What Contributes to Iatrogenesis in WAD?´té_Iatrogenesis_May... · Recommended WAD Treatments...
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Pierre Côté DC, PhD Canada Research Chair in Disability Preven7on and Rehabilita7on Faculty of Health Sciences, University of Ontario Ins7tute of Technology UOIT-CMCC Centre for Disability Preven7on and Rehabilita7on Dalla Lana School of Public of Public, University of Toronto What Contributes to Iatrogenesis in WAD?
Transcript of What Contributes to Iatrogenesis in WAD?´té_Iatrogenesis_May... · Recommended WAD Treatments...
PierreCôtéDC,PhDCanadaResearchChairinDisabilityPreven7onandRehabilita7on
FacultyofHealthSciences,UniversityofOntarioIns7tuteofTechnology
UOIT-CMCCCentreforDisabilityPreven7onandRehabilita7on
DallaLanaSchoolofPublicofPublic,UniversityofToronto
What Contributes to Iatrogenesis in WAD?
“Clinical iatrogenesis refers to the direct ways in
which health care (as an institution) or health care
professionals cause or prolong illness, disease, or
disorders in their patients.”!
- Illich, 1976
What can cause iatrogenic chronic pain and disability in WAD pa:ents?
Misdiagnosis / Overinvestigation
Ineffective Interventions
Harmful Interventions
Drug Indication / Dosage
EndlessTreatment
Nocebo: Creation of Fear and Negative Recovery Expectation
The Whiplash Marathon…
CARE
Howdowemeasureclinicaliatrogenesis?MeasuretheincidenceofeventsDetermineifaninterven7onslowsdownrecovery
6w 6m 12m
50%
100%
�
�
�
98days
3m
23%notrecoveredat1year �
Time
Recovery
ClinicalCourseIatrogenicTreatment
200days
30%notrecoveredat1year
Recommenda:ons for the Management of NAD and WAD
1995 2008 2016
Quebéc Task Force 2000-2010
BJD Task Force on Neck Pain
OPTIMa Collaboration
– Earlyreturntousualac7vi7es
– Passiveinterven7ons(collar,rest)shouldbeavoided
– Longcoursesofprescrip7ondrugs,
manipula7onandphysiotherapyarenot
jus7fied(avoiddependence)
Ø Studytheimpactofhealthcareon
recovery
Recommended WAD Treatments (1995)
Treatments NOT Supported by Scientific Evidence – NPTF (2008)
• Educational pamphlet
• Cortocosteroid injections
• Infusion of methylprednisone
• Immobilization in hard collar followed
by mobilization
• TENS, ultrasound, diathermy
• Fitness or outpatient multidisciplinary
rehabilitation
• High utilization of MD or DC care
What is the evidence?
AllclaimantswithAcuteWhiplash(n=2486)
1year
Median Time to Recovery (days)
251(95%CI:214-296)
213(95%CI:186-284)
139(95%CI:131-149)
30days
GP: 1-2 visits
GP: 2 visits
DC: 1-6 visits
DC: > 6 visits
GP+DC: 1-6 visits
GP+DC: > 6 visits
GP+ specialists
Medical group
Confounders
164(95%CI:153-175)
206(95%CI:166-261)
362(95%CI:297-468)
368(95%CI:252-440)
205(95%CI:165-269)
DC 1 – 6 visits DC > 6 visits GP 1 – 2 visits GP > 2 visits GP & DC 1 – 6 visits GP & DC > 6 visits GP & Specialist MD, no whiplash
Days to claim closure
Pro
porti
on o
f Cla
iman
ts
N=2486
Saskatchewan:No-FaultSystem
Days to claim closure
Pro
porti
on o
f Cla
iman
ts
DC 1 – 6 visits DC > 6 visits GP 1 – 2 visits GP > 2 visits GP & DC 1 – 6 visits GP & DC > 6 visits GP & Specialist MD, no whiplash
N=1,693
Saskatchewan:TortSystem
In a cohort of 6,021 WADpa7ents, those aaendingfi t n e s s t r a i n i n g , amul7disciplinary outpa7ent
rehabilita7on program or amul7disciplinary inpa7entrehabilita7on had worse
recovery than those whoreceivedusualcare.
Comparedwith individuals whoreported low u7liza7on ofphysicianservices,recoverywasslower for those with highh e a l t h c a r e u 7 l i z a 7 o n ,regardless of the type ofprofession (physiotherapists,c h i r o p r a c t o r s , m a s s a g etherapists and physicians)independent of expecta7on ofr e c o v e r y a n d o t h e rconfounders.
CostsofMedical/Rehabilita7onBenefitsinOntario
6visits!
Recent-onsetNAD/WADI-II(0-3months)
Interven7on NotRecommended
Structurededuca7onalone ✖
Strain-counterstraintherapy ✖
Relaxa7onmassage ✖
Cervicalcollar ✖
Electro-musculars7mula7on ✖
Heat(clinic-based) ✖
Electroacupunture ✖
PersistentNAD/WADI-II(>3months)
Interven7on NotRecommendedRelaxa7ontherapyforpainordisabilityoutcomes ✖
Clinic-basedsupervisedhighdosestrengtheningExercisesalone
✖
TENS ✖
Pulsedshortwavediathermy ✖
Botulinumtoxininjec7ons ✖
Strain-counterstraintherapy ✖
Relaxa7onmassage ✖
Cervicalcollar ✖
Electro-musculars7mula7on ✖
Heat(clinic-based) ✖
Electroacupunture ✖
Summary
• ClinicaliatrogenesisinWADisreal!
• Typeandintensityofcareimpactrecovery…notnecessarily
intheexpecteddirec7on
• Theriskofiatrogenesiscanbeminimizedby:
– Avoidingnon-effec7veinterven7ons
– Provide7me-limitedcareusingeffec7veinterven7ons
– Providingpa7ent-centeredcare
Acknowledgements
www.cdpr-research.org �[email protected]
