Whiplash- type Problems Summary of Recommendations Part 1 - The Whiplash Problem in Perspective

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1 Whiplash- type Problems Recent concern has emerged regarding both the number of claims for whiplash- type injuries, and how they are managed. Evidence has also emerged that this kind of claim is inflating the cost of U.K. vehicle insurance, and therefore affects all of us. This two- part report provides a summary of proceedings from a recent scientific conference held in London on the topic of tackling the whiplash culture by considering whether there is a better way of doing things. The first part covers important background information by addressing key questions, and the second part provides a set of key recommendations and action points. Summary of Recommendations Classification of Whiplash Associated Disorders (WAD) A: Insist on the international classification rather than diagnosis for all documentation B: Avoid whiplash language and jargon, it can exacerbate the problem and perpetuate disability. C: Distinguish minor neck injury after a vehicle collision from chronic neck pain and disability. Claims and Compensation Process D: Accept cases and claims if and only if classification has been completed E: Ensure that whiplash claims are not inappropriately or irresponsibly encouraged, and that the claims process does not encourage illness behaviour F: Establish and use independent assessment centres Treatment and Rehabilitation G: Make accurate information about WAD available to public and healthcare providers H: Promote the early use of evidence- based treatment and clinical management I: Manage providers with case management to avoid over- medicalisation: do just what s required using a stepped approach Part 1 - The Whiplash Problem in Perspective Views and opinions about whiplash injuries are many and varied, with evidence less easy to come by. In trying to understand whether there is a problem in the U.K., and why it might have developed, there is need to look at a wide range of issues and how they interact with each other. Why is there a problem with whiplash and diagnosis? The term whiplash has become everyday parlance referring ambiguously to a very diverse range of things. Allowing it to remain so is linguistic laxity. Initially the term referred to a mechanism of injury, then became shorthand for types of neck injury, and has ended up a catchall term. Importantly, it is used in place of other diagnostic terms. That is, a person is said to have whiplash, and this is now widely used in medical documentation. This approach overlooks that any type of whiplash- associated disorder or WAD is a subset of neck pain. It includes the implicit assumption that causality is known and well defined. It lacks information about the severity of the problem, or how it can be most effectively treated and managed. A diagnosis is typically used to determine the causes of symptoms, mitigations for problems, and solutions to issues. The catchall term whiplash simply cannot deliver these hallmark aspects, and to continue using it as a surrogate diagnosis is careless and unhelpful. Can whiplash- associated disorder be reliably categorised? Yes, with respect to: the nature of the clinical problem, it s severity, and what is likely to be the most effective way of treating it and helping the injured person get on with their life. However, this does not by itself differentiate the causes. Knowing how someone s neck pain started can only be based on it being reported by the person, witnessed by an observer, or

2 both. Each is prone to error, and depend on how people attribute cause and effect. This is not a trivial issue, especially for the claims and compensation process. Does it matter what language and terminology is used? Yes, it does. There is good scientific evidence that causal beliefs and attributions following car crashes predict the persistence of disability, over and above the severity of the initial complaints. Under the principle of do no harm this indicates that it is prudent to ensure outcomes for the injured person are not made worse by attributing neck pain to whiplash- type injury unnecessarily. Clearly, this applies mostly to the less severe end of the injury spectrum, but this is by far the greatest number of cases that present. For clinicians this means avoiding a speculative tissue diagnosis, and instead using a simple descriptive classification. Can whiplash- associated disorder be differentiated from other types of neck pain? No, clinically and physiologically they cannot be differentiated (unless there is very severe injury). This has an important implication: effective treatment and rehabilitation for most cases of WAD is the same as that for other types of neck pain. What works, for whom, and when, is the same and we should expect similar outcomes. It can be argued that the only major difference lies in our interpretation of whiplash, and what we do about it. This requires consideration of the claims process and all that surrounds it. Can neck pain be confused with whiplash- associated disorder? Yes. Neck pain is a very common experience; as is other soft tissue pain such as back pain, arm pain, etc. On a given day up to 20% experience neck pain, and across a given year about 40% of us do. It is an episodic experience that usually returns at some stage. That is, once we ve had it, we re more likely to have it again. Inevitably some people involved in traffic collisions will feel pain during the following days, weeks, or months. The question as to whether that is always whiplash- type pain is very difficult to determine because they are clinically indistinguishable. This means calling it whiplash is heavily dependent on the attribution made by the individual, by clinicians, and others. The situation is even more complex when neck pain becomes persistent or chronic. This occurs in between 5% and 20% of people, depending on how it is defined. While it may appear counter- intuitive, it is important to note that mistakenly attributing neck pain to a whiplash event can occur easily, but that this may be unhelpful to obtaining the best health outcome for the person. Can whiplash- associated disorder be prevented? Preventive efforts including vehicle design, road engineering, and driver education seem to hold considerable promise. Analysis of most statistics lead to the conclusion there has been a general improvement in rates of road fatalities and severe injury. However, the situation remains obscure for less severe injuries. There is a clear paradox: the number of minor injuries on roads reported to police has steadily decreased, while the number of claims has steadily increased. This means it is unclear whether preventive efforts have had any actual effect on less severe injuries. The only thing that is absolutely clear is that they have had no impact on reducing the number of claims. Can persistent (chronic) problems be prevented? The answer is probably, based on the collective evidence for all types of soft- tissue pain and injury, and that specific to WAD. To date, more effort has been put into seeking prognostic factors than on looking for interventions that might prevent chronicity. As with all types of musculoskeletal problems the prominent role of psychosocial factors in the development of persistent pain and disability is also evident in WAD. Evidence has demonstrated a greater 2

3 potential to prevent pain- related disability than chronic pain itself, and this can generally be considered cost- effective. Why does the claims and compensation process matter? Discussions surrounding the topics of injury, pain, suffering, blame, compensation, claims, etc. often involve strong opinion, emotive argument, and over- simplification of viewpoints into lobbies or camps. Over time these often end up effectively as a vested interest, needing to be defended. Space does not permit a full consideration of these complex and subtle issues. However, it is possible to briefly look at why the process of making claims can make a difference. There is evidence that compensation processes can impair health outcomes, and that this finding also applies to WAD. Both the quantity and quality of this can be reviewed and debated, but it is not easily dismissed as trivial or irrelevant. Even if these data are considered as only indicative, it obligates us to consider the potential role of the claims and compensation process in negatively influencing outcomes for problems such as WAD, and should not be easily dismissed. It does not in any sense suggest there is no role for claims or compensation, or that symptoms such as pain should be trivialised. What it does suggest is that the process of how claims are initiated, managed, and concluded should be considered with a focus on achieving the best health outcomes and ensuring that nothing is done to undermine this. This is an important challenge, not least because solid rational explanation is so needed in this area. What would a better way of doing things look like? There would be primary prevention that is demonstrated to be effective in reducing the number and severity of neck injuries. Every case of WAD presenting for healthcare should be classified by grade (i.e. nature and severity): Classification Criteria - Bone & Joint Decade Task Force, 2008 Grade 1: no signs of major pathology and no or little interference with daily activities Grade 2: no signs of major pathology, but interference with daily activities Grade 3: neck pain with neurological signs or symptoms Grade 4: neck pain with signs of major pathology For every case the type of clinical intervention (treatment and rehabilitation) can be initially matched to WAD grade, using an evidence- informed pathway. This approach would be outcome- focused, taking into account both symptoms and level of function. The claims and compensation process would be designed so that it does not inadvertently encourage attributing neck pain to whiplash- type injury. Effective case management would be provided to ensure early access to necessary and appropriate treatment and rehabilitation. This would provide objective oversight of cases without being invested in provision of services. Finally, independent expert centres capable of assessing complex and slow- to- recover cases would be developed. These would be capable of providing definitive second opinions, resolving disputes about causation, and devising effective management plans for long- term persistent cases. What underlying principles are required to do things better? A smarter approach to WAD needs to focus on the entire spectrum from new cases, prevention of chronicity, through to managing long- term cases. A selective focus on one area invites problems in the others. The fundamental principle required is to tackle the less severe grades of WAD (i.e. grades 1 and 2) proactively with an evidence- based approach. This involves provision of information and advice, symptomatic relief, positive expectations for 3

4 recovery, and a focus on maintaining activity. Most should never need to enter a compensation process, and encouraging that should be avoided due to the potential for worse outcomes. The same principles apply to grade 3 cases, although the range of interventions offered might be wider and require slightly longer timeframes. Rapid identification of slow- to- recover cases should lead to intervention and clinical management designed to prevent long- term disability. Chronic cases need to be identified and managed as chronic neck pain cases, not subjected to serial ineffective therapy that assumes chronic pain is merely the same as an acute problem. 4 Part 2 - Tackling the Whiplash Problem Approaches to problems such as whiplash associated disorders (WAD) based on simple solutions have little or no track record of success. For these types of problems it seems we are destined to live in a house of many paradigms, and necessarily must find smarter approaches that are sufficiently comprehensive and robust without being over- complicated. Initially this may appear daunting, but we argue there is much that can be done both simply and in a common- sense fashion without additional cost or resources. However, we urge readers to think of this as a package and not as a smorgasbord to pick and choose from. The major focus for tackling WAD must be centred on the needs of the person. Nothing can be gained from denying the existence of symptoms. By definition these are subjective, and only the person can feel them. As already noted, neck pain for any reason is a very common experience. However, there are a number of key things that can be done based on the available evidence. An evidence- synthesis approach to three big questions about whiplash- associated disorder In an ideal world everything would be based on optimal evidence, but controlled experimental trials are neither viable nor practical for many of the big questions about the whiplash field. This means there is an important role for evidence synthesis to provide a buttress for best practice and policy- making. We need to ask, what could actually make things better? A set of recommendations is made across three main areas: classification/diagnosis; claims and how they are managed; and, treatment and rehabilitation. 1. How should whiplash- associated disorders be classified? Recommendation A: Insist on classification according to criteria established by the international Bone & Joint Decade Task Force on Neck Pain and its Associated Disorders in 2008 (this includes WAD). This is a foundation for effective clinical and claims processes and should include all key parties: i.e. A&E, GPs, medical consultants, physiotherapists, insurers, claims management companies, lawyers, case managers, and government departments such as DWP o Cost of implementation is minimal. Recommendation B: Avoid irresponsible, alarming, and ambiguous whiplash language that can exacerbate the problem and perpetuate disability. Making accurate, consistent information and advice available to everyone is essential, in both printed format and internet- based o Cost of implementation is very low, since the material already exists in well- developed form and only requires suitable distribution methods Recommendation C: Distinguish the short- term pain of minor neck injury after a vehicle collision from persistent/chronic neck pain and disability. They are separate entities requiring different treatment and rehabilitation.

5 5 Monitor cases by duration and recurrences to ensure that serial ineffective therapy is not being delivered o Cost implications should be negligible. It can be argued that responsible insurers and funders should be doing this already 2. How should the claims process be improved? Recommendation D: Accept cases and claims if and only if classification has been completed according to the Bone & Joint Decade Task Force criteria. The most effective approach is to ensure this is applied consistently by all relevant organisations, including insurers and governmental bodies o There are no cost implications, this is a procedural measure Recommendation E: Ensure that whiplash claims are not inappropriately or irresponsibly encouraged, and that the claims process does not itself encourage illness behaviour (e.g. individuals currently perceive they have to prove they are injured, which restricts their potential for recovery). The most effective approach is to review existing incentives, and the roles of potential vested interests. It seems axiomatic to remove incentives for opportunistic claims behaviour by individuals or any other party (including accident/injury claims agencies, assessment/reporting agencies, treatment providers, etc.). A key operational issue is to enforce independence between those adjudicating claims, and those providing services to claimants. Insurers and agencies should be encouraged to make cover decisions promptly wherever possible. An additional step that seems necessary is to promote the provision of consistent, evidence- informed information about WAD, and to ensure poor quality advice is challenged effectively. In general, this is best achieved using collegial pressure within the professions (medical, legal, insurance, etc.) o There are potential cost implications depending how this is done, however there should always be a greater return for every spent Recommendation F: Establish and use independent assessment centres. These provide key services, but have no vested interest because they do not provide healthcare to the cases: o Clinical reviews of lack of progress, and devising an effective ongoing management plan o Advice on managing difficult claimants, e.g. long recovery duration, lack of adherence to treatment/rehab, inconsistent presenting features, etc. o Assessments to identify claimants who may be making an opportunistic claim o Dispute resolution about claim attribution and causation o Review of services offered by healthcare providers and the standard of care delivered These should be established as cost- effective services 3. How should people with whiplash- associated disorder be treated and rehabilitated? Recommendation G: Make accurate information about WAD available to public and healthcare providers. Information should be provided early - prior to claim (public health) and at the point of claim. Consistent forms and procedures across A&E, primary care, and reporting agencies will help clinicians to move to a classification (as opposed to diagnosis) approach. They will also act as training aids, and can be supplemented by CPD initiatives. o The cost of implementation would be modest, especially if shared across agencies and sectors Recommendation H: Promote the early use of evidence- based treatment and clinical management. This is effectively achieved by funding treatment and rehabilitation services only when they are evidence- based, and declining funding for all others. It means ensuring all cases are properly classified, giving accurate information and advice about neck pain associated with road traffic collisions, setting clear expectations of how long symptoms should last, maintaining a focus on activity and work, and delivering treatments with known effectiveness for minimum time required o U.K. experience (with insurers) is that this approach results in substantial cost savings and fewer claims, while maintaining high levels of customer satisfaction

6 6 Recommendation I: Use a stepped approach to the provision of healthcare (based on the principle only what s needed when it s needed ) and guide treatment and rehabilitation providers (e.g. through case management) to avoid over- medicalisation The emphasis is on preventing persistent pain and disability (loss of function) Engage professional associations of all types (medical, legal, insurance, etc.) to promote evidence- informed approaches, and to discourage unnecessary medicalisation and over- treatment UK Insurer Experience The effectiveness and benefits of the overall package of evidence- informed recommendations outlined above has been demonstrated in U.K. settings, in addition to other countries. For example, a large U.K. insurer has demonstrated that by using this sort of approach it is possible to: reduce musculoskeletal claim numbers, reduce claim duration, reduce total claim cost by 40%, improve functional outcomes including return to work, and to achieve all of this while increasing customer satisfaction. These findings also hold for whiplash cases. What needs to be done? First, recognise that the situation can be improved. This requires re- examining basic assumptions, and looking for an effective approach that is not over- simplified. Some recommendations may appear challenging to specific sectors or parties, but the overall goal is clear: ensure that those who are injured get early access to appropriate care (not too little, or too much), and those who have little or no need for support or care do not have valuable resources squandered on them. For policy- makers and those involved in managing the processes there are three key actions: require classification of cases; remove incentives such as referral fees that distort behaviours; and, incentivise financial independence between key players, e.g. claims management services should not also be providers of healthcare services. Debate needs to be stimulated among all relevant professions (including medical, legal, insurance, etc.) so they become engaged in influencing their colleagues to adopt the recommendations. This report was prepared by Dr Nick Kendall who served as chairman for the conference tackling the whiplash culture held in London on 2 November The expert speakers consulted on the draft recommendations were: Professor Sir Mansel Aylward; Mr Matthew Avery; Professor Gordon Bannister; Professor Kim Burton; Professor J David Cassidy; Mr James Dalton; Mr Bernie Rowe; and, Dr Doug Wright. Their support and expert advice is gratefully acknowledged.