This is part 2 of two on the enigma of whiplash, which in the meantime is still an enigma. The first edition (BCMJ June 2002) broached the issue of incidence, costs of whiplash, the role of X-rays, and some of the traumatic pathological entities. We also started on the road to reality—the riddle of fibromyalgia and temporomandibular disorder. In this second edition, we start to think outside of the box and challenge the puzzle of trauma and stress and the social impact of whiplash.
Among the scattering of apparent dysfunctional disorders, one stands out as actually being caused by the accident, and even though it is expressed in psychological terms, is nonetheless a physical disorder. The causative factors underlying post-traumatic stress disorder (PTSD) have now been elucidated (Koch), and are shown to be an over-activated adrenergic fear-event triggered by memories of the traumatic event. The locus ceruleus is one of the culprits, being just a little too primed to squirt out its juices. The new treatment approach for PTSD is to involve the patient in repeated conditioning exposure events; desensitization works. PTSD represents an interesting paradigm shift in that it’s physical (albeit in the brain) not psychological (as if nowhere). How many other so-called psychological disorders will eventually be similarly unraveled?
Speaking of the brain, does whiplash damage it? Some collision victims become so distressed by the event that they claim that they have suffered brain damage. Radanov, the author who first stated that whiplash caused brain damage, now finds that it does not. Is there a social momentum that leads a society into reacting so? Ferrari explains how. Part of the social issue of whiplash is chronic pain syndrome, which for some is a socially correct way of rephrasing the anticipated financial gain (Hayes). Can we differentiate these psychosocial dysfunctional disorders from malingering?
One of the key players in the whiplash industry is the lawyer who plays a critical role in counter-balancing the potential abuses of claims-reduction behavior that unchecked insurers might be tempted to pursue. No doctor should look upon the medicolegal process as anything other than a legal process, the medico part is purely ancillary. I like to tell lawyers the following story: “A surgeon calls you (a lawyer) and invites you to participate in surgery. You’re flattered and agree. While scrubbing, the surgeon cautions you that during the surgery, some highly skilled persons in the operating theatre will determine to discredit you. If you screw up, the patient might die, and your career will be destroyed.” Doctors in court are like lawyers in an operating room—they are out of their element, and totally vulnerable.
When treating whiplash, the experts say that nothing actually works except time, a confident attitude, maybe some exercises to keep things functional, and getting on with life. Not very exciting, eh? Your whiplash patients should be given the benefit of the doubt, provided reasonable information on how to look after themselves, and shown a few prudent exercises. The last article in this edition has a tear-out question-and-answer form for your patients and some simple, neck-specific exercises that they can do. Will it work? Maybe. It is, however, about the only thing that appears to have a reasonable chance at helping patients help themselves.
We started off labeling whiplash an enigma, and end noting that it is still an enigma. A judge once gave me a lesson on whiplash; it went something like this: “It’s really very simple doctor. If someone says they were okay before an accident, and now they are not okay, that’s whiplash, and it’s caused by the accident—that’s all you need to know.” If we are ever going to help solve the enigma of whiplash, all the parties need to be educated on the wide spectrum of the issues involved. Whiplash is not in the least way simple. The last word will probably come from outside medicine and anything discussed above. Some policymaker or politician will probably change the entire game by altering the way the golden goose’s cash is distributed. The enigma awaits a brave decision maker.
—Murray Allen, MD
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