Whiplash Care Guidelines

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

I would like to thank Arthur C. Croft, DC, MS, MPH, FACO, FACFE, FAAIM for the generous contribution of these 6 tables from the 12th chapter of his text Whiplash Injuries: The Cervical Acceleration/ Deceleration Syndrome (third edition).   To the best of my knowledge, this is the only on-line source of well documented treatment guidelines for the whiplash patient, which actually suggests the number of treatments which may be necessary. Please refer to Dr. Croft's text (3rd edition, 2001) for further explanation.

You might also enjoy some of   Dr. Croft's Dynamic Chiropractic articles and his November 15, 2000 article, referring to these guidelines, titled Guidelines for the Management of CAD Trauma.

Table 12.1

Effects of Experimental Spinal Fixation 1

Fibrous ingrowth Vascular invasion of tidemark Osteophytosis Subchondral remodeling Chondrolysis and cloning Absence of proteoglycans Fibrillated cartilage Loss of motion 1 Adapted from:   Kahanovitz N, Arnoczky SP, Levine DB, Otis JP:   "The effects of internal fixation on the articular cartilage of unfused canine facet joint cartilage." Spine 9(3):   268-272, 1984

Table 12.2

Common Factors Potentially Complicating CAD Trauma Management 1

Advanced age Metabolic disorders Congenital anomalies of the spine Developmental anomalies of the spine Degenerative disc disease Disc protrusion (HNP) Spondylosis Facet arthrosis Rheumatoid arthritis or other arthritides affecting the spine Ankylosing spondylitis or other spondylarthropathy Scoliosis Prior cervical spinal surgery 2 Prior lumbar spinal surgery 2 Prior vertebral fracture Osteoporosis Paget's disease or other disease of bone Spinal stenosis or foraminal stenosis Paraplegia or quadriplegia Prior spinal injury 1 From Croft AC:   Treatment paradigm for cervical acceleration/deceleration injuries (whiplash).   Am Chiro Assoc J Chiro 30(1):   41-45, 1993. 2 Especially laminectomy and discectomy.

Table 12.3
Guidelines for Frequency and Duration of Care in Cervical Acceleration/Deceleration Trauma 1
	Daily	3x/wk	2x/wk	1x/wk	1x/mo	TD 2	TN 2
Grade I	1 wk	1-2 wk	2-3 wk	<4 wk	....3	<11 wk	<21
Grade II	1 wk	<4 wk	<4 wk	<4 wk	<4 mo	<29 wk	<33
Grade III	1-2 wk	<10 wk	<10 wk	<10 wk	<6 mo	<56 wk	<76
Grade IV	2-3 wk	<16 wk	<12 wk	<20 wk	....4	....4	....4
Grade V	Surgical stabilization necessary--chiropractic care is post-surgical

1 Adapted from Croft AC:   Treatment paradigm for cervical acceleration/deceleration injuries (whiplash).   Am Chiro Assoc J Chiro 30(1):   41-45, 1993.

2 T_D indicates treatment duration; T_N treatment total number;

3 Possible follow-up at 1 month.

4 May require permanent monthly or p.r.n. treatment.

Table 8.12 is from Chapter 8 and explains the Grade I-V classification system used in the Table 12.3 above.

Table 8.12
Classification of Cervical Acceleration/Deceleration Injuries from Motor Vehicle Accidents (SRISD)1
A. Types of Collisions 2
Type I	Primary rear impact (struck car moving or stationary)
Type II	Primary side impact
Type III	Primary frontal impact
B. Grades of Severity of Injury
Grade I	Minimal;   No limitation of motion;   No ligamentous injury;   No neurological findings
Grade II	Slight;   Limitation of motion;   No ligamentous injury;   No neurological findings
Grade III	Moderate;   Limitation of motion;   Some ligamenetous injury;   Neurological findings may be present
Grade IV	Moderate to Severe;   Limitation of motion;   Ligamentous instability;   Neurological findings present;   Fracture or disc derangement
Grade V	Severe;   Requires surgical management/stabilization
C. Stages of Injury
Stage I	Acute;   Inflammatory phase;   Up to 72 hours
Stage II	Subacute;   Repair phase;   72 hours to 14 weeks
Stage III	Remodeling phase;   14 weeks to 12 months or more
Stage IV	Chronic;   Permanent

¹ Adapted from Croft, AC:   "A Proposed Classification of Cervical Acceleration/Deceleration Injuries with a Review of Prognostic Research"
Palmer J Research 1994;   1(1):   10-21

2 Occupant may be driver or passenger

SRISD = Spine Research Institute of San Diego. These criteria do not consider loss of consciousness, the use of seatbelts/shoulder harnesses, or other factors that will be accounted for in a forthcoming revised prognostic index.

Table 12.4
Treatment Adjuncts in Cervical Acceleration/Deceleration Trauma
Modality	Stage I	Stage II	Stage III	Stage IV
Cervical pillow	All grades	All grades	All grades	All grades
Cervical collars
-   Rigid	Grades III-V 1,2	Grades III-V 1,2	--------	--------
-   Soft	Grades II and III 1,2	--------	--------	--------
Home traction	--------	Grades II-IV 2	Grades II-IV	Grades II-IV
Home exercise	--------	Grades II-IV 2	Grades II-IV 2,3	--------
Ice	All grades	All grades	As needed	--------
Vit/min. suppl.	All grades	All grades	All grades	Recommended
DTM 4	Grades II-IV	Grades II-IV	As needed	--------

1 See text for indications.

2 Unless contraindicated.

3 Grade V after surgery.

4 Deep tissue massage.

Table 12.5

Contraindications to Manipulative Therapy

Relative Contraindications Patients with (+) George's test Patient with prior stroke Females on oral contraceptives Abdominal aortic aneurism Vertebiobasilar syndrome Metastatic disease Disc herniation Spondylarthropathy Severe spondylosis Moderate to severe osteoporosis Metabolic bone disease Osteomyelitis Discitis Stable spinal fracture Severe atherosclerosis Osteogenesis imperfecta Clotting disorders Intersegmental instability Absolute Contraindications Unstable spinal fracture Acute spinal cord injury Lack of formal training in spinal manipulation

Table 12.6
Heating Modalities: Modes of Transfer 1
Mode of Heat Transfer	Modality	Depth
Conduction   Convection   Conversion	Hot packs Paraffin bath Fluidotherapy Hydrotherapy Moist air Radiant heat Laser Microwave Short wave Ultrasound	Superficial heat       Deep heat

1 Adapted from Lehman JF, de Lateur BJ:   "Therapeutic heat."
In:   Lehman JF, ed. Therapeutic Heat and Cold. 3rd ed. Baltimore: Williams & Wilkins, 1982:   404-562

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Since 10-18-2000

Updated 5-07-2021