Opening the program was the redoubtable Dr. Patrick Wall (of Melzack and Wall gate pain fame). He began by castigating those who develop classification systems for chronic pain, which rely on our arrogant assumption that we know all there is to know about pain, and that our diagnostic arsenal is fully capable of finding any real form of pain. What is left, say some of these classifiers, must be somatiform in nature. Sheer arrogance, says Wall, and he pointed to some of the very latest discoveries in pain mechanisms, and touched on the subject of referred pain: a notion, he remarked, that "... has failed to pass through the thick skulls of many clinicians." Very refreshing, I thought.
Dr. Wall was followed by Dr. J. David Cassidy, who spoke about the recent Quebec Task Force (QTF) on whiplash. If you've read it there is nothing new to add. If you have not, you should. It has serious implications for those of us who treat whiplash patients. I did notice that the QTF Guidelines were not well received by many of the attendees.
I followed Dr. Cassidy and spoke about the recent literature concerning low speed rear impact collisions (LoSRICs). One of the points that I like to emphasize, particularly considering the framework of the current medicolegal environment where the incorrect notion of "no crash, no cash" prevails (i.e., without significant property damage to a vehicle, any claims for injury are stoutly denied), is that all of the recent work, including research sponsored by the insurance industry itself, shows that the threshold for cervical spine sprain injury is much lower than the threshold for vehicle damage. It was gratifying then to be followed by Mark Bailey, an engineer I had met earlier this year in Canada, who has been involved in car-to-car crash testing for several years. He reaffirmed the noncorrelation between vehicle and human damage.
Dr. Chris Main (University of Manchester) spoke about the guarded movements that can develop into chronic pain syndromes. Dr. Samual Dworkin (University of Washington) spoke of the association between the behavioral and physical findings in TMD. Dr. Dennis Turk (University of Pittsburgh Medical Center) developed a complex model of pain, integrating psychosocial and physical factors, suggesting that the impairment-disability link is weak and that disability is ultimately a form of behavior. Dr. James R. Taylor, well known to those familiar with the pathophysiological arm of whiplash literature, showed how many of the injuries sustained by these patients, including fractures of endplates and facets, eludes even careful retrospective radiographic analysis.
Dr. Ian Coulter presented the RAND study on cervical spine manipulation. Dr. Howard Vernon and I were on that panel, and although I have one or two minor reservations about the outcome, it was nevertheless a multidisciplinary consensus, and as evidence-based as was feasible, considering the literature available. This report is scheduled to be published soon.
Dr. Vernon followed with an interesting discussion of the development and use of his Neck Disability Index and methods of analysis and monitoring of whiplash patients. Dr. Bogdan Radanov, who has recently published a number of very important papers on whiplash, spoke on the issue of long-term prognosis of whiplash injuries. On this subject, his work alone was relied upon by the QTF.
Australian researcher Dr. Susan Lord, well known for her excellent and award winning work with Drs. Nikolai Bogduk and Les Barnsley (for an excellent review of whiplash see Pain, 58:283-307, 1994), presented the latest research on headaches referred from upper cervical synovial joints. Their research strongly suggests that much of the chronic pain from whiplash sufferers emanates from the facet joints.
Consensus Panel
One of the goals of this year's PMRF conference was to form a consensus panel to tackle the difficult issue of whiplash management. On the panel were nine MDs, three DCs, three PTs, one PhD, and one engineer. Several of the panel members gave short presentations, including a very thoughtful outline for management by Dr. Howard Vernon.
Our range of discussions was really quite broad, not particularly surprising since we were not only multidisciplinary but multinational as well. It soon became clear to all participants that in the time we had available a consensus on so many far flung issues would be an insuperable quest. Dr. Cassidy then suggested that the panel representing the PMRF simply endorse the QTF Guidelines, since this represented four years of work along a similar vein. A motion was made to endorse, then seconded, and a vote was called. It was unanimous. The motion passed, and PMRF endorsed the QTF Guidelines.
Well, not quite. Actually, when the "nays" were called for, my reaction was apoplectic. But my vote, I quickly asserted, eyes unglazing, was definitely "nay." Well folks, the silence was deafening. You could have cut the air with a knife. With all eyes upon me, Dr. Chalmers, the consensus co-chair, asked with a surprised look, "Would you like to tell us why?"
I said that my first concern was that the QTF began their project by tossing out 99.4 percent of the body of literature on whiplash. Secondly, although the lofty goal of the QTF was to establish an evidence-based analysis of whiplash, in many instances, owing to a lack of published data, they were forced to rely on a consensus themselves. Case in point: cervical pillows. No hard research material was available, so the consensus of the QTF (many of the members of which, incidentally, I do not recognize as experts in whiplash) was that cervical pillows were unnecessary, and further, that no research in this area was called for. This is a far cry from the evidence-based Holy Grail sought after by the QTF. In fact much of these guidelines appear neither to be supported by research nor a well grounded fundamental understanding of current empirical thinking in treatment circles. This is not surprising given the limited material reviewed (62 papers) and the backgrounds of the QTF members. Another case in point is this example of faulty syllogism: cervical collars do not very much limit cervical spine range of motion. I'll assume that the second premise must have been that this was in fact the clinician's goal. Conclusion: cervical collars are not recommended. Enough said. Read the thing yourself.
You have to ask yourself: if the majority of whiplash victims are treated by DCs, and a large portion of the DCs recommend cervical pillows to whiplash patients, is it really reasonable to rather peremptorily dismiss the whole idea of cervical pillows? Dr. Cassidy acquiesced somewhat and noted that I could certainly do such research if I chose. But then, I asked, wouldn't it now be more difficult to get funding for research that has been branded as unnecessary?
Dr. Cassidy naturally was defensive about the QTF work and accused me of looking at the thing with a magnifying glass (well what did he expect, eh?) and of using circular logic. Me? A phlegmatic discussion among the panel ensued. Dr. Vernon pointed out that we should be careful with such guidelines, since HMOs will tend to follow them to the letter if they are in that insurer's best interest. Dr. Cassidy has a much less cynical view of insurance issues, but I suspect he is fairly insulated from the American rules of play where the soft balls and boxing gloves are left at home.
In the end, thanks to me I suppose, the PMRF's endorsement of the QTF Guidelines was dropped. It's regrettable that we did not reach a consensus in the time allotted, but I am strictly opposed to some of the ambiguous language and questionable conclusions of these guidelines. Maybe next time we can hammer out a consensus that we can all live with.
Summary
On balance, I thought that this was one of the best multidisciplinary conferences I have attended (and very much unlike a previous Canadian slugfest I spoke at that witnessed the upbraiding tag team of Drs. Hamilton Hall and Alf Nachemson gang up on Dr. Len Faye!). In Banff, PTs, DCs, and MDs exchanged ideas in an atmosphere of real harmony. Such I think are the goals of the PMRF: to help unify the thinking of health care providers in all disciplines. It worked nicely.
Some of the proceedings of this conference, as well as those from previous conferences, will be available from the PMRF, a foundation founded by the late Dr. Mennell and now adroitly directed by Marc White. They can be reached by calling (604) 684-4148. If you are not on their mailing list, I'd suggest you get on it. Papers from the presenters will be published in the Journal of Musculoskeletal Pain next spring.
Arthur C. Croft, MS., DC, FACO
San Diego, California
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