ACA News ~ Feb 2000
Whiplash is an enigmatic injury. We spend billions of dollars each year to treat it. Yet many lawyers, legislators, and medical doctors deny its existence. It affects millions of people around the world, yet research is severely under-funded. It is a largely preventable injury, yet we do little to prevent it. Fortunately, times are changing as whiplash enters a new phase of research and understanding.
“We now have a completely new model of whiplash,” says Dr. Arthur Croft, researcher and co-author of the well-respected textbook, Whiplash Injuries: The Cervical Acceleration/Deceleration Syndrome.
“Back in 1982, when I started practice, we had an extremely simplistic view of whiplash-you got hit from the rear; your head snapped back, which may have caused damage to ligaments, muscles, and tendons; your head snapped forward, which may have caused some additional damage; and then you had symptoms. We weren't very sophisticated in terms of what we knew, because there hadn't been much research.”
Researchers now believe that during a rear-end collision, the lower neck goes into hyperextension, while the upper goes into flexion. “That means the bottom and top parts of the neck are going in opposite directions during the initial phase of a whiplash, which forms the letter 'S,'” explains ACA member Dan Murphy, DC, who teaches whiplash throughout the world, including a 120-hour certification course on spine trauma.
“This sequence of events has been captured with cineradiography, which lets us look at the movement of each joint of the spine with motion x-ray. It's remarkable what it shows-especially in the lower neck where people seem to have the most complaints and most findings on examination. In a 6.5g impact, for example, the motion between C7 and T1 is supposed to be about two degrees, but researchers are finding that the joint is moving about 20 degrees - or 10 times more than it is supposed to.”
Researchers initially captured this information by using human cadavers in cars, but those who thought live humans would respond differently were skeptical. Researchers counter-argued that it made no difference because maximum injury occurs in less than one-tenth of a second. "The injuries happen so fast they beat the dynamic of the muscles that would normally protect the joints," Dr. Murphy explains. "For the muscles to kick in to protect the joints, you need approximately two-tenths of a second."
The criticism remained until 1999 when researchers in Japan began using live volunteers. Although researchers have used live volunteers for decades, they had not done so in this situation because of the threat of exposure to ionizing radiation from cineradiography. When changes in technology reduced that threat, ten volunteers participated in research that substantiated the earlier findings.
“The neck's S-shaped configuration puts great stress on the facet-joint capsules and the annulus of the disc,” Dr. Murphy says. “Chiropractors treat facet-joint capsules and treat the disc biomechanically when they do spinal adjusting. We have always known that chiropractors are effective with whiplash, but there were lots of theories as to why. Now, it appears that by the very nature of what we do, chiropractors are most effectively treating the tissues injured during the accident.”
Whiplash has endured a long history of suspicion. In the 19th century, people were suffering similar injuries during train accidents. "They sought compensation from the railroad, but just like modern-day insurance
companies, the railroad had their company doctors examine and label patients with a pejorative condition known as 'railway spine,'" Dr. Croft says. "As far as we've come, with all of our diagnostic and treatment technologies, those basic problems remain."
Today, the largest single contributor to chronic neck pain and overall spine pain is motor vehicle crashes. Of the 6 million injuries per year due to motor vehicle crashes, about three million are whiplash-type injuries. Of those, 500,000 to 900,000 will develop chronic pain. (These figures are based on Dr. Croft's research and
differ from the 1 million figure usually cited.) Despite patient satisfaction, chiropractic whiplash treatment continues to be downplayed or denied. The situation is exacerbated by the fact that the treatment of whiplash, unlike other conditions, is often embroiled in typical motor vehicle crash legal action. Lawyers and insurance-company representatives relish research that says patients will get better all on their own.
"Just this year, a number of papers came out that were absolute rubbish," Dr. Croft says. "They showed a complete lack of scientific thought and logic, offered unbalanced analyses of the subjects, but were published in peer-reviewed literature. They say that whiplash does not exist, yet we spend perhaps as much as $23 billion a year dealing with its effects. This is incredible, especially considering that whiplash is a preventable condition. Legislators also assume that it doesn't exist. Half of my research for the last several years was simply to show that whiplash is a big problem and it does exist, rather than doing more focused and important research into how to prevent it and how to treat it successfully."
The prevention and treatment of whiplash have ramifications that extend beyond the head and neck. Other conditions attributed to whiplash include blurred vision, dizziness, nausea, thoracic outlet syndrome, fibromyalgia, and carpal tunnel syndrome. Fibromyalgia is the third most common diagnosis made by American rheumatologists, and as many as 25 percent of diagnosed cases are attributed to an earlier trauma event, of which whiplash ranks number one in frequency.
But without good randomized trials to show that one treatment is better than another, or better than no treatment, adds Dr. Michael Freeman, suspicions about chiropractic treatment of whiplash will continue. Dr. Freeman, a chiropractor and PhD clinical assistant professor of epidemiology at Oregon Health Sciences University School of Medicine, is currently the only PhD epidemiologist in the United States researching whiplash and the only chiropractic instructor in a medical school teaching about whiplash injuries. "I'm teaching neurosurgeons, orthopedists, and medical doctors about whiplash. They are hearing about chiropractic and seeing chiropractic in a very accepted forum of medicine," he says. Dr. Freeman is involved in a number of research projects that should offer new insights into such issues as disc herniation in motor vehicle crashes, variables predicting disc injury, and risk factors for chronicity following whiplash.
"We are finding that risk factors for acute injury, such as having the head rotated, being out of position in the vehicle, lack of preparation for the crash, and being struck from the rear, are present not only for initial injury, but also for chronic injury. If you are injured, whether the vehicle sustains no damage or is totaled, there is a one-in-three chance you will have chronic pain. It doesn't matter how much-or how little-damage there is to the vehicle." These findings soon will be published as a paper in the Journal of Musculoskeletal Pain with Dr. Croft as co-author. "We believe that people who are able to get chiropractic treatment first are less likely to be symptomatic, but we do not know that for certain. One of my goals is to do a prospective study where we randomize treatment and follow injured subjects for two years."
Dr. Freeman is encouraged by new research and events, such as the North American Whiplash Trauma Congress-the first whiplash symposium ever sponsored by a chiropractic group, the British Columbia Chiropractic Association-where medical researchers came from around the world to talk about whiplash. "The proceedings will be published in the Journal of Whiplash and Related Disorders," Dr. Freeman adds. "That's also a first for a chiropractic conference-to have its proceedings published in a peer-reviewed scientific journal."
He is also conducting research in collaboration with Dr. Croft in a
multi-cultural project in Beijing, China; Tokyo, Japan; Bristol, England; Inowroclow, Poland; and other cities in Sweden, Lithuania, and the United States. "We are comparing the rates of chronicity and the risk factors for injury and the risk factors for chronicity from the various cultures so that we can finally address statements from insurers that claim it's all cultural. We hope this study will put to rest the argument that people aren't really hurt."
Dr. Murphy is excited about two studies that specifically look at people who failed under medical management and were referred to chiropractors for treatment of chronic whiplash pain. "In both studies [1, 2] the results were phenomenal, and one of the conclusions is that chiropractic is the only proven effective treatment for chronic whiplash," he says. "What makes both of these studies even more credible is that the two co-authors, English medical physicians Drs. Gargan and Bannister, have been the two most published people on chronic pain from whiplash injuries."
Drs. Freeman and Croft are working to research and review what they consider to be a disturbing amount of bad whiplash literature.  Dr. Freeman has had an article accepted by the Journal of Manipulative and Physiological Therapeutics that refutes an article published in the New England Journal of Medicine by Dan Cherkin, PhD, and Richard Deyo, MD, about chiropractic and care for low-back pain. "They're well-published, respected spine researchers. Basically, they take the HMO perspective that no care is the best care," Dr. Freeman explains. "They compared chiropractic to the use of an exercise pamphlet and to the use of physical therapy, and said they were all the same, so why go to a chiropractor or physical therapist when using a booklet is just as good and everyone gets better anyway? But their study design was severely flawed. We found there had been significant statistical manipulation to make it look as though there were no difference between the groups when, in fact, the data in the study tables showed the chiropractic group had far outpaced the other two groups."
Drs. Freeman and Croft worked together on their critique of the Quebec Task Force of 1995.  In the June 6, 1995, issue of Spine,  Dr. Walter O. Spitzer, one of the task force researchers, stated that "most whiplash injuries heal on their own in a fairly short period of time." Again, they found the study to be significantly flawed. "It was funded by the SAAQ, the Automobile Insurance Society of Quebec, which only pays for time off work due to disability because all medical costs are paid by national health," Dr. Croft explains. "It's not surprising, then, that the operative definition of recovery in their study was 'returned to normal activities,' which included going back to school or back to work. The researchers did not attempt to find out whether any of those patients were symptomatic or whether they were still in treatment. At the end of one year, they found 97 percent were 'recovered.' What does that mean? They had no idea whether those patients had, in fact, recovered. It's a very flawed and misleading study, yet it was used by most insurance companies as an argument against reimbursement for chiropractic services. They could say, 'Look, according to this study, these things heal by themselves, they're self-limited, and they're not harmful, so we're not paying your bills.' It was used as a pretext for denying claims. So we did the research and published the paper."
Disagreement, of course, is not only outside chiropractic. Within the profession, chiropractors have conflicting opinions about how to treat whiplash. Dr. Croft attributes the root of this dilemma, at least in part, to the lack of whiplash curriculum in chiropractic colleges. "The subject of whiplash was glossed over in both colleges I attended," he continues. "I only received a one- or two-day lecture on whiplash. I specialized in whiplash, so this is roughly akin to a cardiologist who studies the heart for only two days in medical school. I have donated books and tapes to the libraries, but I would like to see more in the formal curriculum. Unfortunately, the only response I got from administrators was that they have a lot to cram into four years to satisfy the CCE, so they don't have room for whiplash."
As a result, most chiropractors tend to deal with whiplash the way they deal with most other mechanical neck disorders. "That's what they're taught to do," Dr. Croft continues. "While that works fairly well for a certain subgroup of these patients, many of them require much more specialized treatment, and they don't get it. I initially treated everybody the same, too, and I got mixed results, including a lot of cases that became chronic. I scratched my head for a long time before I finally developed a better treatment. [See "Avoiding Whiplash."] The biomechanics associated with whiplash are very different from almost any other condition. It's one of the worst neck injuries, in terms of poor outcome, and it requires a very specialized approach. I believe this is one of the reasons we have so many patients with chronic neck pain. Of course, only a fraction of them are treated by chiropractors. On the medical side, the situation is even worse."
In the future, new research is likely to further validate the chiropractic treatment of whiplash. Technological improvements are also being perfected in an effort to prevent whiplash.
Dr. Croft reports that seat and head restraint improvements are already in a few models of Volvo and Saab, for example. Sophisticated forward- and rear-looking systems are also being developed to gauge the distance between cars. A computer chip on board will contain a pre-programmed set of instructions to allow calculation of impending crash conditions.
"One of those will gauge speed,"
Dr. Croft continues, "and if you are gaining on the car in front of you at what the computer is programmed to consider a dangerous rate, it will sound an alarm. Likewise, if someone is approaching too fast, it will warn both the driver who is about to run into somebody-and the driver of the car that's about to be hit. It will give us that split second, perhaps, to try to avoid a crash or brace protectively for impact. Now the question will be, how many crashes can actually be avoided? Perhaps only 10 percent. But what we've found in our whiplash studies is that the people that have the worst outcomes are the ones who were caught absolutely unaware. So we believe that even just a few dozen milliseconds of warning that allow people to brace to some extent are worthwhile."
In addition, Dr. Murphy advocates a broader perspective on treatment. "What are some of the alternative providers that we can co-manage the patient with-those who may offer another aspect of management?" he asks. "It's not just understanding the injury, but understanding all of the things we and the patients can do to accelerate their healing, such as acupuncture, nutrition, and tissue work. These are excellent adjuncts. There are some wonderful studies coming out on resisted-effort rehabilitation, or the exercise protocols for patients who have very serious neck problems. Some of these are brand-new studies that have just come out this year in journals such as the January 1999 issue of Archives of Physical Medicine and Rehabilitation  that give us additional directions for patients who aren't responding to traditional types of management. Or the studies that came out by the Saal brothers in Spine, August 1996,  in which they took cervical-disc-problem patients and managed them conservatively with a combination of exercise, mobilizations, and traction every day and achieved excellent results."
For all the controversy, scrutiny, and frustrations surrounding whiplash, Dr. Murphy sees this as an excellent opportunity for promoting the profession. "It's only a matter of time until someone will ask for your deposition or your expert testimony, which provides an outstanding platform for chiropractic. We all need to learn to be better communicators. I've been involved in cases where the experts on the other side are past presidents of the International Society of Neurosurgery, for example. When we do well in those situations, it makes chiropractic so much more credible in the eyes of everyone listening to our presentation, which means the lawyers, court personnel, jury, and the judge."
- Woodward, MN, Cook JCH, Gargan MF, Bannister GC.
Chiropractic Treatment of Chronic 'Whiplash' Injuries
Injury 1996 (Nov); 27 (9): 643–645
- Kahn S, Cook J, Gargan M, Bannister G.
A Symptomatic Classification of Whiplash Injury and the Implications for Treatment
Journal of Orthopaedic Medicine 1999; 21 (1): 22–25
- Freeman MD, Croft AC, Rossignol AM, Weaver DC.
A Review and Methodologic Critique of the Literature Refuting Whiplash Syndrome
SPINE (Phila Pa 1976) 1999 (Jan 1); 24 (1): 86–96
- Freeman MD, Croft AC, Rossignol AM:
“Whiplash Associated Disorders: Redefining Whiplash and Its Management” by the Quebec Task Force ~ A Critical Evaluation
SPINE (Phila Pa 1976) 1998 (May 1); 23 (9): 1043–1049
Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, Zeiss E.
Scientific Monograph of the Quebec Task Force on Whiplash-Associated Disorders
Redefining “Whiplash” and its Management
Spine (Phila Pa 1976). 1995 (Apr 15); 20 (8 Suppl): S1-S73
- Nelson B, Carpenter D, Dreisinger, T, Mitchell M, Kelly C, Wegner J, (1999-01-01).
Can spinal surgery be prevented by aggressive strengthening exercises? A prospective study of cervical and lumbar patients
Arch Phys Med Rehabil 1999 (Jan); 80 (1): 20-5
- Saal JS, et al.
Nonoperative management of herniated cervical intervertebral disc with radiculopathy
Spine (Phila Pa 1976). 1996 (Aug 15); 21 (16): 1877-83
Resources for More Information on Whiplash
Whiplash Injuries: The Cervical Acceleration/Deceleration Syndrome,
Dr. Stephen M. Foreman and Dr. Arthur C. Croft, Williams and Wilkins, second edition 1997; third edition 2000.
Clinical Nutrition for Pain, Inflammation and Tissue Healing, Dr. David Seaman, Nutranalysis, Inc., 1998. Examines the role of nutrition in pain and tissue healing.
Journal of Whiplash and Related Disorders, Dr. Michael Freeman and Dr. Christopher Centeno, co-editors. Slated for publication in mid-2000. "This journal is very exciting," Dr. Freeman adds. "It's a non-chiropractic journal for chiropractors and a place for chiropractors to find the latest information on whiplash injury, as well as a critique of upcoming literature." Hayworth Medical Press, 10 Alice Street, Binghamton, NY 13904-1580; 607/722-5857.
North American Whiplash Congress II, a two-day, multi-disciplinary whiplash congress scheduled for November 2000 in San Francisco.
"Whiplash: a Patient's Guide to Recovery." 83-page booklet explains whiplash, exercises, nutrition, etc. Spine Research Institute of San Diego at 800/423-9860.
www.whiplash101.com, the 5,000-page Web site of Christopher Centeno, MD, which Dr. Freeman recommends as "the most comprehensive whiplash site on the Web."
www.hwysafety.org, the official Web site of the Insurance Institute for Highway Safety. Research-oriented organization mandated and supported by auto insurers to reduce highway injuries. Includes ratings on cars with the safest head restraints, airbags, bumpers and seat belts, etc.
Dr. Michael Freeman invites colleagues to contact him for more information:
2480 Liberty Street, NE, Suite 180 Salem, OR 97303
Whiplash in the Courts
Because whiplash is almost always the result of an automobile crash, it involves more legal action than any other medical condition, says
Dr. Stephen Foreman, co-author with Dr. Arthur Croft of the textbook Whiplash Injuries: The Cervical Acceleration/Deceleration Syndrome.
"Whiplash is the one medical condition that usually arises out of a situation where one person sues another to recover for damages," he explains. "When lawyers and insurance companies get involved, everyone starts questioning the doctor's clinical decisions, including such things as duration of care, type of care rendered, fees surrounding the care, and so on. They question the doctor's opinions about the long-term prognosis and scrutinize issues such as getting second opinions, sending the patient out for medication, and obtaining additional diagnostic testing."
In addition, as new studies on whiplash lead to possible new treatments, scrutiny in the legal arena will only intensify. "If you are practicing a whole new way of looking at something, someone will say maybe that new way is not good-and why are we having to pay for it?" adds Dr. Foreman, who has been involved in legal cases both as an expert witness and a five-year member of the California Board of Chiropractic Examiners. "Many people have a very conservative attitude toward treatment. They may say only three weeks of care was needed and perhaps the patient only needed to see a therapist six times. If that's their opinion, they will strongly question anything that exceeds those parameters. Doctors need to be able to defend their treatment and make it hold up in court." Dr. Foreman advises doctors to carefully document the history, physical examination findings, treatment rendered, and the patient's response to care. "Doctors must show that what they were doing was effective," he continues, "and be able at a later time to reproduce this care on paper so a third party-a judge, jury, arbitrator, or even the state board of examiners-can understand what happened, start to finish."
Good documentation can be even more important if the patient does not improve or experiences unusual complications and sues the doctor. "If you haven't written anything, it's your word against theirs," Dr. Foreman says. "[Without documentation,] it is very difficult to state with authority in a deposition what the symptoms were, what was found in the examination, what treatment you did, and how the patient responded-all on a given day."
Dr. Foreman also cautions doctors against treating all whiplash cases in an identical manner. "Whether it's a big whiplash or a little whiplash-with a little pain or a lot-some doctors inappropriately use a predetermined schedule of care," he explains. "They try to apply that to every case, instead of looking at patients and their injuries on a case-by-case basis. We need to make a very accurate determination of the severity of the injury and the appropriate care, treat them in an effective manner, use other health practitioners and other diagnostic tests whenever required, and accurately document everything in order to have documentation that shows patients got the care they needed."
In spite of the ongoing courtroom battles, Dr. Foreman feels that doctors who practice professionally get a fair hearing in the courts. "Overall, the court system does a very good job of recognizing chiropractors as experts and allowing them to present their clinical findings regarding the amount of care required. It comes down to the ability of the individual chiropractor to be effective on the witness stand. There are good experts and bad experts. It depends on the individual doctor."
Dr. Arthur Croft shares seven ways to minimize pain and suffering before, during, and after a whiplash accident.
- Shop for a Safer Car
Before you buy your next car, compare vehicle structural design, vehicle size and weight, and restraint systems-belts, airbags, head restraints, and crash avoidance features. Consider mass and crashworthiness. "Small cars put you at greater risk," adds Dr. Croft.
Also, check Insurance Institute for Highway Safety ratings for safest seats, head restraints, etc. For example, Volvo and Saab have introduced new seats similar to the designs
Dr. Croft recommended in 1988 in the first edition of Whiplash Injuries: The Cervical Acceleration/Deceleration Syndrome.
- Keep Head Restraints in Up Position
Eighty percent of cars have the head restraint adjusted in the low position, yet research shows that having no head restraint is safer than having one in the low position. In addition, because head restraints are designed to fit the average man, it can be difficult for taller or shorter people to get a good fit. Some add-on head restraints are available, but check first for safety approval and ease of installation.
- Prepare for Crash
Crashes happen at lightning-fast speeds, but if you have time to prepare:
- Put your head and your neck all the way back so that you're in contact with the seat back and the properly adjusted head restraint.
- Straight-arm the steering wheel and get a good grip.
- Put your foot on the brake as hard as you can (assuming that you are stopped, of course).
- Look straight ahead, not in the rearview mirror. Don't have your head turned at all.
- Put your neck back slightly so your eyes are looking level-up at about the top of the windshield.
- Scrunch your shoulders up toward your ears and then brace.
- Seek Treatment Immediately
According to Dr. Croft, "It's a huge advantage to get patients when they're fresh. Missing that important two-week opportunity increases the likelihood of a chronic condition."
- No Crush, No Crash? Not True
"There's absolutely no truth to that," Dr. Croft says. "Injuries are more prevalent within a certain range of crash speeds when there is no damage, than when there is damage to the vehicle. The reason for this is that the energy that's used up in the crushing of the parts of the car is not transmitted to the occupant."
- Do What the Doctor Orders
Exercises, ice, nutrition, soft collars for the first few days, adjusted work stations, deep tissue work in the early stages-do whatever the doctor prescribes. "I take a shotgun approach," Dr. Croft adds. "That's because, in part, the treatments and the ancillary products we recommend are fairly inexpensive and none of them is dangerous or painful. It's worthwhile to prevent these injuries from becoming chronic."
- Think Ergonomically
Positions to avoid, how to sleep, conditions at work-these are everyday factors that can hasten healing. For example, patients have problems having their heads turned for long periods of time, such as when talking to someone to one side, looking out an airplane window, or working at the computer with the copy on the left side. For the latter, Dr. Croft recommends moving the copy toward the middle and the monitor toward the right to even things out. He also recommends an office desk chair with armrests. Without armrests, the weight of the arms is suspended from the shoulders, which tends to pull against the muscles of the upper back, primarily the trapezius, which, in turn, causes strain on the neck.
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