Whiplash and Other Useful Illnesses

Rating:
Summary: A gem of a book on this controversial subject
Review: An excellent book on the subject of whiplash associated disorders (WAD). Dr. Malleson brings the subject of WAD to life and is able to present his thoughts in a structured, coherent yet entertaining manner.

On page 31 of this scholarly work he presents the findings of Dr. Henry Berry's findings of the presence of, or rather absence of, WAD in demolition derby drivers. In short, WAD does not exist in demolition derby drivers. Surely, such a finding cannot be explained by simply applying biomedical principles.

Those with a vested interest in promoting late WAD as a distinct biomedical entity have unsuccessfully attempted to debunk the writings/ research of Berry, Robert Ferrari and now Malleson. While no one is disputing the existence of the acute/ early WAD the dispute comes when one tries to explain away the findings of studies coming out of Singapore, New Zealand, Germany, Greece, Saskatchewan and Lithuania - which essentially undermine the existence of the phenomenon of the late whiplash syndrome.

From the writings and meta-analysis of Malleson et al is should be patently obvious to all of us managing these VICTIMS that we need a significant paradigm shift in the management of WAD - i.e. we should be adopting a biopsychosocial approach to its management thereby improving the clinical outcomes, both quantitatively and qualitatively, in the VICTIMS who are all too often mismanaged by those practitioners who exclusively subscribe to a biomedical approach. More works like Mallerson's are needed on this very contentious subject.

For additional reading, I'll recommend THE WHIPLASH ENCYCLOPEDIA - The Facts and Myths of Whiplash by Dr. Robert Ferrari (1999) to anyone with an open mind on the subject of WAD.

To Dr. Malleson I'll like to take this opportunity to not only congratulate you, but thank you for such a fine book. I've had the opportunity to read most, if not all of the textbooks that have been published on the subject of WAD over the last 5 years and this ranks amongst the finest. I'll remind Dr. Ferrari and yourself that it was Margaret Mead who one said, "Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has".

PS (August 7th 2003): Having reviewed this page for the first time in six months, I was once again pellucidly reminded how emotive the subject of WAD can get, especially for those having a vested interest in profiting from the WAD VICTIM'S pain and suffering.

The reference line for all MDs involved in the management should be the INJURED PATIENT and the INJURED PATIENT ONLY and this ethical and fiduciary duty must override any other obligation to the persons from whom one may have received instructions or payment (e.g. Insurance companies, plaintiff attorneys, etc.).

To the reviewer from Boston (April 6th 2003), who erroneously stated that I was an insurance company executive, I'll like to take this opportunity to point out that I am a MD who has spent over 15 years in the trenches managing the WAD VICTIMS' pain and suffering.

While in the earlier years of my career a fair percentage of my patients did not respond to the traditional biomedical model, however, over the last 4 to 5 years I've had the opportunity to apply the biopsychosocial model to the management of my patients suffering from Grade 0 to Grade III WAD and I'm pleased to announce that the results have been extremely heartening, to say the least.

The authors of books like "Whiplash and Other Useful Illnesses" must be commended for literally sticking their necks out and challenging the old paradigm that FAILED to benefit the WAD VICTIM.

It must be pointed out to the skeptics that Dr. Malleson goes onto show in his commendable textbook where and how the insurance companies, yes the insurance companies, benefit from WAD. Hence, it is somewhat disingenuous, to say the least, for anyone who has read "Whiplash and Other Useful Illnesses" to classify it as a pro-insurance industry text.

To those contemplating purchasing this text, if your reference is the patient's physical well being I'll commend this book to you, on the other hand if your primary interest lies in how you can profit from the patient's pain and suffering I'll suggest that you look somewhere else.

Just a concluding thought, how is it that those causing the accidents, that is those who have little to gain psychosocially from such, never seem to go onto to suffer from more than a transient neck pain?

Rating:
Summary: Useful for Insurance Company Lawyers and Doctors Who Golf
Review: I am always disheartened when physicians become pawns of the insurance industry, sometimes unknowingly. Dr. Malleson appears to have prostituted himself in this way quite knowingly, however. Like one of the reviewers from Barbados (who can be found easily using a Google search of his name--he is an insurance company executive), Malleson is yet another representative of the automobile insurance industry whose views of whiplash-related disorders are not only biased, but quite outdated. Malleson appears to be second-guessing the millions of injured persons in the United States and abroad and accusing them of secondary gain. However, several scientific studies have clearly shown that litigation has absolutely no effect on the long-term prgnosis and outcome of whiplash-injured persons.

Malleson, in a very predictable way, places a grossly distorted emphasis on studies which support his preconceptions about whiplsh injuries. These studies, such as one which looked at demolition derby drivers (Berry, 2000) subjected to multiple impacts over the span of their careers, or one that supposedly simulated a rear-end collision (it didn't) using fear tactics to intimidate and frighten research subjects (Castro et al., 2002), actually have very little to do with the phenomenon of a rear-end collision in the real world, where significant forces are produced in unaware and unbraced occupants who are struck by 3000-lb. objects.

Malleson, and many physicians, especially those in neurology and psychiatry circles, attribute chronic pain after a rear-end, whiplash-producing collision, to be purely psychological or societal. This theory, a "psychosocial" theory of chronic pain after whiplash, not only has never been proved, but has never even been studied or tested.

I suppose that if you want to treat whiplash as a psychiatrist, it probably helps to couch a diagnosis in the psychiatric realm. But the lack of quality of research for a psychosocial theory in whiplash is glaring, and this paucity has not been commented on by Malleson. This is a great flaw of this poorly-researched book.

The proponents and founders of the "psychosocial theory" of chronic pain after whiplash, Drs. Robert Ferrari and Anthony Russell of Canada (where funding for pro-insurance research has reached a worldwide high), have called their theory instead a "biopsychosocial" one. That is a misnomer, however, since Ferrari and Russell allow for no biological explanation for chronic pain after whiplash. In other words, they do not believe that chronic pain after whiplash is possible from damage to injured human tissues such as cartilage, ligament, muscle or muscle tendon, brain, spinal cord, or other nervous tissues. Unfortunately for injured persons, Dr. Malleson also subscribes to this psychosocial theory, although there is no good scientific evidence for it.

What Dr. Malleson's book ignores are the monumental studies from medical and engineering journals in the past few years. The reviewer who states that Malleson misses the mark is correct. Kaneoka and Ono and their colleagues from Japan have indeed changed the way we look at the biomechanics of a rear-end collision with their brilliant studies using human subjects and cineradiography. What is amazing is that their work supports and agrees with data coming from other studies, both clinical and medical, and other engineering studies.

The Japanese researchers have shown us that the cervical spine takes on an "s-shaped configuration" where the lower neck hyperextends, and the upper neck hyperflexes beyond normal physiologic ranges. The possibility that cartilage in the neck is permanently damaged is very high. This cartilage has also shown to be damaged in clinical whiplash studies performed by Australian research (Bpgduk and colleagues). That the auto insurance industry and its representatives should so easily dismiss the overwhelming majority of studies in the last decade comes as no surprise to me. However, when a physician ignores the importance of this research, or ignores the research altogether, then that is surely disheartening. It is also surprising to many in the lay public (although not as surprising to those of us in medicine).

The doctors who work for the insurance companies and testify in court are clinging desperately to a very small number of studies (less than 30) which deny the existence of chronic pain after whiplash from a biological (that is, injured human tissue) source. The vast majority of studies show the opposite is true: chronic pain is not the result of secondary gain, litigation or cognitive difficulties (over 50 good studies support this), but are the result of good old-fashioned tissue injury (studies number in the thousands in support of this).

Yet, voices like Malleson's, Ferrari's, Berry's, and other physicians, especially neurologists, will continue to bark the loudest, as if by barking louder they will be able to somehow overturn the majority of scientists and researchers in both the medical and engineering worlds who disagree with them. Malleson's views simply do not hold up in the face of the research which he conveniently either ignores or distorts in his book.

There is a great advantage to writing a book like this: your future as a physician working for the insurance industry is virtually guaranteed. You will be able to reap great profits from defense (insurance company bought-and-paid-for) work, performing "expert" testimony for a fantastic income, and insurance medical exams (so-called "IME" exams) at a handsome profit. One doctor I know (most physicians I know refer to him as the local insurance company whore) literally made over $250,000 last year on Wednesdays performing these exams. He's got a lot of time left over for golf!

Nice work schedule! A quarter-mil on Wednesdays, looking for nothing in these patients, and surprise--not finding anything. Since he cannot find anything (he doesn't look for anything wrong), there must not be anything wrong with these patients! The insurance company, based on its own incestuous representative (or its representative once-removed), gets to legally deny payment for any further treatment to the injured patient! It is gone this far, don't let the supporters of this book lie to you any more. Thay all work for the insurance industry.

I wonder how Dr. Malleson's golf game is...?

Rating:
Summary: conflict of interests, anyone?
Review: I would rather prefer that those denying the science behind Dr Malleson's statements would declare their conflict of interests, as it is usually done in scientific papers. Maybe we could have a broader view about their opinions.

Rating:
Summary: A Real Medical Condition Is Trivialized in this Useless Book
Review: One must seriously question Andrew Malleson's research skills, as his inclusion of relevant and modern scientific research (1990-2002) on the topic of whiplash is virtually non-existent in this book. While it is true that surveys of jurors and the general public (including freshman law students) reveal a nationwide skepticism of the validity of whiplash claims in the United States (a recent University of Delaware article quoted a law student who opined that probably only "20% of whiplash claims were valid"), it is not layperson opinion that matters when it comes to whiplash injury. Science must play the defining role in whiplash injury litigation, not hearsay, anecdote, or public opinion.

But Malleson's book offers little beyond public opinion.

While it is true that insurance fraud is a major problem in the whiplash claims according to insurance groups (the Insurance Institute for Highway Safety estimates fraud in whiplash claims MAY be as high as NEARLY 40% of bodily injury claims where sprain OR strain is the ONLY injury, see IIHS Status Report, 1997), clearly even the insurance industry sees that greater than 60% of whiplash claims involving sprains OR strains as the only injury (a statement which, of course, says nothing about crashes producing whiplash injuries other than, or in addition to, sprains and strains, such as nerve injuries, spinal disc herniations, ligament ruptures, concussions or brain injuries, fractures, cartilage contusions and many others documented in the medical literature).

The medical literature speaks very clearly to the injuries sustained in whiplash. There are literally thousands of studies which document the myriad types of injuries (simply go the United States National Library of Medicine website and search PubMed under "whiplash"), a list too exhaustive to list here. There are also several excellent medical textbooks (see Foreman and Croft's textbook on amazon.com, or Yoganandan and Pintar's textbook, or a number of other medical textbooks found on this website such as those by Malanga and Nadler (Eds.), Gunzburg and Szpalski (Eds.), Nordhoff, Melton, and others) on the topic listing the multitude of injuries possible, including, but not limited to, sprains and strains. These textbooks are by authors and editors who understand the seriousness of whiplash injuries.

Clearly, Malleson's book cannot compare to these.

Any assumption, such as the one posed by another reviewer (the only one to date as of 11-08-02), that "... no objective test has been able to demonstrate any pathological lesion in those who have suffered moderate intensity rear impacts...", is simply a ludicrous and uneducated statement. Here is why:

Flexion-extension x-rays (where the whiplash victim bends his head forward and then back for the x-rays, which are taken in side-view of the neck), as well as the more modern flexion-extension MRI (including motion study MRI in weight-bearing positions, i.e., upright posture, where the weight of the head and the position of the neck show disc and ligament problems in whiplash patients not seen with conventional MRI, where the patient is supine or laying flat, face-up, with no weight on the neck), are showing indisputable lesions.

Seen on flexion-extension x-rays and MRI's are substantial ligament injuries, injuries severe enough to cause "ligamentous instability", a diagnosis that can be found in the American Medical Association's 4th and 5th Edition Guides to the Evaluation of Physical Impairment. The AMA Guides lists cervical spine (neck) instability as a "25% whole-person impairment", which is equal in severity to "amputation of the leg, 3 inches or more below the knee", according to the Guides (5th Ed.). Ligamentous instability is a serious injury to the cervical spine, seen in even low-speed rear-end collisions.

Disc herniations are seen on MRI after low and moderate speed rear-end collisions. These are objective findings.

The list of injuries goes on and on.

Cadaver crashes performed by Yoganandan and reported in the journal SPINE in the past year show serious injuries to the ligaments and cartilage of the cervical spine that cannot be seen on x-rays, CT scans or MRI. Cadaver necks were dissected and frozen after exposure to low-velocity, rear-end collisions, then analyzed for injury after the crashes. Multiple injuries were found. While there are problems comparing cadavers to real-world occupants, these studies may be the best at showing the hidden injuries which real sufferers have endured in spite of a hostile medicolegal environment. Doctors and scientists must never forget that just because medical tests and imaging do not always find the injuries DOES NOT MEAN the injuries do not exist. Further, it DOES NOT MEAN that these patients are necessarily suffering from "litigation neurosis" (research does not support this notion anyways), are malingering, are "cognitive underperformers", exaggerators, or hoping for big settlement money (indeed, most of the medical research on this last topic shows that the majority of whiplash patients continue to have chronic pain long after their legal claims settle).

This review cannot possibly cover the vast amount of research dealing with the topic of whiplash, but suffice it to say that a thorough reading of this book will not advance one's knowledge of the topic in any meaningful way. Coherent science is but a distant dream for Andrew Malleson.

Rating:
Summary: an excellent overview
Review: This book clearly illustrates the true nature of whiplash injuries - as a vehicle to help ne'er-do-wells exist without actually contributing anything to society.

Well done!

Rating:
Summary: A Real Medical Condition Is Trivialized in this Useless Book
Review: this is a scholarly and meticulously researched and referenced text by a clinician of great experience,insight and acumen.
Mallenson does not hide behind euphenisms and he eschews 'weasel "words and phrases.He examines the nature of the entity of 'whiplash' and emphasises that despite the legions of sufferers and their claims ,no objective test has been able to demonstrate any pathological lesion in those who have suffered moderate intensity rear impacts.Patients who have had extensive surgery of the neck appear to recover with little of the morbidity of whiplash sufferers.He also highlights the numerous cases of fraud by lawyers,chiropractors and physicians.This is a MUST read for M.D.s who examine claimants and the lawyers and Insurance people who should be cognisant of recent research in
this area.

Rating:
Summary: cold water and real research poured onto a xontentious topic
Review: this is a scholarly and meticulously researched and referenced text by a clinician of great experience,insight and acumen.
Mallenson does not hide behind euphenisms and he eschews 'weasel "words and phrases.He examines the nature of the entity of 'whiplash' and emphasises that despite the legions of sufferers and their claims ,no objective test has been able to demonstrate any pathological lesion in those who have suffered moderate intensity rear impacts.Patients who have had extensive surgery of the neck appear to recover with little of the morbidity of whiplash sufferers.He also highlights the numerous cases of fraud by lawyers,chiropractors and physicians.This is a MUST read for M.D.s who examine claimants and the lawyers and Insurance people who should be cognisant of recent research in
this area.

Rating:
Summary: Not Just About Whiplash
Review: This is an extensive, wonderfully documented discussion of a spectrum of illness that effects a large part of our society (not just in the United States, but in most of the developed world). Malleson does a fine job of keeping it readable with a combination of incisive wit and piercing insight.

Apart from the issue of whiplash itself the author explores the effect of this spectrum of disease on the medical profession (my profession) and the effect of my profession on this spectrum of disease. His insights are clear and revealing.

Malleson further points out relationships between the healthcare system of the developed world and these "useful diseases". His insights and discussions in this regard are, once again, germain and well presented.

In the discussion as to what form of healthcare system we should develop in this country, the subject matter of this book is key.
If legeslators and healthcare planners are unaware of these relationships our healthcare system is doomed.

This book is appropriate reading for any healthcare professional, attorney, and anyone in the insurance business. Legeslators and others involved in healthcare planning should have this material as required reading. The concepts contained in this work are critical to the future of our healthcare system.