The Whiplash Book was the first result of the 2001 ABI whiplash research programme, directed by Andrew Auty, Chaired by Kate Lotts. The book was based on a detailed review of the evidence on causation, diagnosis, prognosis and intervention. A summary of those findings is presented in the attached pdf file. The only difference of view of note was the finding that manual therapy had a useful role to play in rehabilitation. It was conceded that this could in principle sometimes be useful when cases were deteriorating after 2 weeks, but  evidence was absent. For all other cases there was emphatic evidence that there was no measurable benefit. Manual therapy was kept in the guidance because it could not be said that it was always useless. This sentiment was perhaps misplaced; based on a medical view of the world rather than a common law view of the world. The Radar report is available to subscribers: 1#9 1

Intervention before sickness absence would be the prerogative of the employer, it would be difficult to involve liability insurance until actual harm had been done. Evidence from: I Vaananen-Tomppo et al. International Journal of Rehabilitation Research. September (2001) Vol.24 #3. p 171. State employees in Finland have access to rehabilitation services at their usual place of work. The gatekeeper is a fully qualified occupational physician or psychologist, as appropriate. The trigger is any report of a threat to the ability to perform normal duties. Very often the service is triggered before deterioration to the extent that the employees requires time off work. Interventions and return to work programmes take place at the usual place of work. This study was designed to assess the cost benefit ratio of this system. The reference population consisted of those who did not ask for help, but went off sick. The analysis presented here is hard to understand, but suggests a cost benefit ratio

Evidence from: P Boffeta et al. Scandinavian Journal of Work, Environment and Health. August (2001) Vol.27 #4 p 227. A case control study of a proposed association between exposure to titanium dioxide dust and lung cancer. This was a small study, the main result was: for those classified with high exposure for 5 years OR = 1.0 (95% CI = 0.3 to 2.7). Comment Although not a powerful study, the result provides some confidence that any association between Titanium dioxide exposure and lung cancer is very weak.

The most significant source of exposure is exhaust from combustion engines; especially in confined spaces. However, carbon black is also used as an ingredient in composite materials and as such is handled in huge quantities. This study sought associations between exposure to carbon black and bladder cancer in long shore men. Evidence from: R Puntoni et al. The Lancet. August (2001) Vol. 358 #9281 p 562. A study of a proposed association between occupational exposure to carbon black and, bladder cancer. Carbon black has been assessed by IARC as being a possible human carcinogen. 2286 long shore men (Dockers) employed between 1933 and 1980 were the subjects of this study. Of these 596 spent a significant time carrying paper sacks full of carbon black. The work was very dusty. Cases were identified using the local cancer registry for a period between 1986 and 1996. Occupational hygienists assessed exposure as having been: 858 low, 709 moderate and 534 high for members of this population.

MF Jeebhay et al. Occupational and Environmental Medicine. Sept (2001) Vol.58 #9 p 553. A selective review of occupational seafood allergy. In general seafood processing seems highly energetic and manually involved. This creates the potential for extensive skin contact with fish proteins and the production of respirable protein aerosols. The author finds that most types of seafood have been found to cause occupational allergy:

Evidence from: K Turjanmaa. Allergy. September (2001) Vol. 56 # 9 p 810. An editorial on the subject of latex allergy. Allergy to natural rubber latex (NRL) has been known for over 20 years. While there remains no universal consensus on how to diagnose latex allergy- guidelines have been issued by the European Academy of Allergology and Clinical Immunology (EAACI) Allergy (1993) Vol. 48 supplement 14:57-62. Skin prick tests are believed by the author to be the most reliable, but allergen assays are non-standard. That is, the materials applied to the skin to test for allergy differ in allergen composition and concentration. EAACI are working on a revised guideline, now is the time to influence it. Comment Insurers may wish to consider becoming involved in the development of a standard for diagnosis. A widely accepted standard would reduce uncertainty. In fact latex contains a number of allergens, some of which are shared by a wide range of plants and other organisms. A diagnosis of late

Acrylamide exposure is common in construction projects. In this project, blood levels were measured and found to be slowly decreasing with a half life of 40 to 80 days. At the same time, symptoms of numbness and tingling gradually declined. Evidence from: L Hagmar et al. Scandinavian Journal of Work, Environment and Health. August (2001) Vol.27 #4 p 219. A NOAEL was identified. The Radar report is available to subscribers: 1#8 7 Evidence from: F Granath et al. Occupational and Environmental Medicine. Sept (2001) Vol.58 #9 p 608. A comment on an earlier study of a proposed association between occupational exposure to acrylamide and, cancer. A 10-year follow-up study was reported in 1999 Occupational and Environmental Medicine Vol.56, p 181 to 190. The main conclusion of the original report was that there was no significant long-term cancer risk. The letter (here) suggests the original study was severely flawed. Comment Our reading of the criticism of the original work leads us to believ

This was a powerful study of physical and psychosocial risk factors for regular back pain. Neither physical nor psychosocial factors were predictive of new cases of back pain. Emotional exhaustion was predictive.  Evidence from: WE Hoogendoorn et al. Scandinavian Journal of Work, Environment and Health. August (2001) Vol.27 #4 p 258. The Radar report is available to subscribers: 1#8 6

A study of physical and psychosocial risk factors for back pain and chronic back pain.. Evidence from: LAM Elders et al. Occupational and Environmental Medicine. Sept (2001) Vol.58 #9 p 597. The only results, which showed statistical significance, were; associations between general ill health and LPB and, general ill health and LBP-related disability. Strenuous arm position was associated with LBP related disability. The Radar report is available to subscribers: 1#8 5

The study sought an association between exposure to environmental tobacco smoke at work and two measures of lung function (FEV1 and FVC). Actual lung function was compared with expected. Exposure was measured by cotinine levels and by questionnaire. Evidence from: R Chen et al. Occupational and Environmental Medicine. Sept (2001) Vol.58 #9 p 563. The observed effects were small and may have been reversible. The Radar report is available to subscribers: 1#8 4

This powerful prospective study demonstrated some strong associations between work tasks and symptoms. If symptoms are a clear indicator of subsequent injury risk then they could be used as prompts for change to the system of work.  Evidence from: A Leclerc et al. Scandinavian Journal of Work, Environment and Health. August (2001) Vol.27 #4 p 268. Risk factors and their precision estimates were reported along with 3-year incidence. The Radar report is available to subscribers: 1#8 3

Disabling shoulder pain was related to two ergonomic factors and two psychosocial factors. It was not clear whether the disability was signalled by the inability to perform those two specific ergonomic actions or by some other disability. If the former then the result may be significant but could be little more than a self-fulfilling prophesy. Evidence from: GJ Macfarlane et al. Annals of Rheumatic Diseases. September (2001) Vol. 60 #9 p 852. Incidence of bilateral and unilateral shoulder pain was reported. The Radar report is available to subscribers: 1#8 2

A detailed review of expert opinion was converted into a numerical format. Not surprisingly, the issues which safety practitioners regard as important were highlighted. More usefully, the financial context of a construction project gave rise to potentially useful risk rating ideas. Evidence from: A Research Report by the BOMEL Consortium, The Radar report is available to subscribers: 1#8 1

Further evidence that non-severe head injury can lead to significant effects on daily life. Interventions are possible if detected early. Evidence from: CM Stonnington. Brain Injury. July (2001) Vol. 15 #7 p 561. The Radar report is available to subscribers: 1#7 10

The research found symptoms of HAVS in workers who had not previously reported any. Effects of exposure to hand arm vibration were evident in those with and without any symptoms of HAVS. the findings are consistent with a gradually developing disease. Early identification of trend would be possible, but the false positive rate would be high. Evidence from: R Cederlund et al. Disability and Rehabilitation. September (2001) Vol.23 #13 p 570. The Radar report is available to subscribers: 1#7 9

Claims that shoulder pain is a sign of injury are plausible if there has been an impact event or similar. Gradually emerging pain however can have many potential causes, some of which are addressed by ergonomics standards. But is breach material? This would depend on context and degree of breach. Evidence from: H Miranda et al. Occupational and Environmental Medicine. Aug (2001) Vol.58 #8 p 528. It is tempting to assume that breach of duty must imply a material contribution. However, standards developed for regulation may not meet the standards required by the common law. The Radar report is available to subscribers: 1#7 8

This very powerful study found evidence that smoking is associated with a higher risk of multiple sclerosis. If so, the proposed link between physical injury and multiple sclerosis would be less confidently assigned among smokers. Evidence from: MA Hernan et al. American Journal of Epidemiology. July (2001) Vol. 154 #1 p 69. The Radar report is available to subscribers: 1#7 7

There are many risk factors for asthma. Identifying the significance of a guilty exposure must be set in the context of competing risk factors. Causation research should be corrected for known risk factors. Childhood asthma increases the risk of adult asthma. Evidence from: MM Haby et al. Thorax. August (2001) Vol.56 #8 p 589. Risk factors and their statistical strengths were reported in this paper. The Radar report is available to subscribers: 1#7 6

Silica exposure is well known for its effect on lung fibrosis. An unexpected link to autoimmune disease could be a result of fibrosis or of silica exposure. Either way, the impact on liability exposure would be significant. In this research there is good evidence for an association between silica exposure and renal disease and rheumatoid arthritis. It would be worth keeping a close eye on the effects of other fibrosis conditions. Evidence from: K Steenland et al. Epidemiology. July (2001) Vol. 12 #4 p 405. The Radar report is available to subscribers: 1#7 5

If successful, denervation would tend to support the view that back pain was a result of injury or degeneration. This RCT tested the effect of denervation surgery. Evidence from: R Leclaire et al. Spine. July (2001) Vol. 26 #13 p 1411. The Radar report is available to subscribers: 1#7 4

Causation is highly informed by previous history. Back pain is episodic. Back pain in adolescence is very common. Evidence from: DE Feldman et al. American Journal of Epidemiology. July (2001) Vol. 154 #1 p 30. A study of proposed risk factors for the development of LBP in adolescence. It is well established that previous episodes of LBP are prognostic of further problems. LBP in childhood increases the probability of LBP in subsequent years. Identification of risk factors for childhood LBP may lead to more effective prevention measures. 502 adolescents from Montreal were studied between 1995 and 1996 and followed up a year later. LBP was defined as substantial , at least once a week within the past 6 months. Assessment was made at 0, 6 months and 1 year. At time zero 377 out of 502 had no LBP within the past 6 months but 65 of these developed LBP during the year. Growth spurt (>5 cm a year) was a risk factor as was smoking and poor mental health. Activity was not a risk factor. Mus

The policy relationship between genetics and liability continues to be that you must take the person as you find them. Vulnerability is only an issue if you as the duty holder should have known and acted upon it. Probabilistic liability exposure however is affected by genetics. Risk rating would be justified even if duty holders are ethically bound to be gene blind. Evidence from: SE Humphries et al. The Lancet. July (2001) Vol. 357 #9276 p 115. The effect of genetics on disease risk is illustrated by this article on apolipoprotein genotype in smokers. The Radar report is available to subscribers: 1#7 2

Responses to injury should include steps aimed at preventing recurrence. If the cause was at work, then this serves as a prompt for the employer to adapt or modify the system of work. It would also act as a prompt for a compensation claim. The authors have developed a set of tools for deciding whether or not an injury is work-related. Evidence from: Peter Buckle, A Kilbom, A Grieco, Keith Palmer, Cyrus Cooper, Malcolm Harrington et al. Scandinavian Journal of Work, Environment and Health Supplement. June (2001) Vol.27 suppl 1. Although very simple in summary: Step 1 “Did the symptoms begin, recur or worsen after the current job (task) was started”. Step 2 “Are there exposures factors known (believed by the authors) to be (significant) risk factors for that part of the body?” Step 3 “Ask whether or not there are non occupational origins for the symptoms” Step 4 “Make a decision about the level of work relatedness” in practice each of these must be set in the correct context for regulato

Confidence in epidemiological findings is often expressed by a statistical measure. In 2001 the following view was expressed. We have since updated the criterion based on confidence limits. The difference between the upper and lower 95% confidence limits should be smaller than 3 times the (relative risk, minus 1).  (upper – lower) < 3× (RR-1) Understanding the confidence in epidemiology results is essential if the uncertainty in liability exposure estimates is to be usefully expressed. Uncertainty is often greater than the central exposure estimate. Evidence from: andrew@reliabilityoxford.co.uk Epidemiological results are often supported by reference to P values. It has become commonplace to refer with great confidence to results with P values less than 0.05. Such confidence may be misplaced. For example, a P value of 0.04 tells us that if the null hypothesis were true, an association as strong as the one we observe in that particular experiment would occur with a probability