of both patient and practitioners.

  8. Great post Esther. LOVE the video!
    Neil – I agree the time spent on assessment in the Pape study seems on the high side for many patients who will have pretty routine soreness. Another concern is how consistent the message was between the different professions – mixed messages from different health care providers can be a real problem. Finally, the very nature of being seem by an “expert” or “specialist” is that these experts may be even more prone to overcomplicating the nature of the problem, or have the most negative beliefs. A product of being highly trained in biomedical approaches?

    Buchbinder R, Staples M, Jolley D. Doctors with a special interest in back
    pain have poorer knowledge about how to treat back pain. Spine.
    2009;34:1218.

  9. As a patient recovering from chronic pain (whiplash related) this discussion is invaluable to better understanding the variety of treatments, opinions and outcomes. Thankyou to the author and the commenters, especially those who posted insightful references.