Manchester Claims Association Chronic Whiplash

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1 Manchester Claims Association Chronic Whiplash Thursday 03 rd July 2014 Scot Darling, Chief Medical Officer Premex Services Limited, Premex House, Futura Park, Middlebrook, Bolton BL6 6SX. T F

2 Medico-legal Reports Medical Records Service Initial Needs Assessment Physiotherapy Diagnostics Ancillary Reports through our case management partners Atos PIP supply chain partner Document explanation and collection Claims Investigations Risk Solutions and Investigations Risk Assessment Fraud Prevention

3

4 WAD: Mechanism of Injury

5 50 Millisecs, Seatback Pushes Torso Forwards

6 50 Millisecs, Seatback Pushes Torso Forwards 75 milliseconds Spine forms an abnormal S shaped configuration

7 WAD is due to non physiological cervical spine motion Muscular strain Shorter prognosis

8 and the rest Fractures Ligaments Nerves Blood vessels Intervertebral discs Spinal cord Longer prognosis

9 WAD Grading (QuebecTask Force) 0- no symptoms/signs 1- Neck sympts, no signs 2a- Neck sympts, neck tenderness/from 2b- Neck sympts, neck tenderness/reduced ROM 3- Neck sympts, neurological signs 4- Neck sympts, fracture/dislocation 1,2 Shorter Prognosis 3,4 Longer Prognosis

10 Some Prognostic Indicators Accident and Injury Severity Vehicles involved and fittings Site of impact Seat occupancy Delta-V Awareness Body position Female/size Age

11 Some Prognostic Influences Group experience Personal belief of Expert (Hawk vs Dove) AND client Medical training Consensus of medical opinion The literature!!

12 Gargan and Bannister Outcome Measures (n = 50) Time months Years A No Symptoms 30% 52% 38% 38% (asymptomatic) B Nuisance 40% 20% 30% (no restriction or medication) C Intrusive 26% 26% 30% (restriction +/- Medication) D Disabling 4% 2% 2% (off work, on Medication) 62% symptomatic G&B 1994

13 Gargan and Bannister et al Follow up in years Symptomatic % Conclusion: 1/3 injured recover within 3 months, 2/3 will have persistent symptoms. Of the 1/3 who are recovered within 3 months, 93% will remain symptom free after 2 years. G&B et al

14 Quebeck Task Force % returned to usual activity by 31 days 26% are off work between 2 and 6 months 12% remain off work 6 months after injury 2% remain off work over 1 year

15 Lithuania Schrader et al., "Natural evolution of late whiplash syndrome outside the medicolegal context," (Lancet, May 4, 1996;347: ) They double blindly matched 202 Lithuanian drivers whose cars had been rearended in the previous 3 years with a control subject from the same city as the collision victim. 33% of the collision group reported neck pains, but so did 33% of the controls. 53% of the accident group had headaches, but so did 50% of the controls. When told the results, the Lithuanians were amazed that anyone would attribute persistent headache and neck pains to a minor car collision. Concluded that whiplash injuries, and particularly late (chronic) whiplash are rare in countries where auto insurance and personal injury lawyers do not exist. Regarded in many quarters as authoritative proof that whiplash is largely a symptom of avarice.

16 The Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders Spine Volume 33 Issue 4S 15/02/ /31,878 papers Epidemiology of neck pain: 12 month prevalence in general population12-71% Prognosis: 50-80% of previous sufferers will report neck pain again in the next 1-5 years. Similar prevalence in general population as after MVTA s Negative outcomes: age, sex, genetics, smoking, on going litigation, psychological/workplace stress/repetition/ posture, prior neck pain, poor health, Positive outcomes: physical activity, head restraints in RTA s, psychological Equivocal outcomes: manual work, degenerative changes

17 THE BONE AND JOINT DECADE TASK FORCE ON NECK PAIN AND ITS ASSOCIATED DISORDERS A New Conceptual Model for Neck Pain Centred on people with neck pain or who are at risk for neck pain. The model proposes neck pain as an episodic occurrence over a lifetime with variable recovery between episodes.

18 Chronic Whiplash -For Consideration: Classification 1 and 2. STI s that resolve in a timely manner (WAD is not unique) Classification 3 and 4. More significant injuries potentially longer prognosis Some minor (1 and 2) injuries may be perceived to go on disproportionately long -? Constitutional Some injuries of all classifications may be perceived to go on disproportionately long, but genuinely live the life BIOPSYCHOSOCIAL group

19 Constitutional Changes? The physical make up of a body including the mode of performance of its functions including the manner & degree of its reactions to stimuli & its power of resistance to these factors Degenerative changes symptomatic or asymptomatic Other pre-existing conditions Posture Lifestyle Occupation Greater sensitivity/awareness Psychological Malingering

20 The Biopsychosocial Model The term biopsychosocial pertains to the complex interaction of biological, psychological and social aspects of daily living. The biopsychosocial approach to health takes a holistic view of health conditions, regarding them to be a function of the interplay between biological (e.g. physical stress on tissues), psychological (e.g. coping strategies, personality), social (e.g. social support) and macro (e.g. socio-economic status, policies & ethnicity) levels.

21 The balance of probability 51% CAUSATION - What is it? Are the on going symptoms accident related? If not what are the causes???

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23 % Cases Prognosis Premex Statistics Prognosis % 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 0-3m 15% 3-6m 20% 6-12m 45% (increase) Prognosis 12-18m 15% >18m 5% (decrease) % Cases Increased G.P. vs Orthopaedic Medical consensus Clients seen sooner Single joint Expert

24 Prognosis Transport Select Committee April 2013 Prognosis period based on Whiplash type injury (last 36 months) Up to 1 month 1-3 Months 3-6 Months 6-9 Months 9-12 Months Over 12 Months No Prognosis Grand Total Grand Total Count 37,166 36,408 99,464 56,539 26,064 15,616 7, ,148 Grand Total - Percentage 13% 13% 36% = 62% 20% 9% 6% 3% 100%

25 Premex Annual Conference 2010 (n=170) Soft tissue whiplash physical injury can persist beyond 2 years True 25% False 20% Sometimes 48% Don t know 7%

26 Questions

Prognostic factors of whiplash-associated disorders: A systematic review of prospective cohort studies. Pain July 2003, Vol. 104, pp.

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