Medical News

Did Something Happen to Our Necks?

It used to be that whenever someone on TV or in a movie fell off the roof or had a skiing mishap or got into any sort of auto accident, the odds were pretty good that they’d end up in a neck brace. You know what I mean: a circlet of beige foam, or else a rigid ring of plastic, spanning from an actor’s chin down to their sternum. Jack Lemmon wore a neck brace for a part. So did Jerry Seinfeld, Julia Roberts, and Bill Murray. For many decades, this was pop culture’s universal symbol for I’ve hurt myself.

Now it’s not. People on TV and in the movies no longer seem to suffer like they used to, which is to say they no longer suffer cervically. Plastic braces do still crop up from time to time on-screen, but their use in sight gags is as good as dead. In the meantime, the soft-foam collar—which has always been the brace’s most recognizable form—has been retired. I don’t just mean that it’s been evicted from the props department; the collar has been set aside in clinics too. At some point in the past few decades, a device that once stood in for trauma and recovery was added to a list of bygone treatments, alongside leeches and the iron lung. Simply put, the collar vanished. Where’d it go?

The story naturally begins in doctors’ offices, where a new form of injury—“whiplash”—started to emerge amid the growing car culture of the 1940s and the early ’50s. “It is not difficult for anyone who travels on a highway to realize why the ‘painful neck’ is being produced daily in large numbers,” two Pennsylvania doctors wrote in 1955. Following a rear-end collision, a driver’s body will be thrown forward and upward, they explained. The driver’s neck will flex in both directions, “like a car radio aerial.”

The damage from this jerking to and fro could not necessarily be seen in any medical scan. It was understood to be more of a sprain than a fracture, causing pain and stiffness in the neck that might spread into the shoulder. Many patients found these problems faded quickly, but for some of them—maybe even half—the discomfort lingered. Whiplash in its graver forms led to dizzy spells, sensory disturbances, and cognitive decline (all of which are also signs of mild traumatic brain injuries). And it could leave its victims in a lasting state of disability—chronic whiplash, doctors called it—characterized by fatigue, memory problems, and headache.

[Read: Chronic whiplash is a mystery]

From the start, standard whiplash treatment would include the wearing of a soft appliance: a foam collar to support the patient’s head and stifle excess movement. But the underlying problem had a squishiness about it too. If the damage to the neck was invisible to imaging, how was it causing so much misery? Some doctors guessed that the deeper, more persistent wounds of whiplash might be psychic. A paper on the problem published in 1953, in the Journal of the American Medical Association, suggested that the chronic form of whiplash might best be understood as neurosis—a “disturbing emotional reaction” to an accident that produces lasting ailments. These early whiplash doctors didn’t claim that their patients were malingering; rather, they argued that the underlying source of anguish was diverse. It might comprise, in various proportions, damage to the ligaments and muscles, brain concussion, and psychology. Doctors worried that these different etiologies were hard to tease apart, especially in a legal context, when “the complicating factor of monetary compensation,” as one study put it, was in play. (These uncertainties persist, in one form or another, to this day.)

A clinical unease colored how the neck brace would be seen and understood by members of the public. For about as long as it was used for treating whiplash, the collar held opposing meanings: Someone had an injury, and also that injury was fake. In The Fortune Cookie, the Billy Wilder comedy from 1966, a cameraman (played by Lemmon) gets knocked over at a football game and then persuaded by his sleazy lawyer—a guy called “Whiplash Willie”—to pretend he’s gravely hurt. They’re planning to defraud the big insurance companies, and Lemmon’s plastic neck brace will be central to the act.

Indeed, the stock setting for the collar, soft and hard alike, has always been the courtroom. When Carol Brady finds herself before a judge in an episode of The Brady Bunch from 1972, the “victim” of her fender bender, Mr. Duggan, hobbles into court with an ostentatious you-know-what. “A neck brace—do you believe that?” she asks. Of course you don’t; that’s the point. Mr. Duggan tells the judge that he’s just come from the doctor’s office, and that he has whiplash. (He puts the stress on the word’s second syllable: whipLASH. The condition was still new enough, back then, that its pronunciation hadn’t fully settled.)

[Read: No one in movies knows how to swallow a pill]

Concerns about unfounded civil suits multiplied in the ’70s and ’80s, thanks in part to what the law professor Marc Galanter would later term the “elite folklore” of seemingly outrageous legal claims, stripped of context and diffused throughout the culture by mass media. There was the woman who said she’d lost her psychic powers after getting a CT scan, the worker at a convenience store who complained that she’d hurt her back while opening a pickle jar, the senior citizen who sued McDonald’s after spilling coffee in her lap. And then of course there was the granddaddy of them all: the whiplash faker in a neck brace—the Mr. Duggan type, familiar from the screen.

Car-insurance premiums were going up and companies were pointing to exaggerated whiplash claims from drivers whose “soft injuries” could not be verified objectively. Financial motives did appear to be in play for certain plaintiffs: In Saskatchewan, where a no-fault system of insurance had been introduced and most lawsuits for pain and suffering were eliminated, the number of whiplash-based insurance claims appeared to drop. (Similar correlations have been observed in other countries too.) In the early 1990s, the New Jersey Insurance Department even staged a series of minor accidents involving buses wired up with hidden cameras—they’d be rear-ended by a slowly moving car—to test the prevalence of fraud. The department’s investigators found that Whiplash Willie–style lawyers quickly swooped on passengers to cajole them into making claims of damage to their neck and back.

By this time, the neck brace’s mere appearance in a movie or TV show would be enough to generate a laugh. It just seemed so silly and so fake! In the courtroom, insurance companies and other businesses grew less inclined to settle whiplash cases, Valerie Hans, a psychologist and law professor at Cornell, told me. Instead they’d try their luck, and mostly find success, in jury trials. To find out why, Cornell and a colleague did a formal survey of potential jurors’ attitudes about such injuries in 1999, and found that the presence of a neck brace on a plaintiff might only make them more suspicious. Fewer than one-third believed that whiplash injuries were “usually” or “always” legitimate.

[Read: Whatever happened to carpal tunnel syndrome?]

If the soft neck brace was already well established as a joke on television and a liability in court, the medical establishment soon turned against it too. A series of randomized controlled trials of whiplash treatments, conducted in the 1990s and 2000s, all arrived at the same conclusion: Usage of the soft foam collar was “ineffective at best,” as one evidence review from 2010 described it. At worst, it could be doing harm by preventing patients from engaging in the mobility and exercise programs that seemed more beneficial.

A broader shift away from telling patients to keep still, and toward assigning active interventions, was under way in medicine. Bed rest and other forms of immobilization were falling out of favor in the treatment of back injuries, for example. Concussion doctors, too, began to wonder whether the standard guidance for patients to do nothing was really such a good idea. (The evidence suggested otherwise.) And uncertainty was even spreading to the other kinds of cervical orthoses, such as the stiff devices made of foam and plastic called trauma collars, which remain in widespread use by EMTs. These are meant to immobilize a patient’s neck, to help ensure that any damage to their upper spine will not be worsened. But their rationale was being questioned too.

In 2014, a team of doctors based in Norway, led by the neurosurgeon Terje Sundstrøm, published a “critical review” of trauma-collar use. “For many years, the cervical collar was the symbol of good health care, or good pre-hospital care,” Sundstrøm told me. “If the patient wasn’t fitted with one, then you didn’t know what you were doing.” But he described the evidence of their benefits as “very poor.” His paper notes that at least 50 patients have their necks immobilized for every one that has a major spinal injury. Trauma collars can interfere with patients’ breathing, according to some research, and their use has been associated with patients’ potential overtreatment. They’re also quite uncomfortable, which may agitate some patients, who could then make just the sorts of movements that the EMTs are, in theory, trying to prevent.

In short, despite trauma collars’ near-universal use since the 1960s, no one really knows how much they help, or whether they might even hurt. Sundstrøm said that his own health-care system gave up on using trauma collars a dozen years ago, and has yet to see a single injury as a result. Official guidelines for the emergency use of cervical braces have lately been revisited in a small handful of countries, but Sundstrøm does not expect major changes to take hold. “I don’t think there will ever be really good studies for or against collars like this,” he said, in part because cervical spinal injuries are very, very rare. For the same reason, we may never even know for sure whether collars are appropriate for patients whose cervical fractures have been confirmed in the hospital. “There hasn’t really been any interest in this research topic either,” he told me. Instead, doctors just rely on common sense about which interventions are likely to be helpful.

So the use of rigid trauma collars is likely to persist regardless of uncertainty. In health care, that’s more the norm than the exception. Research is difficult, the human body is complex, and tradition rules the day. Lots of standard interventions, maybe even most of them, aren’t fully known to do much good. Viewed against this backdrop, the soft foam collar—rarely useful, always doubted, often mocked—may finally have flipped its meaning. For years it stood for fakery and false impressions and also, ironically, for a lack of proper evidence in medicine—for a failure of support. Now it may signify the opposite. By disappearing from the movies, the courtroom, and the clinic, this form of neck brace has become a rare example of a lesson duly learned. It shows that science can correct itself, every now and then. It shows that progress may be slow, but it is real.