Follow-up studies of personal injury litigants

This chapter describes whiplash injury as the supposed injury that is sustained during a whiplash movement. The symptoms that supposedly result from this injury have been referred to variously as “whiplash symptoms,” “whiplash syndrome” and “whiplash-associated disorder (WAD).” Patients with acute symptoms do not need to be investigated and medicalized. If patients are treated well, ab initio, compensation claims should diminish. The treatment should include dealing with distress and any desire for recognition. The chapter reviews that a minority of patients develop chronic symptoms. For these patients there are no data to justify most forms of treatment currently used. There is emerging evidence that behavioral therapy can help behavioral features. There is substantial evidence that exercises can be of some benefit, but they do not eliminate pain. Epidemiologic studies have shown that the pain can be traced to one or more of these joints in some 60% of cases. It explores that the concept of cervical zygapophysial joint pain is thus sustained by convergent validity: as multiple and independent lines of evidence point to the same conclusion. Treatment for this condition is available in the form of radio-frequency neurotomy.

Objectifs. – Faire le point sur un sujet de traumatologie et de rééducation devenu récemment un problème de santé publique très controversé.

Méthode. – Une recherche bibliographique sur la base de données Medline avec le mot clé Whiplash a été réalisée. Étaient sélectionnés les articles avec un résumé en français ou en anglais et permettant de faire le point sur l’accidentologie, la biomécanique, la démonstration de lésion, l’épidémiologie et les traitements.

Résultats. – À partir de 1664 références trouvées, 232 ont été analysées. Le mécanisme habituel de l’accident est un choc arrière entraînant chez les occupants du véhicule heurté une brutale extension cervicale basse avec flexion haute suivie d’une flexion globale. Dans près de 50 % des cas, le traumatisme est équivalent à celui obtenu dans des autotamponeuses. Les changements de vitesse sont rarement supérieurs à 15 km/h. Un appui-tête en regard du centre de gravité de la tête limite considérablement l’extension cervicale. Toutes les structures de la colonne cervicale peuvent être lésées et principalement les articulaires postérieures mais les lésions ont été seulement mises en évidence dans les traumatismes sévères. La variation de l’incidence entre les pays pourrait être liée à leur système médicolégal. Quoique subjectifs, les symptômes initiaux sont assez univoques suggérant un réel support anatomique ou fonctionnel mais la chronicité semble relever surtout de facteurs psychologiques et sociaux. L’association de : absence de douleurs postérieures médianes précises, absence d’intoxication, absence de troubles de la conscience, absence de signes neurologiques et de polytraumatisme a une valeur prédictive excellente de l’absence de lésions ostéo-articulaires. Hormis le stade 4 de la Quebec Task Force (0, aucun symptôme et aucun signe d’examen physique ; 1, plainte de douleur, raideur et sensibilité sans anomalie clinique ; 2, la cervicalgie s’accompagne d’une limitation objective des amplitudes cervicales et il existe des points douloureux à la palpation ; 3, la symptomatologie cervicale s’accompagne d’anomalies neurologiques (abolition d’un réflexe, déficit sensitif, déficit moteur) ; 4, les signes cliniques sont importants et il existe des lésions graves ostéo-articulaires (fracture ou luxation)), il faut éviter la mise en place d’un collier et mobiliser précocément le rachis cervical.

Conclusion. – Dans la plupart des traumatismes cervicaux en coup de fouet, la bénignité doit être affirmée rapidement, la mobilisation cervicale recommandée et les procédures d’indemnisation raccourcies au maximum.

Objectives. – To focus on a topic of traumatology and rehabilitation becoming recently a much debated public health problem.

Method. – A references search from Medline database with whiplash as keyword was carried out. Were selected articles with abstracts in french or english and focusing on accidentology, biomechanics, demonstrated lesions, epidemiology and treatments.

Results. – From 1664 references found, 232 were reviewed. The usual mechanism of crash is a rear-end collision inducing in the occupants of the bumped vehicle a sudden lower cervical spine extension with upper flexion followed by a global flexion. In nearly 50% of the cases, the stress occuring in the collision is comparable to that observed in bumper cars. The velocity changes are seldom up to 15 km/h. A headrest at the level of the center of gravity of the head restrict significantly the extension of the neck. Every structure of the cervical spine could be damaged and mainly the facet joints but the lesions were only demonstrated in severes traumatisms. The discrepancies in incidence among the different countries could be related to their medicolegal system. Although subjectives, the early symptoms are rather similar among patients suggesting true anatomical or functional disorders but the chronicity seems to be mainly related to social and psychological factors. The association of: no posterior midline cervical tenderness, no intoxication, normal alertness, no focal neurological deficit and no painful distracting injuries has a good predictive value of the lack of osteo-articular lesion on X-rays. Except the grade IV of the Quebec task Force (0, no symptom; 1, pain and stiffness; 2, neck complaint and physical signs; 3, neck complaint and neurological signs; 4, fracture or dislocation) the use of a collar should be avoided and the cervical spine should be mobilized.

Conclusion. – In most whiplash injuries, the mildness should be early stated, mobilization encouraged, and procedures of compensation shortened.

Minor injuries of the cervical spine are essentially defined as injuries that do not involve a fracture. Archetypical of minor cervical injury is the whiplash injury. Among other reasons, neck pain after whiplash has been controversial because critics do not credit that an injury to the neck can occur in a whiplash accident. In pursuit of the injury mechanism, bioengineers have used mathematical modelling, cadaver studies, and human volunteers to study the kinematics of the neck under the conditions of whiplash. Particularly illuminating have been cinephotographic and cineradiographic studies of cadavers and of normal volunteers. They demonstrate that externally, the head and neck do not exceed normal physiological limits. However, the cervical spine undergoes a sigmoid deformation very early after impact. During this deformation, lower cervical segments undergo posterior rotation around an abnormally high axis of rotation, resulting in abnormal separation of the anterior elements of the cervical spine, and impaction of the zygapophysial joints. The demonstration of a mechanism for injury of the zygapophysial joints complements postmortem studies that reveal lesions in these joints, and clinical studies that have demonstrated that zygapophysial joint pain is the single most common basis for chronic neck pain after injury.

Interpretation of a patient’s neuropsychological examination involves the determination of the role motivational and psychiatric factors may have played. The ability to detect malingering becomes crucial, particularly when the examination occurs as a result of litigation. Moreover, falsely identifying a performance as distorted has serious consequences for the patient. The present study was conducted to replicate previous research that discriminated between malingered and nonmalingered responses to a neuropsychological self-report inventory. An overall hit rate of 84% for malingerers and neurologic headache patients demonstrated replication of the inventory’s ability to identify malingerers. Of those predicted to be malingerers, 27% were false positives indicating the need to use this inventory in conjuction with other neuropsychological measures.