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What’s driving the rise in whiplash injuries?

Insurance companies are reeling from the number of claims being made by people who say they have whiplash injuries. Helen Mooney examines the implications for physios

We live in the ‘whiplash capital of Europe’, according to the Association of British Insurers. The association estimates that one adult in 140 in the UK makes an insurance claim for a whiplash injury every year.

Thanks to the activities of ‘ambulance chasing’ lawyers and claims management firms, as well as staged ‘cash for crash’ accidents, the number of claims continues to rise, it notes.

Last month the House of Commons transport committee blamed the spiralling cost of motor premiums on insurers, solicitors and claims management companies that encourage people caught up in road traffic accidents to make personal injury claims.

Committee chair Louise Ellman said: ‘Many of these claims are for whiplash, an injury where diagnosis is often subjective and therefore very costly for insurers to challenge.’

The committee is calling for the compensation threshold for whiplash cases to be raised and, if the number of claims does not fall significantly, for the introduction of new legislation requiring tougher medical evidence on the injury and its impact on the claimant before compensation is paid.

Last July Jack Straw, an MP and former justice minister, called for the insurance industry to be overhauled. He said that ‘referral fees’ – in which insurance companies are paid by personal injury lawyers to refer clients who have been involved in accidents - should be banned.

Mr Straw described whiplash injuries as being ‘usually entirely trivial’ and said they were mentioned in four out every five insurance claims.

Despite the hype, road accidents involving personal injury have fallen since the mid -1990s. In 2009, for example, the number of road accidents involving personal injury fell by almost one third compared to the average for the years from 1994 to 1998.

But the cost of personal injury claims has doubled in 10 years (from £7 billion to £14 billion) and motor insurance premiums rose dramatically at the end of the last decade.

An insurance fraud index produced by law firm Keoghs shows that rates of whiplash insurance fraud vary according to claimants’ postcodes.

Consequently, some physiotherapists will see far more cases than others. Certain parts of Birmingham are particularly associated with high rates of fraud, for example.    

So is everyone who claims to have whiplash out to defraud the system or are some cases genuine?

Injuries ‘exaggerated’

Most physiotherapists agree that whiplash injury - or whiplash associated disorder (WAD) - exists, but acknowledge that psychosocial factors can exacerbate the problem.

Chris Worsfold, director of the Tonbridge-based Kent Neck Pain Centre, has a background as a musculoskeletal physiotherapist.

He is convinced that highly-organised criminal gangs deliberately crash cars in order to make fraudulent claims.

Some drivers brake sharply to cause accidents, while a number ‘exaggerate their injury’ - whether consciously or unconsciously – in order to gain attention from their families and friends, or even for financial gain.

‘However my experience suggests that there is a good percentage of people who really do suffer following whiplash injury,’ he notes.

Mr Worsfold estimates that whiplash injuries trigger high levels of pain in one victim in five. As a result, their ‘activities of daily living’, such as concentrating, reading, sleeping postures and driving, are curtailed to some extent.

Roger Kerry, associate professor of physiotherapy education at the University of Nottingham, believes whiplash is not a ‘clear cut’ topic.

Most fraudulent claims arise from intermediary ‘no-win no-fee’ companies which, in some cases, pressure people into exaggerating their injuries in their claims, he says.

‘Any skilled physiotherapist would be able to identify quickly through examination if there is a genuine problem or not,’ he adds.

Léonie Dawson, CSP professional adviser and musculoskeletal specialist, says that physiotherapists must be ‘very clear’ when recording clinical decisions about patients with WAD. Physiotherapy reports can be viewed in court following a compensation claim, she explains.

‘They must remain objective and evidence based in their treatment plan.’

Mr Worsfold says physiotherapists should identify those patients who are likely to fail to recover from whiplash on their own at an early stage.

‘At the outset they should be looking out for a post-traumatic stress response. Those who don’t get better might not be very good at managing trauma and might have nightmares and recurrent flashbacks associated with the accident.’

The consensus is that whiplash injury exists and that CSP guidelines provide a clear care pathway for physiotherapists to follow in treating patients with suspected whiplash injuries.

Ms Dawson explains that whiplash happens when the neck moves suddenly and passes its normal range of movement.

She says physiotherapists assessing someone who might have whiplash-associated disorder will look out for signs that suggest he or she should be referred back. Such patients are assigned a red or yellow ‘flag’, Ms Dawson suggests.

‘For example, a red flag might indicate there is an underlying pathology while a yellow one indicates the patient is harbouring negative thoughts, attitudes, and beliefs about their injury. These patients might not respond to treatment.

‘A physiotherapist seeing somebody in the acute stage of whiplash will seek to exclude red and yellow flags, and, in the same session, give postural advice, and encourage the patient to keep moving and go back to work.

Hopefully, he or she will recover in about six weeks,’ Ms Dawson adds.

Controlling physio costs

A number of insurance companies employ physiotherapists who assess and triage patients claiming for whiplash injury.

Nicola Hunter is chair of the Association of Chartered Physiotherapists in Occupational Health and Ergonomics.

She set up a physiotherapy and triage service for Aviva insurance company customers four years ago through the RehabWorks group, which provides injury management and rehabilitation services.

Through its links with three insurance companies, RehabWorks assesses and treats some 400 whiplash patients a month.

‘Many of the whiplash patients who come to us never need to see a physiotherapist.

They have a comprehensive 30-minute telephone interview with a physiotherapist and we give them the standard advice to take painkillers, use heat and ice and keep mobile. We follow up in a week’s time to reassess their injury,’ she explains.

Ms Hunter says the organisation saves around £2,500 a case by ‘controlling’ the costs of physiotherapists and the add-on costs of ‘unnecessary’ consultations with doctors and further tests such magnetic resonance imaging (MRI) scans and x-rays.

Jan Vickery, lead physiotherapist at insurance company AXA PPP healthcare, believes that social and cultural beliefs are exacerbating what she calls the ‘whiplash epidemic’.

‘The frustration is that in some cases these present obstacles to patients’ recovery. Regardless of how good a job we do, unless these obstacles are addressed it will be difficult to make a meaningful impact on the reduction of whiplash injury claims.’

A research team in Lithuania in the late 1990s followed up more than 200 victims of rear end vehicle collisions (Obelieniene D et al. ‘Pain after whiplash: a prospective controlled inception cohort study’, J Neurol Neurosurg Psychiatry 1999;66:279-283).

They found the victims’ symptoms were generally brief and self-limiting, and linked this to the fact that Lithuanians do not have preconceived notions about developing chronic pain or a long-term disability after such collisions.  

Another factor, they suggested, was that therapists and insurance companies do not get involved in such cases, and litigation is rare.

Physiotherapists in general appear to believe that whiplash injury exists, and that a minority of people make fraudulent claims as a result of their ‘injury’. The consensus seems to be that the vast majority of cases resolve within months.  

However, as with many other areas of healthcare, diagnosis and treatment is not an exact science.  

As a result, the debate over how many people are feigning injury is likely to continue for some time. fl

What’s new in whiplash prevention?

Swedish manufacturers are designing dynamic seats that change the position of the car seat and head restraint in response to pelvic pressure in the event of a crash, for example. By tilting, and bringing the restraint closer to the back of the head, they absorb the force created by the impact and lessen any rebound effect on the occupant.

In Japan and the United States, crash-activated head restraints are being designed with head protectors that push up and protect the occupant’s head on impact.

Whiplash claims: a rising tide

Around 1.200 whiplash claims are made in the UK every day, six times the rate made for workplace-related injuries.

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