Capita Clinical Conference Whiplash Injury and Medico-Legal reporting Tuesday 10 June 2014 Martin Gargan Consultant Orthopaedic Surgeon
Law Other Medicine
Common aims Prevent injury Treat injured Compensate appropriately Stop fraud
Whiplash Fact or Fiction?
Definition a collection of symptoms produced by a soft tissue injury of the cervical spine
Railway spine
Malingering the imprecise correlation between symptoms and signs!
FRCS 1988
Test hypothesis all better by 2 years
Natural evolution of late whiplash syndrome outside the medicolegal context Lancet 1996; 347:1207-1211 Scrader H et al
The controversy over late whiplash: are chronic symptoms after whiplash real? Whiplash:current concepts, Ed Gunzburg 1998 Freeman M et al
5 PHASES: Ramping S phase Transition Hyperextension Flexion
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): 665-674
Gargan MF and Bannister GC The long term prognosis of soft-tissue injuries of the neck J Bone Joint Surg 1990; 72-B: 901-903 Gargan MF and Bannister GC The rate of recovery after following soft tissue injury of the neck Eur Spine J 1994; 3: 162-164 Gargan MF, Bannister GC, Main C et al The behavioural response to whiplash injury J Bone Joint Surg 1997; 79-B: 523-526
A no symptoms B nuisance C intrusive D disabling Gargan MF & Bannister GC 1990
Long-term disability after neck injury Joslin CC, Khan SN & Bannister GC J Bone Joint Surg (Br) 2005; 86B: 1032-4
80 patients 1 stable cervical spine # 2 unstable cervical spine # 3 litigating whiplash patients 4 non-litigating whiplash Vernon & Mior NDI
Litigating whiplash greater disability Pathophysiology of injury Demographics Treatment received Psychological differences
The fluctuation in recovery following whiplash injury: 7.5 year prospective review. Tomlinson PJ, Gargan MF and Bannister GC Injury 2005; 36(6): 758-761
Factors predicting outcome after whiplash injury in subjects pursuing litigation. Lankester B, Garneti N, Gargan MF et al Eur Spine J 2005; 15: 902-907
Retrospective 277 patients Pre-accident, accident and response variables Multivariate analysis
97 males, 180 female average age 39.9 (15-81) f/u 21 months (9-60)
Poor outcome: Strongest associations present before impact
back pain high frequency GP attendances depression/anxiety front position radiating pain
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
Mean group differences for the fat indexes in the right and left rectus capitis posterior minor and rectus capitis posterior major muscles. (mean+/-sd)
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:853-855
Whiplash injury Bannister GC, Amirfeyz R, Kelley S and Gargan MF J Bone Joint Surg 2009 ; 91-B (7): 845-85
1971 1992 2011
Jones v Kaney (2011) Jack Straw v Everyone (except insurers)
Epiphany
Home Secretary 1997-2001 Justice Secretary 2007-2010
third rate doctors
Homo Orthopaedicus
..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
3g at 10km/h 8g at 25km/h
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."
proportionality
Medical Records -? relevant - crucial - but for
MEDICOLEGAL WORK 1980s 90% Consultant Orthopaedic Surgeons 10 % other
MEDICOLEGAL WORK 2012 15% Consultant Orthopaedic Surgeon 80% General Practitioner 5% Other
> 500,000 whiplash claims pa 5bn Claimants/RTA
Intermediaries
If you are going to tell lies you need to have a good memory
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
.apparently disproportionate disability!
Symptoms v Signs...conscious exaggeration of complaints for financial gain
Waddell G et al Symptoms and signs: physical disease or illness behaviour BMJ 1984; 289: 739-741
? extrapolate to the cervical spine Whiplash test?
- good days/bad days - use of analgesics - unfair video?
Has the expert asked the right questions? Is the victim telling the truth? Is any discrepancy significant?
is it black? definitely? is it not a bit grey? can you see any white?
Change the law?
Is there a whiplash culture? Is there a better way? Evidence-Informed Recommendations about Whiplash- Associated Disorder 2 November 2011
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
9 Recommendations Classification Claims and Compensation Process Treatment and Rehabilitation
Future black box (Witkit)
Common aims Prevent injury Treat injured Compensate appropriately Stop fraud
Sutton s Law
GP notes
Thank You