Wilson Carswell argues that clinical guidlines over whiplash are needed to properly handle claims involving the soft tissue injury
In personal injury circles, whiplash is a very emotive word. which is the subject of ongoing arguments between lawyers and insurers.
Lawyers say that those suffering from whiplash are often denied both justice and appropriate financial compensation by mercenary insurers, who in turn argue that some whiplash claims are exaggerated or even fraudulent.
There seems to be no common ground between the two camps and these arguments seem doomed to carry on into the far distance, with no prospect of resolution. Even the prospect of impending legal reform seems unlikely to diminish these continuing arguments.
Almost completely absent from these arguments, however, is the voice of authoritative medicine. In fact, mainstream and academic medicine have ignored whiplash, as a medical condition.
There are some valid reasons from this.
These include the following:
1. The suggested mechanism of whiplash injury is not supported at the cellular level by evidence of either macroscopic or microscopic damage
2. The natural history of the condition is far from clear
3. Management of any medical condition depends firstly on diagnosis and thence on treatment. Unfortunately there are no objective criteria to establish a confident diagnosis of whiplash. Despite a number of reports on the treatment of whiplash these have not been able to provide robust evidence of efficacy. Thus the Cochrane Collaboration, an arbiter of evidence based treatment, finds itself unable to say what treatment is best for whiplash.
These very real problems offer an opportunity for a diagnosis of whiplash to be surmised by any number of medical attendants, starting in A&E departments. And once a diagnosis has been made, it is difficult, if not impossible, to refute.
An iatrogenic condition
I would suggest that the diagnosis of whiplash is often made on the slightest of evidence by medical attendants.
A gloomy prognosis may reinforce the supposed severity of the condition and may impede natural resolution. Whiplash thus has some of the features of an iatrogenic condition. The creation and confirmation of this iatrogenic condition may be reinforced by contact with some elements of the legal and allied professions. In some cases, whiplash may even evolve to a iatrogenic/lexogenic condition – a condition not known to be amenable to standard medical interventions.
The answers to the current practical problems around whiplash are unlikely to be found in the law and its processes, irrespective of any reform, as the law is not fundamentally geared to providing treatment for any medical condition. Likewise, the insurance industry has a limited contribution to make to the effective management of whiplash. Would you ask a lawyer or an insurer to medically manage one’s gallstones?
For many medical conditions, such as gallstones or a heart attack there is an evolving body of best practice, usually based on trials or case analysis. The evidence that these studies generate allow independent bodies, such as NICE (The National Institute for Health and Care Excellence) or the Cochrane Collaboration to draw up clinical guidelines, which, being based on strong evidence, are widely accepted and implemented as a matter of good medical practice
Role of medical and insurance professions
The absence of an evidence base for whiplash management prevents NICE or the Cochrane Collaboration from producing clinical guidelines.
The medical profession has some responsibility to alleviate this omission.
As has been established since the 1950s, the preferred method of generating evidence–based treatment is by way of a Randomised Clinical Trial (RCT). These trials are complex and costly and need, for starters, a sound statistical base, perhaps situated in an academic department.
The numbers in the trial must be sufficient to allow statistically significant results to be generated and, in the case of whiplash, are likely to be large. The trials should conform to Good Clinical Practice (GCP) (and where relevant to Good Laboratory Practice (GLP) and Good Manufacturing Practice (GMP)) and the monitoring and auditing of proper RCTs is usually carried out by separate and independent bodies. Many RCTs extend over several years and costs can be huge. Thus if the RCT needed a 1,000 participants and monitoring for each was £1,000 the costs would be £1 million – not an exceptional figure for an RCT.
This sort of figure automatically reduces the number of possible financial backers for a whiplash RCT. The NHS in any of its guises is unlikely to be a backer, nor is the Medical Research Council, or the medical charities. These bodies do not consider whiplash to be a medical or research priority. Universities do not have sufficient intrinsic funding to contemplate such research. Pharmaceutical companies are also unlikely sponsors, as the role of novel medications in whiplash is limited.
However, members of the ABI collectively pay out about £2 billion a year for whiplash and, if nothing else, have a financial imperative for ensuring that acceptable clinical guidelines for whiplash are developed and subsequently implemented.
Ideally, the evidence generated by a whiplash RCT would allow NICE to develop clinical guidelines. Then whiplash could be treated as an ordinary medical condition, rather than as a shuttlecock knocked between insurers and lawyers. A financial settlement, if appropriate, would be made only at the end of treatment.
Everyone would benefit. Those directly affected by whiplash would be much more likely to receive an evidence based treatment, while insurers’ costs are likely to be reduced in time. Lawyers would have the satisfaction that they would be dealing with fewer, and properly medically-managed cases.
Wilson Carswell OBE FRCS, is a medical director at Moving Minds Psychological Management