Tuesday, 14 August 2012

Lessons from history #3: From railway spine to whiplash

‘Railway spine’ was the name given to the widespread finding of chronic back pain and disability associated with railway injuries, and reaching near epidemic proportions in mid and late nineteenth century England. It has many similarities with other post-traumatic conditions and provides lessons about chasing physical diagnoses, and the role of psychosocial factors (in particular, the role of compensation). Lessons that we never seem to learn.

Railway spine was characterised by a variety of physical disorders attributed to a railway accident, in patients with no significant organic injury. The symptoms varied and included back pain, limb pain, headache, fatigue, dizziness, memory loss, and sensory changes and weakness in the limbs. At the time, the mechanism for the condition was still thought to be organic, but without identification of an organic process, theories developed which matched the thinking of the time. The condition was thought to be a form of neurasthenia: irritation of the nervous system secondary to the physical shock of the accident. Various terms were used for this such as spinal concussion, traumatic neurosis and nervous shock.(1)

In the nineteenth century, neurosis, neurasthenia and nervous shock were seen as physical disorders of the nervous system, separate to mental or emotional conditions. Although the mechanism was thought to be through the physical impact of the collision, some element of exaggeration was suspected in claims for railway spine.(2) Later, near the end of the nineteenth century, psychological theories were developed for conditions like railway spine.

Whatever the mechanism behind railway spine, the association with compensation was indisputable. By validating the physical nature of the disease (albeit with theories only), the medical community smoothed the way for sufferers to successfully sue the railway companies and by the 1860’s the railway companies were paying out large sums in compensation for this condition and were losing almost every personal injury case that went to court.(3,4)

The difficulty with assessment of the cases (due to lack of physical evidence of injury) was noted at the time and, interestingly, a proposal for an independent review panel, consisting of physicians, surgeons and a legal advisor was suggested,(2) similar to solutions proposed and implemented for compensation cases today. When the theories regarding the cause of the condition turned towards psychological factors rather than physical, claims became harder to support and the reporting of railway spine subsided.

The bottom line
Railway spine was a constructed condition that had no physical basis and was completely determined by psychosocial phenomena. Doctors explained it in physical terms and falsely attributed the symptoms to a mechanical cause (the railway injury), no matter how slight that injury. Does anybody else see the similarities with whiplash?


1. Trimble MR. Post-traumatic neurosis: from railway spine to whiplash. New York: John Wiley & Sons; 1981
2. Railway injuries: a medico-legal subject, The Lancet, 1861, Sept 14, 255-6
3. Cohen ML, Quinter JL. The derailment of railway spine: a timely lesson for post-traumatic fibromyalgia syndrome. Pain Reviews. 1996;3:181-202.
4. Harrington R. The railway accident: trains, trauma and technological crisis in nineteenth century Britain.  York: University of York, Institute of Railway Studies; 2004. Available from: http://www.york.ac.uk/inst/irs/irshome/papers/rlyacc.htm.


9 comments:

  1. Hah, I tell all my residents about railway spine.

    Have you read "Whiplash and Other Useful Illnesses" by Malleson? He starts with railway spine, follows Edward Shorter for the most part (the "symptom pool") but adds an interesting layer of medicolegal aspects (he's an expert witness against the diagnosis).

    I'm a neurologist, see a lot of cases of post concussion syndrome that are more disabled for longer than one would expect from the mechanism of injury. Malleson points to a similar trend in the chronic whiplash population: low impact velocity is a risk factor for a more prolonged and severe syndrome. Will be interesting to see if the latest generation of MRI techniques can find a structural / organic basis for that (not just neuropsychological testing, which simply provides evidence that the symptoms described are in fact taking place, without showing why they happen).

    ReplyDelete
    Replies
    1. Hi
      Just wondering that my links don't show yet.

      Maybe because they cansel all former doubt. The mysteri is solved.
      Whiplash can be fixed through surgery now.
      That's what those links confirm

      Delete
    2. Anonymous,

      I have no idea what you are talking about.

      Delete
    3. I reconed - that's why I tried again :D

      I rather send the links one more time

      http://www.lfn.no/pdf/PainResManage_2006-No11_BengtJohansson_NikolaiBogduk_Oversettelse-AliceReite.pdf

      http://ptu.dk/fileadmin/FILER/PDF/Whiplashforskningen_rykker_markant.pdf

      Delete
    4. From my limited Swedish, these articles appear to be case reports and a non-systematic review. Unfortunately, there are many case reports and case series of individuals reporting improvement after treatment of any kind, including placebo treatments and treatments that have no possibility of having a specific therapeutic effect, like homeopathy and prayer.

      The facts that whiplash has more connections with non-physical factors than physical ones indicates to me that it is not a clearly identifiable physical condition with an clearly identified treatment aimed at correcting the physical defect. You would need ot show me some better comparative studies.

      Delete
  2. http://www.lfn.no/pdf/PainResManage_2006-No11_BengtJohansson_NikolaiBogduk_Oversettelse-AliceReite.pdf

    At last -

    ReplyDelete
  3. http://w3.cns.org/dp/2012cns/1436.pdf

    http://www.montazem.de/english/html/op_question.html

    It's your decision - not mine. ;)

    ReplyDelete
    Replies
    1. I am sorry, but uncontrolled case series do not provide much support. And if the condition was only seen in 75% of patients, why did nearly everybody improve? Why do whiplash symptoms very between countries and why are they so strongly related to psychological factors?

      I am also turned off by titles that include the phrase "A new hope"; it is bad enough in movies, but doesn't have much place in scientific reporting.

      Unfortunately, the world is full of case series reporting excellent results from many treatments that turn out to be no better than placebo (if they are ever put to the test). If they are not put to the test, it is assumed that they work, and this drives much of the medicalisation, overtreatment and overdiagnosis in medicine today.

      Delete
    2. It's okay
      One Way or the other - you have decided that psykological reasons are the major problem.

      I Can't change that.
      You Can't upset me.
      I lived whiplash for 35 years not knowing why I was in that awfull pain the first 18 years.
      You Can't say anything I haven't heard before.
      But I feel sad for those reading what you and your friend are writing. If they haven't the strength to let go.
      It is poison for Them.
      Once that poison hurt me bad. But no more.
      I Can't convince the whole World.
      I just know.
      MR1 functional scannings is the answer.

      Delete