Patients with whiplash-associated disorders (WAD) commonly assume that the road to recovery starts when they begin receiving health care for their injuries. Health care providers, on the other hand, believe that the prognosis of patients with WAD is mainly dependant on prognostic factors such as age, sex, and markers of injury severity.1 However, these popular beliefs are increasingly challenged by recent scientific evidence which suggest that psychosocial, health care, and societal factors may be the main determinants of a patient's prognosis.2 For example, patients with a poor expectation of recovery, those compensated under a tort insurance system and those who are represented by lawyers tend to take longer to recover.1,3,4 Although clinical indicators of injury severity are known to influence recovery, their impact on prognosis pales compared to nonclinical markers of severity such as expectation of recovery and coping styles.5 Moreover, in countries like Canada, a culture of disability has grown out of our compensation systems.6,7 The consequence of this cultural shift is that an important proportion of our population now believes that a mild traffic collision can lead to chronic pain and disability. Overall, this new body of evidence suggests that patients’ beliefs and expectations, and the social environment in which they live are powerful determinants of how a whiplash injury evolves over time.
This new reality places a growing burden on health care providers to adjust their traditional management of patients with WAD. Health care providers are now managing a complex web of clinical, psychosocial, and societal determinants of pain and disability. They are also expected to mediate the dynamic relationships between these determinants by tailoring the clinical managements of patients to address the poor prognostic factors that may impede recovery. Consequently, physicians, physiotherapists, and chiropractors can no longer rely on medication, exercise, or manipulation alone to manage patients; they must also educate, reassure, and promote early resumption of daily activities.8 This new reality asks that health care providers shift their traditional role of deliverer of clinical interventions to one of a prevention manager.
These challenges do not occur in a clinical vacuum. In most industrialized countries, the management of WAD is delivered within complex insurance regulatory frameworks with various incentives and disincentives to manage patients and reach favorable outcomes. For example, in Canada some provinces (e.g., Saskatchewan and Quebec) use fee for service schedules to regulate the reimbursement of health care services for traffic injuries. Other provinces, such as Ontario, use a guideline-based approach with capped fees. The effectiveness and cost-effectiveness of the reimbursement systems in improving health outcomes and reducing costs remains unclear. For example, according to the Insurance Bureau of Canada, the accident benefits paid by Ontario insurers have risen from just over Can $1.5 billion in 1997 to Can $4.12 billion in 2007.9 This increase occurred despite reforms of the insurance system and changes in reimbursement structure from fee for service to a capped fee system. Nevertheless, we know that health care providers’ behaviors are influenced by reimbursement structures and that those who practice under a fee-for-service system are likely to see patients more often.10,11 The complexity of the environment in which patients must be rehabilitated and the uncertainty that surrounds the clinical management of WAD leaves the door open for iatrogenesis.
The purpose of our narrative review and commentary is to discuss how the early management of WAD can lead to clinical iatrogenesis. We also explore how social and legal iatrogenesis interact with the clinical management of a relatively benign disorder paving the way to chronic pain and disability. We examine the risk for iatrogenic disability from an epidemiological and from a sociological perspective.
WHAT ARE THE EFFECTIVE INTERVENTIONS FOR THE EARLY MANAGEMENT OF WHIPLASH-ASSOCIATED DISORDERS?
The goal of treating WAD patients shortly after a traffic collision is to reduce their pain, improve their function and ultimately prevent the development of chronic WAD. Therefore, an effective clinical intervention improves the natural course of the condition. In 2008, the Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders highlighted that we still know very little about the best way to treat acute WAD and prevent chronicity. Although the Neck Pain Task Force found evidence that the interventions described below were superior to usual care for acute Grade I and II WAD, it cautioned that they were associated with small benefits to patients and no one intervention was clearly superior to the others.12 In other words, it is questionable whether these interventions significantly improve the natural course of WAD.
- Watching an educational video that provides reassurance, home exercises and advice to return to normal activities. Brison et al found that usual care provided in the community plus watching an educational video at home is slightly more effective than usual care alone in preventing persistent WAD at 1 year after the collision.13 This evidence is augmented by a recent Swedish randomized trial of patients with acute minor traffic injuries (61% with WAD). Patients were randomized to usual medical care combined with four 1½-hour weekly information sessions that focused on the importance of self-care and physical activity or to usual medical care alone.14 A higher proportion of patients who received the information session (52.4%) reported self-perceived recovery compared to the medical care alone group (30.5%).14
- Completing a course of McKenzie-type exercise. A Swedish randomized trial suggested that physiotherapy-based McKenzie exercises are slightly more effective than standard care (educational leaflet providing information on home exercise, postural correction, suitable activities, and use of a soft collar) in reducing head neck or shoulder pain 6 months after the collision.15–17 It is unclear whether this type of intervention earlier in the course of recovery would be more or less effective. However, a recent Danish randomized trial found that a 1-hour education session with a nurse that focused on fear reduction and staying active was as effective as a 6-week course of McKenzie exercises instructed by a physiotherapist or 2 weeks of immobilization in a Philadelphia collar followed by 4 weeks of McKenzie exercises in reducing neck pain, headaches, neck disability, and sick leave.18
- Receiving a course of mobilization with or without exercises. Mealy et al19 found that a course of mobilization combined with home exercise in the acute phase of WAD recovery was more effective that wearing a soft collar and resting in reducing pain and improving range of motion of the cervical spine. These results were supported by a second trial where patients with acute WAD who were randomized to a course of physiotherapy that included mobilization and those who were instructed in a home mobilization program had less neck pain and better neck motion 2 months after the injury than patients randomized to wearing a collar, postural advice and home mobilization.20
As illustrated earlier, few interventions have been demonstrated to provide clinically important benefits to patients with WAD I-II.12 It is an unsettling fact that most interventions used in clinical practice are not supported by scientific evidence. The Neck Pain Task Force recommended that educational pamphlets alone, soft collars, rest, and passive modalities (heat, cold, diathermy, and hydrotherapy) have not been shown to confer any benefits to patients with acute WAD.12 Moreover, there was not enough evidence to comment on the effectiveness of spinal manipulation, traction, medications, and injections. Therefore, it is likely that a high proportion of patients are treated every day with ineffective or unproven clinical interventions.21 These findings emphasize that clinicians need to be educated on the use the evidence-based interventions.
“TOO MUCH HEALTH CARE TOO EARLY AFTER THE INJURY CAN DELAY RECOVERY”: FACT OF FALLACY?
The Neck Pain Task Force warned that high health care utilization within the first few weeks after the injury can delay the recovery of WAD. A growing body of evidence suggests that the type, intensity, and timing of health care delivery are strongly and independently associated with time to recovery. Côté et al studied two population-based cohorts from Saskatchewan, Canada, and found an inverse relationship between the number of health care visits made within the first 30 days postinjury and the time it took patients to recover from their WAD.22,23 Specifically, acute WAD patients who made (in the first 30 days postinjury) more than two visits to general practitioners, more than six visits to chiropractors, received care from general practitioner and chiropractors and those who consulted both general practitioners and specialists took longer on average to recover than patients who visited general practitioners only once or twice. In another Saskatchewan cohort, Cassidy et al investigated the effectiveness of a province-wide rehabilitation policy and found that patients who attended fitness training or a multidisciplinary outpatient rehabilitation program within 120 days of their injury had slower recovery than those who received usual community care.24 These findings are supported by a recent Norwegian study which suggests that early multidisciplinary evaluation and advice increases the risk of chronic neck pain after a whiplash injury.25 Finally, a Dutch randomized trial compared “education and advice” by general practitioners (mean number of treatments = 3.9; mean duration of care = 18.8 weeks) to “education and exercises” by physiotherapists (mean number of treatment = 12.7; mean duration of care = 19.9 weeks) in patients with WAD lasting more than 4 weeks.26 One year after the injury, patients in the general practitioner group reported lower levels of neck pain and headache intensity than those treated more frequently by physiotherapists.26 The positive effect of the physician intervention occurred despite an average of nine fewer visits per patient!
In summary, the epidemiological evidence suggests that the type and intensity of clinical care are associated with the prognosis of whiplash injuries. The current body of evidence also suggests that acute whiplash injuries should be treated with education, exercises, mobilization, reassurance, pain control, and encouragement to resume their normal activities of daily living. Health care providers must be aware of the perils of clinical iatrogenesis during the early stages of WAD; the evidence appears to support the hypothesis that “too much too early after the injury can delay recovery.” It is likely that overtreating patients with WAD promotes the development of chronic illness behaviors by emphasizing the use of passive coping behaviors.
PAIN, ENTRENCHED BELIEFS, AND SCIENTIFIC UNCERTAINTY: A FERTILE GROUND FOR IATROGENESIS.
Has the complexity of the environment in which patients must be rehabilitated opened a clinical, social, and legal iatrogenic Pandora's box for the early management of WAD? An understanding of how the concept of whiplash developed, the wider sociopolitical implications, and whiplash as a type of moral hazard provides some insight into this very complex question.
The widespread use of the term “whiplash” instead of medical terms such as strains, sprains, and fractures to describe the types of injuries one may sustain following a traffic collision have produced varied and unanticipated health outcomes. Clinical iatrogenesis refers to the direct ways in which health care as an institution and/or health care professionals cause or prolong illness, disease, or disorders in their patients.27 From a clinical perspective, whiplash has been defined in medical terms; assimilated into dominant medical paradigms, theories, and research; and described through dominant medical discourse. Whiplash has become a medicalized concept. Medicalization describes a process by which nonmedical problems become defined and treated as medical problems, usually in terms of illness, disease, and disorders. The main point when considering medicalization is that which is regarded as an illness or disease is not ipso facto a medical problem; rather, it becomes defined as one.28 The process of medicalization is a double edged sword. On the one hand, the identification of a new disease or disorder is good for those that suffer without treatment because it offers hope (i.e., the discovery of epilepsy). On the other hand, turning ordinary ailments into medical problems, seeing mild symptoms as serious, treating personal problems as medical, seeing risks as diseases, and framing prevalence estimates to maximize potential markets leads to iatrogenic illnesses.29 Our expectations and actions are influenced by whether or not something is regarded as a medical problem.
The term “whiplash” was first used in 1928 by Dr. Crowe, an orthopedist, presenting a report on eight cases of neck injuries resulting from traffic collisions. In this presentation, he described a motion that the head and neck underwent in conjunction with a collision. The intent of the presentation was to illustrate the way in which the body moves when subjected to a particular kind of external force. It was not meant to presuppose the medical result of this external force. However, in 1958, the term “whiplash injury” was coined by the medical profession and although, no pathoanatomical foundation has been found for whiplash, it has rapidly gained popularity as a medical term to describe an injury.30 Today, whiplash is accepted by health care providers, patients, and attorneys as a medical term and considered to be a treatable disorder. Therefore, one might wonder if the medicalization of the 1928 case series of eight “whiplash” cases led to an epidemic of pain and disability.
Health care providers know that individuals involved in a traffic collision do experience injury and painful sequelae. There are many medical terms such as strains, sprains, fractures, and concussions to describe the types of injuries one may sustain. A classification to describe neck pain due to WAD comes from the Quebec Task Force on Whiplash Associated Disorders. Under the leadership of Walter Spritzer, a group of scientists completed the largest international study of whiplash.31 They divided whiplash-associated disorders into the following grades:
0 = No complaints about neck, and no physical signs;
I = Neck complaints of pain, stiffness, or tenderness only, and no physical signs;
II = Neck complaints and musculoskeletal signs (limitation of movement and point tenderness);
III = Neck complaints and neurological signs; and
IV = Fracture or dislocation.
The Quebec Task Force found that in Quebec, most persons with WAD have a benign disorder (WAD I-II) that resolves spontaneously in days or weeks and requires very little treatment.31 Studies conducted at Saskatchewan found that it took longer for WAD patients to recover than previously reported by the Quebec Task Force suggesting that time to recovery may be jurisdiction-specific.3,24 However, health care providers are seeing more people for treatment with WAD I-III. What factors contribute to this increase?
Social iatrogenesis has been suggested as a term for illness caused or prolonged by wider sociopolitical inputs.26 Our expectations of and actions toward whiplash are influenced by whether or not it is regarded as a problem. Astutely pointed out by Malleson,32 whiplash is all about context. He asks us to consider why individuals in stock car racing, demolition derbies, and bumper cars do not experience whiplash. Fair ground bumper car riders experience the same speeds as collision that apparently cause whiplash in highway accidents and do not get whiplash symptoms. Other studies have shown how whiplash outcome differ between physicians and nonphysicians. For physicians, whiplash tends to be a short-lived syndrome with the majority recovering in less than a month, whereas nonphysicians took anywhere from a few days to over a year off to recover.33 Injury and the social context in which it occurs matters, and as illustrated by these various and varying studies, will determine an individual's psychosocial experience and physical trajectory of recovery. And if social context matters and affects a patient's recovery, it must also impact on a health care provider's treatment and management of WAD.
In fact, we can conceptualize WAD as a type of moral hazard with the health care provider as the involuntary negotiator among these iatrogenic forces. For example, health care providers trust their patients and may accept their claims of a whiplash injury. This trust is based on the difficulties of diagnosing whiplash; given it is a vague and ambiguous term with no foundation in medical science. Trust is also based on the multifaceted nature of the provider-patient relationship whereby many health care providers often take on the role of patient advocate.
From the patient's perspective, it is a matter of their personal integrity; they are claiming for an injury. They may feel angry that they were injured through no fault of their own, and want some form of retribution for the other driver. They may feel the need to legitimize their injuries to receive compensation. They may be faced with the fear of not being eligible for any entitlements from their insurance company following a traffic collision. Perhaps their relationship with their insurance company becomes adversarial thus perpetuating a type of medical iatrogenesis whereby injury-like symptoms are built up to the point of dysfunction and the give the appearance of disability. Perhaps lawyers are involved with the claim; their job is to work toward the best possible settlement for their client (while indirectly contributing to a form of legal iatrogenesis). These forces are carried into therapeutic relationship between the health care providers and their patient. Health care providers are often caught among these interacting forces of iatrogenesis in their everyday practice and these forces may inadvertently affect their management and treatment of WAD.
The purpose of this article was to answer the question: Does early management of WAD assist or impede recovery? The answer is both! Health care providers can assist recovery by providing effective modalities (education, exercise, and mobilization), reassuring patients about the favorable course of the condition and by promoting the resumption of activities. However, they can also impede recovery and promote chronicity by providing ineffective interventions and overtreating patients. Although health care providers and their patients may have legitimate concern and principled motives, there is a tendency to promote the view of whiplash as a widespread, serious, and treatable condition. Barsky and Boros point out that the public's tolerance of mild symptoms has decreased, spurring a “progressive medicalization of physical distress in which uncomfortable body states and isolated symptoms are reclassified as diseases.”34
This is particularly problematic in countries with a culture of disability where individuals believe that WAD is a crippling condition. Thus, symptom expectations may be an important factor that accounts for some of the recovery outcomes between the “whiplash cultures” (Canada, United States, United Kingdom, etc.) and the “non-whiplash cultures” (Lithuania, Greece, and Germany), where acute whiplash injury is common but the outcome benign with recovery being measured in days to weeks.7 When the boundaries between the social context and the actual disorder blur we might ask ourselves whether we are treating a disorder or trying to manage a larger social issue at hand.
We suggest that in today's context, health care providers shift their role of deliverers of clinical interventions to one of prevention managers. It is possible that the incidence of chronic WAD will be reduced if health care providers recognize the potential for iatrogenesis and assist patients to cope with their acute pain within a broad psychosocial and societal environment.
- Early clinical management of WAD can lead to iatrogenic morbidity.
- Psychosocial, health care, and societal factors may be the main determinants of a patient's prognosis.
- High health care utilization within the first few weeks after the injury can delay the recovery of WAD.
- Injury and the social context in which it occurs will determine an individual's psychosocial experience and physical trajectory of recovery.
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