There are no studies that confirm a "valid whiplash syndrome." Perhaps what annoys Harold Merskey about my book (1) is not that I presented inaccurately the studies that do exist but that I presented them too accurately, leaving the studies, their authors and their advocates bereft of scientific credibility. Merskey cites a report of the reputable Norwegian Centre for Health Technology Assessment to condemn my book. Ironically, the authors of that report, (2) after commenting on the lack of science in the whiplash literature, confirm the very thesis of my book with the following conclusions: · "There is no documented evidence supporting a causal relationship between type or grade of injury and specific symptoms or symptom constellations. · "Evidence-based documentation has not been found to support the contention that chronic complaints following a whiplash injury mechanism are specific or are directly related to the actual injury mechanism." The Norwegian–Lithuanian study (3) was the first controlled study to examine the association between rear-end collisions and the development of chronic neck pain and headaches. Following the sudden occurrence in Norway of a devastating "epidemic" in which 70 000 people, from a population of 4.5 million, claimed to have been disabled by whiplash, Harald Schrader and his Norwegian colleagues wanted to learn more about the course of whiplash uncomplicated by the availability of insurance and fashionable beliefs that whiplash causes disabling symptoms. They chose Lithuania, a country in which there was no personal injury insurance and where few people had heard of whiplash. They matched each of 202 Lithuanian drivers whose cars had been rear-ended in the previous 3 years with a control subject from the same city as the collision victim. Without revealing the purpose of the study, the investigators sent health questionnaires to all study subjects. Thirty-three percent of the collision group reported neck pains, but so did 33% of the controls. Fifty-three percent of the accident group had headaches, but so did 50% of the controls. (3) When told the results, the Lithuanians were amazed that anyone would attribute persistent headache and neck pains to a minor car collision. In contrast, in much of the developed world, where whiplash is believed to cause chronic symptoms, collision victims, particularly those already in psychosocial distress, "capture" persistent whiplash symptoms. (1) The publication of the Norwegian–Lithuanian study in the Lancet (3) caused a furor among professionals who make a living from whiplash. The Norwegian researchers repeated their study, incorporating refinements designed to answer legitimate criticisms of the first study, but the results remained substantially unchanged.4 A case–control study, such as those of Schrader and his colleagues, is the only acceptable way to exclude a causal link between collisions and the development of chronic whiplash symptoms. As to obtaining a sufficient number of subjects to reach significance, this problem now appears to have been solved (5) by combining the results of the 2 studies. (3,4) To reach significance in a study of whiplash, a large number of subjects is needed because the prevalence of neck pains and headache in the community is high, and any possible addition caused by whiplash injury is small. This means that for any individual whiplash claimant, the chances of persistent symptoms being due to the collision rather than to the ordinary exigencies of life are much below the 50% probability required by civil law for the perpetrator of the accident to be held financially liable. If lawyers and medical expert witnesses refrained from bringing to court "junk" whiplash science, judges would seldom award compensation for whiplash complaints. Given that the high cost of auto insurance premiums reflects the excessive cost of whiplash claims, premiums could thereby be reduced to more manageable levels. Andrew Malleson University of Toronto Toronto, Ont. References 1. Malleson A. Whiplash and other useful illnesses. Montreal and Kingston: McGill-Queen's University Press; 2002. 2. Rø M, Borchgrevink G, Daehli B, Finset A, Lilleås F, Laake K, et al. SMM Report 5/2000: Whiplash injury — diagnosis and evaluation [English summary online]. Oslo: Senter for Medisinsk metodevurdering [Norwegian Centre for Health Technology Assessment]; 2000. Available: www.oslo.sintef.no/smm/Publications/Engsmdrag/FramesetPublications.htm (accessed 2003 Sep 2). 3. Schrader H, Obelieniene D, Bovim G, Surkiene D, Mickeviciene D, Miseviciene I, et al. Natural evolution of late whiplash syndrome outside the medicolegal context. Lancet 1996;347:1207-11. 4. Obelieniene D, Schrader H, Bovim G, Miseviciene I, Sand T. Pain after whiplash: a prospective controlled inception cohort study. J Neurol Neurosurg Psychiatry 1999;66:279-83. 5. Ferrari R, Schrader H. The late whiplash syndrome: a biopsychosocial approach. J Neurol Neurosurg Psychiatry 2001;70:722-6. (Author/publisher)
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