Driving and football: admittedly two very different skills. Yet for me they have a common ground: a very low point scoring history. Great for one but not the other. My annual car insurance premium offer has just come through the letter box this morning and it, much like my past glories of attempting long range shots with the outside of my right boot, has not been welcomed. With Black Friday and Christmas approaching isn’t an “offer” something that should excite and entice us if even just a little? Weren’t penalty points introduced to discourage poor driving behaviour with more than just a fine? Or more so reward the more compliant driver? But motor insurance companies have taken it upon themselves to make their own criteria for the rise in premiums and they may not be entirely to blame.
The Personal Injuries Assessment Boards (PIAB) is Irelands independent state body set up to assess personal injury compensation. Their 2018 Annual Report might go some way in explaining some of the reasons for the price hikes. The number of applications to the PIAB in 2018 was 33,371. Of these applications 70% were related to motor liability. Of the 33,371 applications 12,112 were awarded compensation with an average award of €24,649, a total cost to our little nation of €300 million. Most if not all of these claims can be attributed to a form of whiplash associated disorder (WAD).
WAD is the term given to what can be a variety of symptoms following an acceleration/deceleration injury mechanism to the neck, usually from road traffic accidents (RTA) but sometimes other scenarios such as high impact contact sports. For a long time we’ve thought of WAD as just neck pain after a RTA. Radiological findings are normally clear and the symptoms get attributed to a “soft tissue injury”. Typically the facet joint structure is the most common source of this type of neck pain. But like an ankle sprain once you roll it and over stretch the ligaments it can cause the surrounding muscle recruitment pattern to become a bit more sluggish, rigid and often left feeling unstable and unsure about putting weight through it. The same applies with WAD but unlike the ankle sprain symptoms can extend far beyond neck pain and for more extended periods of time.
Three quarters of WAD patients will experience a form of sensorimotor impairment. This means feelings of unsteadiness, dizziness, light-headedness, and difficulty concentrating. Patients with whiplash will demonstrate more of a postural sway and balance impairments, as those sluggish and mis-firing muscles work harder than they need to to maintain postural equilibrium (Field et al 2008, Anabela et al 2013). Sometimes people do not make the connection with these symptoms and their neck pain. 50%, despite reporting no dizziness, will be unable to tandem stand with their eyes closed and that number increases to 74% with those who do report dizziness. It has been documented that neck pain patients take shorter and slower steps, likely in an attempt to feel less unstable while walking (Uthaikhup et al 2013). So how might you think we could go about treating such symptoms? Quite a lot to address there don’t you think?
Data has emerged this year citing a high percentage of WAD patients cease attending treatment at pain clinics once their medico-legal case has been settled. The cynical part of all of us will look at this with one acutely raised eyebrow. A whiplash injury in Ireland will be compensated 4.5 times higher than the same injury in the UK. But more research has shown links with mental health and WAD with the prevalence of psychiatric disorders in people with long standing WAD being 25% for post-traumatic stress disorder, and 20% for anxiety (Mayou and Bryant 2002). To further complicate an already complex issue individuals with mental health problems report higher levels of disability, pain, and reduced physical function and where physical injury and psychiatric disorder coexist have shown to be off work longer duration than those with just physical pain (Kenardy et al 2011).
As complex a condition as this is, collectively as professionals (solicitors, healthcare professionals, and insurance companies) we’ve been doing a lousy job. As well as a review around the monetary awards given to victims of RTA’s, we too need to reevaluate how we are managing this group. 40% of injured WAD patients are predicted to still have moderate symptoms remaining at 12 months (Stirling 2014). We have been too focused on pain and not progressive (or arguably aggressive) enough with the other treatment and management strategies out there. We’ve been reluctant to prescribe strength training for neck muscles yet if weakness was detected for any other structure in the body like the knee, ankle, hamstring, or low back, it would the first thing we would do (or at least should be doing!). What message must that send to patients? Fear avoidance is a pattern that many neck and back pain patients will experience and with this very group we are avoiding the very thing they need to be doing. We should encourage balance and coordination, and eye movement exercises. We know that this has an effect on normalising muscle imbalances with neck pain and why challenging and not avoiding this system should be an integral part of the rehabilitation process.
With a PIAB 2019 Strategic Plan in the pipeline to try to reduce the monetary value and indeed emphasis placed on the label “whiplash” the focus needs to shift towards education and function – an early assessment followed by optimal advice and management strategies from the start. A quicker return to work, if even in a modified capacity, is better for long term outcome. By this I mean better for that persons overall health and wellbeing. But too often the focus tends to be on the legal case in question. An extended delay in return to work for medical assessments or reports, or fear of onset of some symptoms casts doubt over future prospects of return to work.
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