The moral hazard of whiplash

A whole edition of Spine was recently dedicated to whiplash associated disorders (WAD) (Vol 36 Number 25S). One paper by Cote and Soklaridis (1) caught my attention. They warn that health professionals should be aware of the danger of iatrogenesis during the early stages of WAD. According to Wikipedia the term iatrogenesis means brought forth by a healer (from the Greek iatros, healer). In this case, it refers to the development of iatrogenic disability through the promotion of illness behaviour. This paper discusses how whiplash has been medicalised, transforming it from a benign problem to a medical condition with significant societal costs.

A recent article by the Chartered Society of Physiotherapy (UK) called for greater involvement by physiotherapists in the management of acute WAD (2). However, this paper presents evidence that “too much too early after whiplash injury can delay recovery”(1). The Neck Pain Task Force also came to this conclusion in 2008 suggesting that “less is more” in acute WAD (3).  The provision of intensive treatment in the early phase post injury may be harming patients. Whiplash injuries are complex, complicated by societal and compensation influences, however, it made me consider the role of health professionals in managing acute WAD. Cote and Soklaridis suggest this is a moral hazard. They suggest that health professionals should no longer provide clinical interventions but need to be prevention managers. We need to educate, reassure and promote the return to activities early on after whiplash injury. We need to think carefully about the treatments we provide, avoiding treatments for which there is little evidence of benefit (even if that means providing less treatment) or passive treatments that encourage patient dependence. My experience of working on a large clinical trial evaluating treatments for acute WAD is that many health professionals view acute injuries through a   biomedical lens. If you don’t believe me then have a look at this:

httpvh://www.youtube.com/watch?v=Ap4sAqVnG5s

The biomedical approach, embedded with medical jargon and descriptions of tissue damage, has most likely contributed to the medicalisation of WAD. Health professionals need consider the information provided to patients and how the language used can impact on patients’ conceptualisation of their injury and resulting symptoms. It is clear that social and psychological factors impact on outcome in WAD. These factors need to be considered right from the start which is essentially the conclusion by Cote and Soklaridis. So what is the way forward with the early management of WAD? For a start, as health professionals we need to view WAD through a biopsychosocial lens, providing patients with information aimed at promoting wellness behaviours rather than illness behaviours. Unfortunately, the best way to achieve this is still not clear but there are some excellent suggestions in the final discussion paper in that special edition of Spine (4).

About Esther Williamson

Dr Esther WilliamsonEsther is originally from Brisbane, Australia where she did her physiotherapy degree at the University of Queensland. Esther has lived in the UK for the past 15 years and recently completed her PhD at the University of Warwick where she worked part-time as a research fellow in the Clinical Trials Unit. Esther’s main research interest is finding out ways that physiotherapists can improve the management of acute injuries and prevent long term disability. Her other job is looking after her two kids, Fraser and Annie.

References

1. Côté P, & Soklaridis S (2011). Does early management of whiplash-associated disorders assist or impede recovery? Spine, 36 (25 Suppl) PMID: 22101750

2. CSP: ‘Give physios a bigger role in assessing whiplash injuries‘. 12 January 2012.

3. Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, Peloso PM, Holm LW, Côté P, Hogg-Johnson S, Cassidy JD, Haldeman S, & Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (2008). Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine, 33 (4 Suppl) PMID: 18204386

4. Jull G, Söderlund A, Stemper B, Kenardy J, Gross A, Côté P, Treleaven J, Bogduk N, Sterling M, & Curatolo M (2011). Towards Optimal Early Management After Whiplash Injury to Lessen the Rate of Transition to Chronicity: Discussion paper 5. Spine PMID: 22020602