GUIDELINES
In this section we will discuss the area of what are called guidelines These are exactly what their name describes, a set of recommendations meant to guide those involved in your case as to what are considered average time spans of care for your condition and recognized treatments that have some degree of research behind them as to their effectiveness, cost effectiveness and efficacy.
A brief history is in order. In the early 1990's motor vehicle insurance companies were being faced with ever increasing whiplash injury claims even though car designs were evolving. The overall problem was best summarized in a February 22, 2005 ICBC news release "In the early 1990's, ICBC like many other motor vehicle insurers across North America, faced significant increases in the number of whiplash claims being presented by the public. Surprisingly, this was occurring even though vehicle design was improving and crash rates were decreasing."
ICBC acknowledged, as far back as 1994, that 'soft tissue injuries' of the neck accounted for over 75% of the personal injury claims filed with them. They also made mention that the majority of those claimants 'recovered' (without defining to what degree) within 30 days, but up to 25% didn't.
Occupational Disability Guidelines
Presently, ICBC, our province's only provider of 'basic' automobile
insurance is utilizing the Occupation Disability Guidelines (ODG)
which are the property of the Work Loss Data Institute (offices
in California and Texas). The Institutes primary focus is on WORKPLACE
(emphasis mine) health and productivity.
Their 'guidelines' have attracted much attention and have a number
of satisfied insurance companies more than happy to utilize them
(i.e. Allstate, AIG, State Farm, Liberty Mutual, Geico, etc). The
fact some of the largest insurance providers now utilize the ODG
sounds like a hearty endorsement as to their authenticity and validity.
After all if it wasn't, the aforementioned insurance providers would
not be front and foremost mentioned by ICBC and on the Work Loss
Data Institutes website as clients. Hold that thought and read on.
The actual full name, of the 'guidelines', is the Official Disability Guidelines-Treatment in Workers' Compensation. The ODG (as they are more commonly referred to) are intended to be used as a benchmark for insurance adjustors to ask for more information about the case when treatment schedules are going beyond a ODG recommended time frame, NOT (emphasis mine again) to cutoff care! In other words the guidelines are designed to assist insurance representatives (ie. ICBC adjustors) to flag cases that are falling outside of the guidelines recommended treatment parameters (ie. Frequency of treatments and over what time frame). In that way they can ask informed questions of the patient's care giver(s).
Until recently, ICBC had been paying $10,017.00 US annually, for access to the ODG, for their use by ICBC staff (adjustors, etc.) throughout the province. To get a wider provincial recognition of the American data base, ICBC now allows all of the province's medical physicians complimentary access to the ODG at a cost of $47,700.00 US annually, all paid for out of yours and my insurance premiums.
What has made for interesting reading is ICBC's constant inclusion in the BC Medical Journal (BCMJ). They have attempted to maintain a constant profile in the BCMJ thereby trying to focus the medical community, that reads it, on ICBC articles (i.e. ICBC and the BCMA-Working together, The ICBC medical record, ICBC studies risky behavior, ICBC medical claims coverage to name but a few), thereby giving readers the impression that they are an authority in the car accident arena. Now remember this is all coming from the second biggest automobile insurer in all of North America.
Then, in BCMJ, Vol. 49, No. 10, December 2007, edition ICBC announces the free access. The free access is only free to the province's medical doctors. As an enticement, ICBC offered up a survey consisting of 4 skill testing, multiple choice questions. With questions like "The information in ICBC's articles has increased my understanding of ICBC's medical policies, services, and programs for people injured in motor vehicle accidents?", you get the idea of just what the purpose of the survey was. Finish the survey, and send it into ICBC and doctors got in on a draw for 2 nights at a BC Coast Hotel/Resort. The survey was for "ICBC would like your feedback on the article and others published in the BCMJ."
Such enticements all sound fine and good. But when a provincial insurer, which has a province wide monopoly on basic auto insurance, goes out of it way to court the health care provider group with the greatest amount of cultural authority, but marginal/minimal training in the largest injury (called neuromusculoskeletal-injuries to the skeleton) it definitely makes one sit up and take notice.
Even more interesting is ICBC points out the ODG's are "Based on over 3 million cases from the US Centre for Disease Control and Occupational Health and Safety." It might interest ICBC that the ODG's are based on over 10 million cases. The Occupational Safety and Health Administration contribution deals mostly with injury and diseases that are occupationally related. The Center for Disease Control contributes non-occupational injury information, i.e. that from car crashes. It is the proportion of occupational v. car accident injuries which is the issue. Said proportion is different for each diagnostic code in the ODG's database. When you acknowledge that the term 'sprain/strain' all too often is used as a default diagnosis, instead of a thorough workup (to rule out other conditions, i.e. discopathy, instability, etc.), you can see how the data for a specific diagnostic code can get very watered down.
You have a provincial auto insurer, with a monopoly on basic insurance required by every vehicle on the road, utilizing a foreign countries database which focuses on mostly work related injuries and applying them to a specific subgroup of the general population. Then they offer up totally free access, to every medical doctor in the province even though said medical personal's primary training is in diseases (pathology), not neuromusculoskeletal injuries.
The ODG are widely used by US property and casualty insurers primarily in the realm of automobile and worker's compensation arenas. By utilizing a data base which includes a range of causes for injuries, ie. car accident based injuries (called non-occupational injuries) to workers injuries, you basically dilute the results compared to utilizing a data base made up exclusively of those having been injured strictly in car accidents. What's even better is the proportion of occupational and car-accident injuries are different for each specified medical condition.
Speaking of specific conditions, the ODG are based on what are called diagnostic codes. Those codes are assigned to a diagnosis. The ODG's web site walks you through a sample diagnosis of Lumbar Strain/Sprain. They fail to inform the reader their database assumes the thousands of doctors offering up the 'sprain/strain' diagnosis formal training backgrounds varies considerably. When you walk through the entire sample demonstration, about how the guides are to be used, you realize how they water down an injuries severity. There is not a single mention of giving any weight or consideration to each claimant's intrinsic and extrinsic risk factors (see Risk Factors) regarding their return to work.
Understand, it is important to know how your health care provider arrived at their diagnosis of your complaint(s). If it was simply by asking you to try and move the injured body part(s) to the point of pain and then press with their fingers on the area you pointed to, does not make a diagnosis. With that said why does it continue to happen. As common as a diagnosis of 'sprain/strain' is what conditions were ruled out, i.e. instability, discopathy (herniation vs. protrusion, vs. Internal Disc Disruption, etc.). If there is no evidence, found in the care providers records they make about you, of attempting to rule out other conditions how can you be so sure you have the one they say you do? Can you sprain or strain the soft tissue of your back? Of course you can, but make sure it is not used due to your care provider not knowing how to perform a 'Differential Diagnosis'. Understand that true muscle injuries typically heal within a few weeks because of their large blood supply. It is well documented that a true ligament injury, and the related structures (i.e. facet joint capsules, discs, posterior ligament complex, ligamentum flavum, etc.) are all capable of partial/full tearing. Yet the ODG's groups all of them together, thereby often painting a far too rosy a picture for your return to work. So if your diagnosis was based on nothing more than the ole 'hunt and peck' workup a, and ICBC says you should be back at work because all you suffered was a muscle strain, you might want a second opinion, but only if that second opinion is familiar with all I have put in front of you here. A clinician can have the best hands in town, but all too often have great difficulty transcribing it onto paper. Therefore, if you are dealing with ICBC and your care provider has diagnosed a 'neck sprain/strain' and they are of the opinion you should have been recovered (or back to work) by a certain date, ask if anything more serious could be wrong. See the web site section regarding Diagnosis.
The Work Loss Data Institute's own web site states ODG are reference materials, by adjustors, as benchmarking resources, re. case management: treatment plans and disability, medical case management. They assist adjustors in communicating with primary care physicians and other health care practitioner. Effectiveness is measured by adjustors frequency of use (web site 'hits') and anecdotal feedback from adjustors, primary care physicians, chiropractors and physiotherapists. To summarize, ICBC pays tens of thousands of dollars a year to an American corporation to tap into their diluted guidelines and the only way they gauge whether or not they are getting their monies worth is count how many times the ODG are accessed and ask those involved what they think. I kid you not, that's the only way they gauge whether you and I are getting our monies worth regarding the effectiveness of the ICBC's use of the ODG's.
ICBC declares "Not ICBC policy to direct care." They go on to state "The medical management of the file rests with the health care providers who are treating the claimant."
Therefore, if you are faced with any reference to the ODG or they are used to cut off your care, feel free to email me and I will be happy to point you in the right direction, or answer your queries, should you care to look into them yourself. Starting with ICBC having to answer the BC Utilities Commission questions, regarding the ODG's, makes for a good place to start and is quite an eye opener!
At this point one would think there is not a lot more to say about insurance providers. In light of the fact the above mentioned list of American insurance companies are making use of the ODG, as is ICBC now, here is what the American Association of Justice reported in their paper The Ten Worst Insurance Companies In America:
1. Allstate: "There is no greater poster child for insurance industry greed than Allstate." and Allstate's CEO Thomas Wilson stated "our obligation is to earn a return for our shareholders." The paper points out that the investigation produced documents that forced Allstate to make public "The company that publicly touted its "good hands" approach privately instructs agents to employ hardball "boxing gloves" strategy against its own policy holder."
Similar to what the February 22, 2005 ICBC, above mentioned, press release stated the in the 1990's Allstate needed to develop a way to boost its bottom line. They did it by hiring the consulting firm of McKinney and Co. They recommended that Allstate to disregard a claim's validity and focus on reducing the amount of monies it paid out on claims. The paper states Allstate combines lowball offers with hardball litigation.
It had the desired effect. If the claimant accepted the low ball offer they received the 'good hands' approach and if they didn't they got their deny the claim at any cost approach. The approach was to basically wear the client out and hopefully they would give up their desire for more than the low ball offer. As despicable as the approach was it was verified by a former Allstate agent. It was also divulged that Allstate even had a cute way of expressing their companies hardball directive "three D's: deny, delay, and defend." As one former Allstate agent confessed, the goal was to make claims "so expensive that lawyers would start refusing to help clients." Is it any wonder Mr. Wilson's 2007 compensation was $10.7 million US.
2. AIG: As the world's largest insurer, it has been labeled "the new Enron" due its multi-billion dollar fraud charges. Once again the old we are paying out too much and need to stop kicked in. In AIG's case it was after the CEO decided losing $210 million US on auto warranty claims was too much. They did it by handballing even minor claims all the way to court. It's amazing what former employee(s) and supervisor(s) are willing to confess/admit to/divulge when they are no longer in one's employ. AIG's former staff was no exception. They admitted to all sorts of manipulation tactics from destroying important documentation, not paying claimants until they complained, not paying lawyer fees for up to a year, etc.
It was pointed out what set AIG apart, from the other insurance companies mentioned, in how it took advantage of its policyholder's misfortunes. In 1992 an Executive vice president sent out a company wide memo, the day of Hurricane Katrina. It said "We have the opportunity from this and everyone must probe with brokers and clients. Begin by calling your underwriters together and explaining the significance of the hurricane. This is an opportunity to get price increases now."
Even the September 11 twin tower attacks were considered an opportunity. Shortly after the attacks the then CEO Maurice Greenberg declared "It's a global opportunity." He went on to point out "It's not just the United States, but rates are rising throughout the world. So our business looks quite good going forward."
There's more, i.e. State Farm, Liberty Mutual, etc., but I think you should have gotten the point by now.
A National Association of Insurance Commissioners (NAIC) senior executive best summed it all up when he said "The bottom line is that insurance companies make money when they don't pay claims."
American Medical Association's Guides to the Evaluation of Permanent Impairment, 6th edition.
The 'Guides' started in 1958 as an annual update in the Journal of the American Medical Association. In 1971 they took on a life of their own as this was the first year a compendium was produced becoming the 1st edition of the Guides. The 3rd edition came out in 1988 and introduced pie charts for ranges of motion. The 4th edition came out in 1993 and the 5th was published in 2000. The 5th edition was where things in the neuromusculoskeletal arena really started to get rolling. It was that edition that introduced us to Diagnostic Related Estimates (DRE) and expanded range of motion method for spinal impairment evaluations.
The 6th edition introduces us to a 'paradigm-shift' to impairment assessment. Gone are the DRE's as we now have Diagnosis-Based Impairments (DBI). For the first time Pain-Related Impairment (PRI) has a chapter all to itself, chapter 3. One would refer to the PRI Guides if the DBI are not applicable, which is to say when objective evidence is lacking, but you state you are in pain. The Guides note that at any given time 18%-50% of the general population are experiencing continuous pain for 3 of their last 6 months. I know you will agree that is a very large proportion of the population. A large part of the paradigm-shift has taken place in the pain arena. For quite some time pain itself has been considered a symptom meaning it was thought to be nothing more than a warning signal of an underlying disease process. With the formal introduction of PRI's the Guides are acknowledging that pain itself can be considered a disease entity all on its own. Think about that for a minute. The recognition that pain itself can be the problem, and not just a symptom is huge! I say that, with emphasis, because of how often those suffering from pain caused by a whiplash injury (remember there does not have to be visible damage to your vehicle) have typically undergone numerous tests (i.e. X-rays, CT Scans, MRI's, etc.) and been told they found nothing. Yet, the only thing really affecting your lifestyle is the chronic level of pain.
When we are typically discussing pain it is accepted there are 2 types, nociceptive and neuropathic. Nociceptive pain describes physiological events that occur all the way from tissue injury to your perceiving the end pain. There are 3 phases: Transduction (what happens at the site of tissue injury), Transmission (pain signals going from the injured tissue into the spinal cord to an area called the Dorsal Horn and progress up your spinal cord to your brain to he point where you perceive the pain) and Modulation (occurs along numerous points in the pain pathway). This is your 'normal' pain pathway and is the mechanism that results in your quickly withdrawing your hand from a hot stove element.
Neuropathic pain is when you experience pain because something is wrong with your nervous system because of an injury or a disease. The difference of this pain, from the earlier described nociceptive pain, is that with neuropathic pain the original peripheral tissue damage that was responsible for the pain in the first place has long since healed. In other words the original nociceptive caused pain is now gone and your central nervous system has adapted (called Central Sensitization) to keep the pain going and this is where the problems arise with your being assessed by a third party. They often perform a myriad of tests on you trying to find 'objective' evidence of an injury/cause of the pain you state you are in and they can't find much of anything. The above mentioned adaptation is easily explained, with a diagram/drawing, which is something I am asked to do on a regular basis. Therefore, if you are feeling a notable level of pain, and told 'they can't find anything wrong with you' feel free to email me (via the web site's Appointment' page, and I will be happy to walk you through it. Also, see my web site's Diagnosis section.
An 'impairment' is defined as reduced body structure/function due to a disease/disorder/condition. A 'disability' is defined as a reduced participation/activity due to an impairment. Page 5, of the guides, states "The same level of injury is in no way predictive of an individual's ability to participate in major life functions (including work) when appropriate motivation, technology and sufficient accommodation are available." In other words because one is suffering from a marked impairment does not mean that they have to be equally disabled. Let's use Christopher Reeve as an example. For those of you that don't know he was a famous movie actor (played Superman) who suffered from tetraplegia (full body paralysis after falling off his horse while jumping). Because of his personal drive, and financial resources, he was able to demonstrate a low activity limitations yet he had a severe impairment. One can have a highly disabling impairment (i.e. removal of the big toe=your ballerina days are over) yet minimal disability at a construction job (i.e. wearing appropriate footwear). In other words the relationship between impairment, activity limitations and participation are not linear or unidirectional. That said, one can be severely limited in activity participation, with minimal impairment, and the opposite also.
What is really interesting is that range of motion (how far the injured body part(s) can be moved) is no longer considered a reliable indicator for use. Yet, the greater body of scientific literature, in the whiplash arena, has long espoused one's range of motion is a direct correlation with recovery both short and long term.
Back to the Guides. You must first be assigned a DBI which is to say slotted into an appropriate diagnostic class. From there one has to decide which 'class' applies to your case, each DBI has 5 to choose from. I realize it is starting to get confusing. The 5 classes are percentages and are an attempt to determine your Whole Person Impairment (WPI) to a specific number compared that which was offered in the 5th edition. If you are really interested in applying them to your case, email me and I will assist in how the Guides apply to your case.
Because this portion of the web site deals with whiplash I will briefly talk about the Guides and neck pain. With the 6th edition chronic neck pain is only able to be placed in either class 1 or 0. Class 0 is exactly what it states 0 % disability. In other words you have a history of the ever popular diagnosis of 'sprain/strain' which has resolved at the time you are examined. Grade 1 only allows a maximum of 1-3% WPI, that's it. In class 1 you have history of documented neck 'sprain/strains' and objection findings are revealed at the time of the examination, with or without non-verifiable complaints going into your arm(s) (called 'radicular').
Now here is one of the British Columbia specific parts, remember that ICBC is now offered free access to every medical doctor to the above mentioned ODG's. Lets put it all together: medical physicians primary formal training is in diseases, not these type of injuries (neuromusculoskeletal), in an attempt to appear as the go to source for scientific articles in the area of whiplash ICBC has maintained a subtle presence in their literature (the BCMJ), M.D.'s get free access to the ODG's as described above. Because of their lack of formal training in these types of injuries it is rare to see instability (evident on an X-ray) ruled out. Discopathy (requires a special type of CT Scan, re. Internal Disruption vs. Protrusion/Herniation) also needs to be ruled out, not to mention other conditions (a true full/partial tissue tear). In the end the 'sprain/strain' diagnosis, which cross references with the AMA's 6th edition of the Guides, wins out. The end result is you cannot receive higher than a 3% WPI. Remember, ligament sprains and muscle strains do occur, but to still have a noticeable level of pain and disability months after the collision suggests your caregiver(s) might wish to rule out the conditions just discussed.
Not to belabor the point, but instability (called Alteration Of Motion Segment Integrity-AOMSI) and Disc Herniation are the DBI category directly below 'sprain/strain' and can result in up to a 30% WPI if properly assessed. We haven't even gotten into the area of Videofluoroscopy (for documenting instability). For more on this point see the Imaging page of this web site.
Of special note is the downgrading that having > 3.5mm AOMSI (instability), in the cervical spine, received in the 6th edition vs. the 5th. In the 5th edition just having >3.5mm motion resulted in your condition being categorized as DRE 4 (remember the DRE categories are not used in the 6th) which meant you were in the WPI range of 25-28%. With the 6th edition, the same instability rates you no higher than 4-8% if your radiculopathy has resolved at the time of the examination. If you have ongoing radiculopathy, at the time you are examined, along with >3.5mm segmental translation (instability) you can only receive a WPI rating of 9-14%. A dramatic difference to say the least from one edition to the next. It can get a little confusing. Email me regarding any particulars and I will be happy to walk you through it.
Relating to the Guides, a special mention should be made about the term 'Radiculopathy'. The Guides define radiculopathy as "…a significant alteration in the function of a single or multiple nerve roots…" They go on to say "The diagnosis requires clinical findings including specific dermatomal distribution of pain, numbness, and/or paresthesias." A radiculopathy can also include associated muscle weakness and/or altered deep tendon reflexes.
It is not enough to have a CT Scan ordered -> produce a report that makes note of a bulge/herniation/protrusion, but not demonstrate any of the above mentioned objective radicular findings, to be placed in the AOMSI/Disc Herniation class of the Guides. It clearly states objective clinical findings must be present, at the time you are examined, along with the corresponding imaging (X-rays, CT Scan, etc) to be considered for inclusion to this category. Therefore, if you are experiencing 'subjective' (nonverifiable) complaints in a radicular pattern (i.e. pain, numbness, etc. into your arms and/or legs) with no 'objective' evidence then this line in the Guides says it best "Although there are subjective complaints of a specific radicular nature, there are inadequate or no objective findings to support the diagnosis of radiculopathy." See the Imaging and Diagnosis sections for more on this topic.
Suffice to say if there is a disagreement as to how much your impairment/level of pain is affecting your life , and the only issue is whether or not you are fit to return to work and your diagnosis is 'sprain/strain' you might want to get a second opinion. Based on the scientific literature you have a 33% chance of having pain/level of disability 33 months after the collision, regardless of whether or not there was damage to your vehicle. Guidelines created (not to mention funded by the insurance industry), with a focus on return to work equaling resolution of your condition (QTF, BCWI, Saskatchewan study, etc.) have as many detractors as they do pundits.
All in all the 6th Edition is an improvement over the 5th. After
all this is the first edition in which whiplash is named in a DBI.
I am impressed with the authors recognizing Pain itself (PRI) as
a condition all unto itself. But to the general populous, informing
them their wpi impairment is 14% vs. 16% is really of little value.
BC Whiplash Initiative
In 1995 there was a seminar held in Banff Alberta by the Physical Medicine Research Foundation (PMRF). At the time the PMRF was funded by ICBC and Woodbridge Industries (a corporation in which very little information could be found). What is interesting is that the PMRF didn't have a single prominent scientist on its board until 1997. Yet, ICBC still decided to fund. The aftermath of the Banff seminar was the creation of the beginnings of the British Columbia Whiplash Initiative (BCWI). Similar to the QTF these were whiplash guidelines that were created and paid for by a provincial automobile insurance provider, namely ICBC.
The BCWI was a set of guidelines that were made of 4 modules that turned into a traveling roadshow to the province's medical physicians " ." Their intentions were most laudable, "The overall objective of the BC Whiplash Initiative is to assist physicians to diagnose and treat patients with WAD(whiplash associated disorders) using, where possible evidence-based guidelines." Notice the use of the term 'evidence-based guidelines'. What was most original was the ICBC paid for guidelines attempting to spin a physical injury (namely whiplash caused pain) into a psychological condition.
The committee's medical profession members wasted no time establishing the medical community was behind it. They did that by bringing a number of medical groups under their umbrella (i.e. The BC College of Family Physicians, UBC Division of Continuing Medical Education, etc.). Front and center was the endorsement of the BCWI by the BC Medical Association.
Their objective was laudable that being to assist medical doctors in diagnosing and treating whiplash patients. Because Canadian medical physicians formal training in these types of patients is minimal, at best (see the Training section of this web site) the Corporation paid for guidelines sounded like a positive step in the right direction.
The BCWI over relied on the Quebec Task Forces (QTF), see below, findings right from the start by endorsing the QTF in light of its glaring flaws that had been widely published by this time.
Module 1 had to do with the natural history (how the condition/disease would typically progress through the general population if no interventions occurred) and pathophysiology (how conditions/disease occur in our bodies). Now remember this 'roadshow' was directed exclusively at the province's medical physicians. It is in this module that with no supporting evidence they state "Pre-existing psychological problems and personality are widely considered to have a major influence on injury behavior." It insinuates that all whiplash injuries should heal up fast and if they don't then psychosocial reasons are to blame.
Module 2 had to do with diagnosis (putting a label on what is the problem) and management (the care itself). Here was something interesting. The BCWI stated that if your symptoms were delayed then the medical physician was to classify your injury as what was called WAD 1 (minor injury). To back up such a statement they state "pain severity itself, is a poor marker of injury severity." The fact is pain severity is a literature cited factor for injury severity and increases one's possibility of experiencing 'late' whiplash. Understand, it has long been an established literature cited fact that the maximum pain, from whiplash injury takes 3 days to reach maximum intensity! After reading that you might like to know the scientific literature has long stated the exact opposite. Basically, pain severity is a literature cited risk factor for the sufferer ending up with chronic pain from a whiplash injury.
Examinations performed on you before 3 days post collision, often do not mean much. That statement is based on the fact that if the examiner fails to isolate/reproduce the exact complaint (see the Diagnosis section of the web site) you presented with, using standardized testing, how can they comment on your condition? Therefore, if you have had an examination(s) within the first 1-2 days, post-collision, and they could not find anything (i.e. isolate a specific injury), and the insurance company/Corporation bases its conclusions that you weren't injured based on the early examination(s) then call them on it. Better yet, contact me and I will be happy to put the facts on paper!
It is also in this module that they manage to attempt to quote the International Association for the Study of Pain's definition of pain. Unfortunately they didn't quite get it right. The misquote coincidently enough reinforced the BCWI's attempt to turn an organic complaint (pain from a whiplash injury) into a psychological one.
What was so outlandish about this ICBC funded venture was the attempt to group recognized physical conditions (TMJ disorder, fibromyalgia, myofascial pain syndrome, etc.) under the nonphysical headings. The authors did so with absolutely no supporting documentation other than their concensus derived opinion.
Module 3 had to do with the managing of chronic pain cases, i.e. those that don't get better quickly. Rather than dwelling on its many errors suffice to say it too was more entertaining than factual. An example is their section on Illness Behavior having psychological conditions being broken into 6 categories. Suffice to say grouping what are called Somatoform disorders, under Conversion Disorders is a real no-no.
The authors were careful to proclaim that the management model they created does not consider causation, but it pronounces outcomes in the form of WAD 1-4 (physical) and nonphysical. The nonphysical outcomes not directly called psychological were interestingly enough all treated by psychological treatments.
Suffice to say that the bottom line, of the BCWI, was that those diagnosed with whiplash should all get better in very short order. If not, then psychosocial variables must be at work. Thankfully this endeavour in an insurance provider creating their own whiplash guidelines, that treat organic pain like a psychosocial condition, have not reared their ugly head for quite awhile. Let's hope they stay that way.
Quebec Task Force
In 1990 Quebec's major auto insurer (Societe d'Assurance Automobile
du Quebec-SAAQ) decided to confront the problem head-on by funding
the creation of their own set of guidelines by a group it created,
called The Quebec Taskforce (QTF). The QTF defined whiplash as "an
acceleration-deceleration mechanism of energy transfer from rear-end
or side impact, predominantly in motor vehicle collisions…"
The QTF committee reviewed >10,000 academic paper's abstracts
about whiplash. In the end they accepted less than 1% (62 papers)
for basing their recommendations on. Some of their recommendations
were based on nothing more than committee consensus as they found
there were no quality studies to base their recommendations on.
The fact the QTF was solely funded by an insurance provider and
the QTF came out with the miraculous conclusion that 97% of whiplash
patients had 'recovered' at the end of 1 year (contrary to what
most of the scientific literature out there) was most interesting.
Do you know what they used to determine such a finding - the fact
that a claimant returned to work. I kid you not! What they were
really stating was that at around 1 year, post-collision, 97% of
their carefully selected, narrow inclusion criteria group stopped
being compensated for their injuries. There was no attempt made
to discover how many returned to work in what amount of pain/disability.
It would be fair to state a large proportion of those who returned
to work at one year did so for financial reasons, regardless of
the amount of pain they were in.
As common sense would dictate, those injured return to work, after 1 year off, regardless of their level of pain and disability, for any number of reasons, one of which is feeling fine. Therefore, to claim the majority of whiplash sufferers returning to work after 1 year, from the time of the collision, are 'recovered' is and was absurd.
Such conclusions were the result of SAAQ opening up their files to the QTF. They followed 3014 of those who suffered a whiplash injury and subsequently filed a claim against SAAQ. For some reason they decided to exclude 6.8% (204 claimants) of eligible participants because they suffered a recurrence. The recurrences were not due to other car accidents and what was really interesting was, of the 204 claimants in rear-impact collisions, were higher in frequency. So as you can see by eliminating a large proportion of the study population, that were of greater severity, the findings must have made the insurance industry much happier by skewing the results that were loudly touted in the QTF's final findings (re. 97% 'resolved' by 1 year post-collision). Findings of note were about 75% had greater than 7 days off work and again about 75% of the compensation costs were for lost wages, not health care costs.
The greatest benefit that occurred, as a result of the QTF, was the creation of a whiplash grading system, called Whiplash Associated Disorders (WAD). There were 5 grades of severity. Suffice to say WAD's Grade's 2&3 are the most common. Grade 2 is when you are suffering neck pain with positive musculoskeletal signs (reduced neck range of motion, positive orthopedic/provocation testing and tenderness to palpation). Grade 3 is when neurological signs (reduced reflexes/dermatomes-areas of skin sensation and/or muscle(s) weakness). Note, signs and symptoms are not the same thing. Signs are more of an objective finding. Whereas you can have a symptom (i.e. lack of sensation over an area of skin), but the examiner cannot find any 'objective' evidence of anything wrong. The web sites Diagnosis section explains it better.
They even had a grade 0. To be diagnosed with this one you had to present to the examiner with 'no neck complaints and no physical signs'. It begs the question, why would you be presenting, for examination, if you were feeling fine in the first place?
I have to make note of one other thing the QTF was guilty of. The fact they did not acknowledge Dr. Croft's CAD grading system was bad enough. They also took the unprecedented step of changing the term 'neurological symptoms' and substituted it with 'neurological findings'. Such 'findings' are objective in nature which is to say are demonstratable deficits present at the time you are examined (i.e. reduced muscle strength, dermatomes (skin sensation in a specific pattern(s), reduced deep tendon reflexes). By making such a change in terminology, persons experiencing symptoms of pain, numbness, paresthesia, but don't demonstrate any of the required objective findings, are downgraded from what is termed Crade 3 WAD to GRADE 2. It might not sound like much, but in the medicalegal field it is huge. More about that in the Diagnosis and Injury sections of the web site.
Following the QTF findings being published, research into whiplash was ramped way up.
Cervical Acceleration-Deceleration (CAD)
The CAD grading system was first published in 1992, by Dr. Arthur Croft (chiropractor and researcher at the San Diego Spinal Research Institute), 3 years before the QTF guidelines and their WAD grading system.
Dr. Croft literally wrote the book when it comes to the field of whiplash. He co-authored the text Whiplash Injuries: The Cervical Acceleration/Deceleration Syndrome, first published in 1988. The tome is now in its third edition and is one of the most widely referenced texts on the subject having been translated into 2 foreign languages. It doesn't hurt to know that it is also used as the core textbook for courses in biomechanics and epidemiology.
Dr. Rene Caillet, M.D., retired Chairman of the Dep't. of Physical Medicine University of Southern California summed it up best, "…Forman and Croft and their contributors have presented the comprehensive literature and the most current and progressive knowledge of WAD."
It begs the question why the likes of Drs. Croft and Foreman were not a part of the QTF committee. What was most interesting was how the QTF's grading system was almost identical to those of Dr. Croft's. His CAD grading system never received the recognition that it should have (and I assume did not take $1,000,000 as the QTF cost), but I digress.
The biggest difference between the 2 grading systems was that the CAD system did not see a need to have a grade 0, like the WAD ones did. Dr. Croft's CAD grading system even incorporated the term 'Neurological Symptoms'. Such symptoms are what you are feeling, typically extending into your arms and/or legs, i.e. numbness, pain, paresthesia, etc.. Was it just an oversight or did the QTC committee just not want to give credit where it was due? I will leave that up to you.
These and all of the other topics discussed, under the Whiplash portion of our office's web site are covered in Dr. McDiarmid's Classes. If you are interested, in attending/being notified as to the date and location of the next class, email the office via the web site's Appointment' page.