Chapter 1 Introduction
Perhaps there are no other conditions that beg more for a patient-centered approach to management than whiplash injuries. Individual variability to the whip-like action associated primarily with motor vehicle accidents continues to generate controversy, much needless suffering, and in many cases unnecessary legal action. The range of works on the subject includes those whose authors are clearly patient advocates, including one with a foreword by a noted claimant’s attorney,1 and on the other end of the spectrum, a study funded by an insurance society.2 Patients with injuries from whiplash have often been maligned as malingerers who are seeking a large settlement from a third party.3 Unusual symptoms such as blurred vision, tinnitus, dizziness, nausea, paresthesias, numbness, and back pain are often suspect when added to the more common symptoms of neck and head pain.4 Acknowledging patients’ symptoms with medically unexplained disorders becomes easier with a patient-centered approach.5 There is an enormous difference between getting patients the care they need to prevent needless disability and helping them to get a monetary settlement based on disability that can be prevented. Clinicians have an ethical responsibility to provide care that returns the patient as close to pre-injury status as possible.
Whiplash as an Entity
In 1923 an American orthopedist, H.E. Crowe, applied the label “whiplash” to the effects upon the neck and upper trunk from a sudden acceleration/deceleration force.6 Injury from whiplash associated with the rear-end collision was recognized by the mid 1930s as more patients with neck injuries were seen.7 In 1945 Davis8 described the mechanism of head-on collisions where a sudden forceful flexion of the neck is followed by recoil in extension. By the 1950s traumatic injuries associated with whiplash were increasingly diagnosed by the medical profession. In a published report in 1953, Gay and Abbott9 used the term “whiplash injuries of the neck.” By 1974 Hohl10 reported on a longitudinal study on the factors influencing prognosis of soft tissue injuries of the neck in automobile accidents.
Whiplash: What Is It?
“Whiplash” is a term used to describe a mechanism whereby the neck is whipped in one direction and recoils in the opposite direction. It is not a diagnostic term and it does not give an indication of the structures injured from this action. There has been an effort to replace the term “whiplash injuries” with other terms, including “acceleration/deceleration syndrome,”11 yet the term persists. Other terms used to describe these injuries include cervical strain or sprain,7 whiplash-associated disorders (WADs),2 and soft tissue injuries of the neck.10 For consistency in this book “whiplash” will be used to refer to the mechanism of injury and not a diagnosis, while the structures and tissues injured will be specifically named. Abandonment of the term “whiplash” will not change the issues surrounding the term; only addressing the issues directly will address the many controversies that surround injuries caused by this mechanism.
The Epidemiology of Whiplash Injuries
The epidemiological characteristics of whiplash injuries have not been adequately studied, and there is much controversy surrounding the studies to date. (See Chapter 9.) To better understand the epidemiology of whiplash, good population-based research is needed both for incidence rates and risk factors and for clinical presentation and prognosis.4 Population rates of whiplash injury, determined from automobile claims, vary from country to country and region to region. This variability may be due to accident rates, population characteristics, vehicle size, traffic density, and distances driven. Variability is also caused by automobile structures and administrative rules governing claims and compensation and differences in jurisdictional tort systems. Studies that rely on emergency room departments generally underrepresent the incidence of whiplash injury because the signs and symptoms of these injuries may not develop for some time after the event.4 Emergency room data from rural and small town hospitals may be overrepresented when a major route for long-distance travel passes through the area. Personal risk factors for whiplash injury include age and gender. The late teens and early 20s have the highest risk of whiplash injury. Men have greater neck musculature for a given head size than women; consequently, they may have lower actual injury rates.
Patient-Centered Care
Health care has been evolving away from a “disease or condition-centered” model toward a patient-centered model.12 Patient-centered care can be traced back to the humanistic psychology and the client-centered therapy developed by the psychotherapist Carl Rogers.13 Based on philosophical and ethical considerations, patient-centered care became the family practice model for the Department of Family Medicine at the University of Western Ontario in London, Ontario, Canada, in the 1980s.14 Similarly, a patient-centered paradigm based on traditional chiropractic practice was identified as the optimal paradigm for chiropractic education and research in 1995.15 By 2001 a report by the Committee on the Quality of Health Care of the Institute of Medicine included patient-centered care as one of the aims for the 21st-century health care system.16
Patient-centered care is not found in any single country,3,17–19 nor is it the purview of any one discipline or specialty.14–15 There are remarkable similarities in the characteristics of a patient-centered paradigm identified as the optimal paradigm for chiropractic education and research14 and a model of patient centeredness found in the British literature19 (Table 1-1). This similarity occurs across disciplines and in a number of countries. An interdisciplinary approach to the management of whiplash-associated disorders based on patient-centered care can prevent needless suffering and disability as well as lower health care costs.20
TABLE 1-1 Characteristics of Patient-Centered Care
| Characteristics of Patient-Centered Care* | Domains of Patient Centeredness Model† | Characteristics of Integrative Medicine‡ |
|---|---|---|
| Recognition and facilitation of the inherent healing capacity of the person, with a preference for minimally invasive care | Less reliance on drugs; only 25% wanted a prescription | Understanding of the body’s innate mechanisms of healing and CAM strategies |
| Recognition that care should ideally focus on the total person | Understanding the whole person | Refocus on the patient as a whole |
| Acknowledgment and respect for the patient’s values, beliefs, expectations, and health care needs | Exploring the experience of disease and illness and the patient’s feelings and ideas about the problem | Practitioner acts with compassion and pays attention to patient’s spiritual and emotional needs |
| Health promotion and a proactive approach that encourages patients to take responsibility for their health | Health promotion, health enhancement, risk reduction, and early detection of disease | Care that promotes health by teaching patients the best way to improve their health |
| The patient and patient-centered practitioner act as partners in decision making | Finding common ground (partnership), sharing power, and establishing priorities and treatment goals | Involves patients as active partners in their care |
CAM: complementary and alternative medicine.
* Gatterman MI: A patient-centered paradigm: a model for chiropractic education and research J Altern Complement Med 1995; 1:371-386.
† Little P, et al: Preferences of patients for patient centred approach to consultation in primary care: observational study, BMJ 2001; 322:1-7, 2001.
‡ Snyderman R, Weil AT: Integrative medicine: bringing medicine back to its roots, Arch Intern Med 2002; 162:395-397, 2002.
The Characteristics of Patient-Centered Care
Patient-centered care emphasizes self healing, a holistic approach to the patient, and a humanistic attitude with regard to the patient-practitioner relationship. Patient-centered practitioners work with patients as partners, both preferring minimally invasive procedures and therapies when appropriate. They provide care that is respectful of and responsive to individual patient preferences and needs, ensuring that patient values guide all clinical decisions.15 Clinician expertise, scope of practice, and supporting evidence are all determining factors in patient-centered care.
Emphasis on Self-Healing
It is important that patient-centered practitioners emphasize to patients that their body has the innate ability to heal based on knowledge of the mechanisms that regulate and repair the human body.15 Patients with whiplash injuries commonly fear that they will not return to pre-injury status. Whereas a small percentage of patients will have residual problems, the vast majority can return to pre-injury status with appropriate care. Reassurance and understanding are intrinsic and important components of patient management.18 Emotional support is essential to allaying fear and anxiety. Suffering is not just physical pain and other distressing symptoms; it also encompasses significant emotional and spiritual dimensions.16 Patient-centered care attends to the anxiety that accompanies injury whether due to uncertainty, fear of pain, disability, or disfigurement.16 Patients with whiplash-associated injuries commonly feel vulnerable. They may be overly concerned that they have suffered an injury to their neck which they associate with permanent disability. It is important that patients understand that the body is endowed with a basic vitality and adaptability giving it the ability to heal.21 Patient-centered care that embraces self-healing strategies promotes compliance when life habits and environmental factors are addressed.17
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