Capita Clinical Conference Whiplash Injury and Medico-Legal reporting Tuesday 10 June 2014

Transcription

1 Capita Clinical Conference Whiplash Injury and Medico-Legal reporting Tuesday 10 June 2014 Martin Gargan Consultant Orthopaedic Surgeon

2 Law Other Medicine

3 Common aims Prevent injury Treat injured Compensate appropriately Stop fraud

4 Whiplash Fact or Fiction?

5 Definition a collection of symptoms produced by a soft tissue injury of the cervical spine

6 Railway spine

7 Malingering the imprecise correlation between symptoms and signs!

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9 FRCS 1988

10 Test hypothesis all better by 2 years

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12 Natural evolution of late whiplash syndrome outside the medicolegal context Lancet 1996; 347: Scrader H et al

13 The controversy over late whiplash: are chronic symptoms after whiplash real? Whiplash:current concepts, Ed Gunzburg 1998 Freeman M et al

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15 5 PHASES: Ramping S phase Transition Hyperextension Flexion

16 Viano D and Gargan MF Seating position relative to headrest during normal driving: implications to neck injury in rear crashes Accident Analysis & Prevention 1996; 28(6):

17 Gargan MF and Bannister GC The long term prognosis of soft-tissue injuries of the neck J Bone Joint Surg 1990; 72-B: Gargan MF and Bannister GC The rate of recovery after following soft tissue injury of the neck Eur Spine J 1994; 3: Gargan MF, Bannister GC, Main C et al The behavioural response to whiplash injury J Bone Joint Surg 1997; 79-B:

18 A no symptoms B nuisance C intrusive D disabling Gargan MF & Bannister GC 1990

19 Long-term disability after neck injury Joslin CC, Khan SN & Bannister GC J Bone Joint Surg (Br) 2005; 86B:

20 80 patients 1 stable cervical spine # 2 unstable cervical spine # 3 litigating whiplash patients 4 non-litigating whiplash Vernon & Mior NDI

21 Litigating whiplash greater disability Pathophysiology of injury Demographics Treatment received Psychological differences

22 The fluctuation in recovery following whiplash injury: 7.5 year prospective review. Tomlinson PJ, Gargan MF and Bannister GC Injury 2005; 36(6):

23 Factors predicting outcome after whiplash injury in subjects pursuing litigation. Lankester B, Garneti N, Gargan MF et al Eur Spine J 2005; 15:

24 Retrospective 277 patients Pre-accident, accident and response variables Multivariate analysis

25 97 males, 180 female average age 39.9 (15-81) f/u 21 months (9-60)

26 Poor outcome: Strongest associations present before impact

27 back pain high frequency GP attendances depression/anxiety front position radiating pain

28 Elliott J et al Spine 2006 (31): 22 quantifiable MRI changes in the fat content of the cervical musculature, in whiplash patients with no history of neck pain

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31 Mean group differences for the fat indexes in the right and left rectus capitis posterior minor and rectus capitis posterior major muscles. (mean+/-sd)

32 Whiplash injury: 30 year follow-up of a single series Rooker G, Bannister M, Gargan M & Bannister GC J Bone Joint Surg 2010; 92-B:

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35 Whiplash injury Bannister GC, Amirfeyz R, Kelley S and Gargan MF J Bone Joint Surg 2009 ; 91-B (7):

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40 Jones v Kaney (2011) Jack Straw v Everyone (except insurers)

41 Epiphany

42 Home Secretary Justice Secretary

43 third rate doctors

44 Homo Orthopaedicus

45 ..whiplash is hardly an injury at all, more a profitable invention of the human imagination..whiplash is undiagnosable except by third rate doctors in the pay of claims management companies or personal injury lawyers

46 3g at 10km/h 8g at 25km/h

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48 Cabinet Office/Department of Health (June 2006) "There is a rebuttable presumption, agreed by the Law Society, Association of British Insurers and the Association of Personal Injury Lawyers that subject to the Expert Witnesses view, no patient records will be requested for claims below 10,000."

49 proportionality

50 Medical Records -? relevant - crucial - but for

51 MEDICOLEGAL WORK 1980s 90% Consultant Orthopaedic Surgeons 10 % other

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54 MEDICOLEGAL WORK % Consultant Orthopaedic Surgeon 80% General Practitioner 5% Other

55 > 500,000 whiplash claims pa 5bn Claimants/RTA

56 Intermediaries

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58 If you are going to tell lies you need to have a good memory

59 Thomson, a 32-year-old unemployed chef, faces jail after pleading guilty yesterday to unlawfully and maliciously causing grievous bodily harm with intent. Miss Hingston, who has since split from Thomson, is not facing charges but a judge said the 24-year-old was "lucky not to be in court herself". Precise details of the attempted swindle, which took place in October last year, were not revealed in court. But one of Thomson's friends who has seen the film said the couple had been going out for only two months when the incident happened. She added: "They shot it in a house and you can see Elizabeth lie on the floor. Gordon, who is a big guy, then jumped on her leg with both feet. "It was horrible - you could hear a cracking sound. It still makes me sick thinking about it." Police said the 20-second footage, which is thought to have been filmed by a third party, was discovered when they raided Thomson's home in Plymouth on an unrelated matter Daily Mail 21/11/2007

60 .apparently disproportionate disability!

61 Symptoms v Signs...conscious exaggeration of complaints for financial gain

62 Waddell G et al Symptoms and signs: physical disease or illness behaviour BMJ 1984; 289:

63 ? extrapolate to the cervical spine Whiplash test?

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65 - good days/bad days - use of analgesics - unfair video?

66 Has the expert asked the right questions? Is the victim telling the truth? Is any discrepancy significant?

67 is it black? definitely? is it not a bit grey? can you see any white?

68 Change the law?

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70 Is there a whiplash culture? Is there a better way? Evidence-Informed Recommendations about Whiplash- Associated Disorder 2 November 2011

71 Dr Nick Kendall (chair) Professor Sir Mansel Aylward Professor Kim Burton Professor David Cassidy Professor Gordon Bannister Mr Matthew Avery Mr James Bolton Dr Doug Wright Mr Bernie Rowe

72 9 Recommendations Classification Claims and Compensation Process Treatment and Rehabilitation

73 Future black box (Witkit)

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76 Common aims Prevent injury Treat injured Compensate appropriately Stop fraud

77 Sutton s Law

78 GP notes

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80 Thank You