Canadian Underwriter

Syndrome Versus Injury

January 31, 2011   by Laura Kupcis

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Distinguishing between someone suffering from whiplash syndrome and someone suffering from whiplash injury can be tricky for for both the medical and insurance community. Both clients are experiencing real pain, one simply has no physical cause for the hurt.

“They are feeling true pain, there is just no physical cause,” said Dr. R.J. Kamatovic, family and emergency medicine doctor, of those suffering from whiplash syndrome. “It’s thought largely to be due to psychological issues. They are not faking it, they are not just trying to cash in; in most cases they are actually experiencing true pain.”

Whiplash injury, on the other hand, is a musculo-ligamentous sprain, Kamatovic said during a recent seminar in Toronto hosted by Giffin Koerth. And, as with any minor sprain, there is the expectation that it will heal and the injured person will recover.

A 1995 study conducted by neurologist Dr. Henry Berry looked at injury suffered by demolition derby drivers. “He couldn’t find one single case of whiplash,” Kamatovic said. The study looked at 20 drivers, aged 19 through 48 who had been in the sport an average of 6.8 years. The average driver is hit 48 times per derby and will drive in roughly six derbies per year, accounting for about 1,900 hits for one driver. A quarter of these hits were considered severe. Most of the drivers had a sore neck or sore shoulders and were back driving in the derby within three days. One driver was hit on the driver’s side, suffered acute back pain, was hospitalized for three days, and was off work for one month, before getting right back in the driver’s seat. There were no reports of dizziness, headaches, numbness, poor memory, poor sleep or anxiety.

Somatiform disorder

However, there are those injured in a motor vehicle accident who continue to believe that they have  – and continue to be treated for – whiplash injury, when in fact they whiplash syndrome – a somatiform disorder. The patient continues to receive treatment for a sprain, when in fact they should be treated for the underlying psychiatric or psychological disorder which is causing them to feel pain, Kamatovic said.

“The important thing about recognizing somatiform disorder and appreciating it is . . . they are experiencing true pain,” he said. In fact, it is a pain severe enough to disrupt their every day life; it just does not have a physical cause. There is, however, often a psychological reason for the pain – one that can be triggered and exacerbated by a visit to the emergency room and follow-up trips to a family doctor. Certain common characteristics tend to be present among those prone to somatiform disorders: female, questionable coping skills, pre-existing psychological or psychiatric issues, depression, anxiety, history of abuse, low levels of job satisfaction and general unhappiness with life. Oftentimes they have a catastrophizing personality – where everything is the worst-case scenario.

When looking at the classic patient who is at risk of developing whiplash syndrome or chronic pain syndrome, there is a strong desire to assume the “sick role,” Kamatovic added. This often stems from an unhappy childhood where the only time the person felt good was when they were sick – they stayed home from school and didn’t have to deal with bullies, their overly critical parents might have been a little lax – and in fact provided some nurturing – when they were ill. “So, on a subconscious level, with a fragile psyche, there’s a strong drive to stay in that sick role,” Kamatovic said. “And most of this is subconscious; they don’t realize they are doing it. They find it better off being sick than trying to deal with the world around them.”

But how do we go from having an injury, which more often than not heals within a few days, to having a somatiform disorder?

Step 1: The emergency room

Wait times in ERs can be upwards of six hours – at times higher – for non-emergency cases. It’s overcrowded, there are people on floors, on stretchers, in hallways. “It’s mass chaos . . . You’ve got to be nuts to go to an emergency room,” Kamatovic laughs. “But, that is red flag number one: They have come to the emergency room.”

Those who come in hours, or even a few days, after an accident, and are willing to wait around for hours in the ER can signal one of two things: The person either has poor coping skills or they are looking for documentation to confirm a first encounter for insurance purposes.

These patients, because they are not actual emergency cases, end up sitting around for quite some time, waiting to see a doctor. While there are very few whiplash patients who need an x-ray of their neck – based on the Canadian C-Spine Rule – most will still receive one. A big part of this is customer satisfaction, Kamatovic said. This person has been waiting for upwards of six hours, if not more, and are not going to be very pleased when a doctor finally comes over to speak to them and says, “You’re fine, you can go,” without running any tests, he said. So, some of it is about avoiding complaints. But, other times it’s a fear of missing something. Every ER doctor has heard the horror story of a patient who walked in with an unstable C-Spine fracture, and now every doctor is afraid this patient is coming back, so they order x-rays. “We’re afraid that we might missing something; either a real injury or an imaginary injury or a coincidental injury later on,” Kamatovic said.

A doctor will diagnose whiplash, because it is a symbolic diagnosis and the patient leaves because they have been told they have a sprain, which seems reasonable. This can be followed up by a prescription for anti-inflammatories, which is a reasonable course of action for a sprain, though not required and will not speed healing. This makes the doctor seem active in the treatment process, and the patient is happy.

“We use the term whiplash because it’s a symbol, and human beings are more symbolic thinkers than anything else,” Kamatovic said. “They recognize the term whiplash, they know it’s not fatal, they feel safer leaving.” However, this can cause problems down the road. “By giving them that prescription, you’ve just told them that they have an actual disease,” he added. “Treatment equals disease. You wouldn’t have given them anything if there wasn’t anything wrong.”

Step 2: The family doctor

After a trip to the emergency room, the patient follows up with their family doctor – a patient advocate. “It’s very hard, because you have a therapeutic alliance and so when the patient comes in, there is almost this sense that you should be on the patient’s side and you’re in this together,” Kamatovic said.

The patient who is best off is the one who never goes to see a doctor, Kamatovic said, noting that this is with respect to a low-grade sprain. He cited a low-back strain study (the equivalent of whiplash injury in motor vehicle accidents) where 186 patients were split into three groups: Two days of best rest, an hour of back school where they were educated on their lower back and exercises to do at home, and a third group who were told to continue their life as normal. The third group fared the best, seeing better recovery, less pain and greater functional status. Those in the back school fared the worst, because they were forced to focus on the pain. “There’s no better way of making sure they won’t recover from their pain, than having them think about it every day,” Kamatovic said. A little bit of benign neglect is probably the best thing offered to a patient, he added.

The problem with whiplash syndrome is that the sprain isn’t the actual problem, and trouble starts with continuing to try and treat the sprain and not the actual psychological concerns.

There are symptoms, including anxiety, depression, headaches, fatigue, neck pain, etc., which are accepted as legitimate. The issue is that, more often than n
ot, these are symptoms of a somatiform disorder, and not actual injury; a disorder which is extremely difficult to treat in a family doctor’s office. The problem is that pain is subjective – it is very difficult to prove or disprove. “We are afraid to let it end with the idea that they are somaticizing, because they might not be,” Kamatovic said. “And the stakes are so high, it’s a risk we can’t take.”

This means that tests are ordered – MRIs, bone scans, x-rays, blood tests – and, frankly, if enough tests are ordered, something will show up, he said. An MRI is, in fact, the worst test to order, because most people have bulging discs – a finding which has very little to do with actual symptoms. But it’s enough for a person to cling to, which means the illness is reinforced when treatment is prescribed for the bulging disc.

“The problem is continuing to treat at the tissue level for an illness that is psychological or psychiatric,” Kamatovic said. “You can’t make something go away when it’s never really there.”

The solution

The ideal solution for Kamatovic would be to get family doctors out of the equation: The minute a whiplash injury walks through the door, the doctor is at a conflict of interest. “In the absence of being able to prove or disprove, all we can do is rubberstamp their symptoms,” he said.

Anybody who suffers from a whiplash injury could be sent to a third party whiplash treatment and assessment centre, where the doctors are “bulletproof” and able to make “schoolyard diagnoses.” (This is a reference to when kids are playing in the yard, one gets hurt and another tells them to suck it up and get on with it, and they do – not realistic, however, in a professional setting, Kamatovic notes).

The third solution is to rebalance the scale: If there are no secondary benefits to having whiplash injury, the actual number of cases would decrease. Kamatovic cited how self-employed people take next to no sick days, because the benefits of being sick do not outweigh the benefits of going to work.

There is, unfortunately, a strong enticement on both sides of the fence to keep whiplash syndrome alive, and more often than not patients are caught in the middle, Kamatovic said.

“The solution would be to stop paying patients for having whiplash, stop paying us for treating it, and then you’d rebalance the scale,” he said. “The benefits of not having whiplash would start to outweigh the benefits of having whiplash and you would see whiplash syndrome cease to exist.”