A Symptomatic Classification of Whiplash Injury
and the Implications for Treatment

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

FROM:   Journal of Orthopaedic Medicine 1999; 21 (1): 22–25

Khan S, Cook J, Gargan M, Bannister G

University Department of Orthopaedic Surgery,
Bristol, UK

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Chiropractic Care for Spinal Whiplash Injuries By David BenEliyahu Studies on the efficacy of chiropractic care for patients suffering with pain secondary to whiplash injury are appearing in the literature. In 1996, Woodward et al. published a study in Injury on the efficacy of chiropractic treatment of whiplash injuries. [1] The authors of this study were from the Department of Orthopedic Surgery in Bristol, England. In 1994, Gargan and Bannister published a paper on the recovery rate of patients with whiplash injuries and found that if patients were still symptomatic after three months, there was almost a 90% chance they would remain so. [2] No conventional medical treatment has been shown to be effective in these established chronic whiplash injury patients. [3, 4] However, most DCs treating whiplash injury patients have empirically found high success rates in the recovery of these types of patients. In the Woodward study, 93% of the 28 patients studied retrospectively were found to have a statistically significant improvement following chiropractic care. [1] Chiropractic care in this study consisted of spinal manipulation, PNF and cryotherapy. Most of the 28 patients had prior treatment with NSAIDs, soft collars and physiotherapy. The average length of time before the patients began chiropractic care was 15.5 months post-MVA (range of 3-44 months). This study clearly documented what most DCs experience in clinical practice: that chiropractic care is an effective modality for patients injured in a motor vehicle accident. Symptoms ranging from headaches to neck pain, back pain, interscapular pain and related extremity pain with parasthesias all respond to quality chiropractic care. The literature has also suggested that cervical disc injuries are not uncommon after whiplash injury. [5] In a study published on chiropractic care for disc herniations, I demonstrated that not only do patients improve clinically, repeat MRI imaging demonstrates decreased size or resolution of the disc herniation in many cases. 6 Of the 28 patients studied and followed, several had post-MVA disc herniations that responded well to chiropractic care, with good clinical and anatomical outcome. [6, 7] In a recent retrospective study by Khan et al., published in the Journal of Orthopedic Medicine, on whiplash injured patients with respect to cervical pain and dysfunction, patients were stratified into groups based on degrees of good outcome to chiropractic care: [8] Group I:   Patients with neck pain only and restricted neck ROM. Patients had a "coat hangar" distribution of pain with no neurologic deficits; 72% had a good outcome. Group II:   Patients with neurological symptoms or signs and restricted spinal ROM. Patients had tingling, numbness and parasthesias in the extremity; 94% had a good outcome. Group III:   Patients had severe neck pain with full neck ROM and bizarre pain distributions in the extremities. These patients often described blackouts, nausea, vomiting, chest pain and visual dysfunction; 27% had a good outcome. The results of this study showed that in group I, 36/50 patients (72%) responded well to chiropractic care: in group II, 30/32 patients (94%) responded well to chiropractic care; and in group III, only 3/11 cases (27%) responded well to chiropractic care. There was a statistically significant difference in outcomes between the three groups (p < .0001). This study provides new evidence that chiropractic care is effective for whiplash injured patients. However, the study did not take into account those patients who also had back injuries, extremity injuries and TMJ injuries, and did not identify which patients had disc injuries, radiculopathy and concussive brain injury (most likely group III patients). In my experience, these types of patients respond better than 27% of the time with a more extensive model of chiropractic care, in conjunction with multidisciplinary providers. These studies show what most DCs have already experienced that the doctor of chiropractic should be the primary care provider in these types of cases. It is my further opinion that in cases like the group III patients, care should be multidisciplinary so as to achieve the best possible outcome in difficult clinical cases. References: Woodward MN, Cook CH, Gargan MF, Bannister GC. Chiropractic Treatment of Chronic 'Whiplash' Injuries Injury 1996 (Nov); 27 (9): 643–645 Gargan MF, Bannister GC. The Rate of Recovery Following Whiplash Injury Eur Spine J. 1994; 3 (3): 162–164 Barnsely L, Lord S, Bogduk N. Whiplash injury, a clinical review. Pain 1994; 58: 283 Bogduk N. Post whiplash syndrome. Aust Fam Phys 1994; 23: 2303 Schofferman J, Wasserman S. Successful treatment of Low back pain and neck pain after MVA despite litigation. Spine 1994; 9: 1007-1010 BenEliyahu DJ. Chiropractic management and manipulative therapy for MRI documented disc herniations. J Manipulative Physiol Ther 1994; 17: 177-185 BenEliyahu DJ. MRI and clinical followup study of 27 patients receiving chiropractic care for cervical and lumbar disc herniations. J Manipulative Physiol Ther 1996; 19 (9): 597-606 Khan S, Cook J, Gargan M, Bannister G. Symptomatic classification of whiplash injury and the implications for treatment. J Of Orthopedic Medicine 1999; 21 (1): 22-24

Whiplash usually occurs when the head is suddenly whipped or snapped due to a sudden jolt, usually involving a motor vehicle collision. However, it can also occur from a slip and fall injury. So the question on deck is, which of the health care services best addresses the injured whiplash patient? This question was investigated in a published study titled, A symptomatic classification of whiplash injury and the implications for treatment. The authors state conventional medical treatment utilized in whiplash care, “is disappointing.” The authors’ reference a study that demonstrated chiropractic treatment benefited 26 of 28 patients with chronic whiplash syndrome. The objective of their study was to determine which type of chronic whiplash patient would benefit the most from chiropractic treatment. They separated patients into one of 3 groups: Group 1   patients with “neck pain radiating in a ‘coat hanger’ distribution, associated with restricted range of neck movement but with no neurological deficit.” Group 2   patients with “neurological symptoms, signs or both in association with neck pain and a restricted range of neck movement.” Group 3   patients who described “severe neck pain but all of whom had a full range of motion and no neurological symptoms or signs distributed over specific myotomes or dermatomes.” These patients also “described an unusual complex of symptoms,” including “blackouts, visual disturbances, nausea, vomiting and chest pain, along with a nondermatomal distribution of pain.” The patients underwent an average of 19.3 adjustments over the course of 4.1 months (mean). The patients were then surveyed and their improvement was reported: Group 1 38% Asymptomatic 43% Improved by Two Symptom Grades 13% Improved by One Symptom Grade 6% No Improvement Group 2 24% Asymptomatic 24% Improved by Two Symptom Grades 24% Improved by One Symptom Grade 28% No Improvement Group 3 0% Asymptomatic 9% Improved by Two Symptom Grades 18% Improved by One Symptom Grade 64% No Improvement 9% Got Worse These findings show the best chiropractic treatment results occur in patients with mechanical neck pain (group 1) and/or those with neurological losses (group 2). The exaggerated group (group 3) was the most challenging and, the only group where a small percentage worsened. The good news is, the number of cases that responded well to chiropractic treatment (groups 1 & 2) far out number those that don’t (group 3). Hence, most patients with whiplash injuries should consider chiropractic as their first choice of health care provision.

The Abstract:

Objective:   To determine which patients with chronic whiplash will benefit from chiropractic treatment.

Design:   Retrospective review by structured telephone interviews of 93 consecutive patients seen in chiropractic clinic.

Setting:   Independent chiropractic clinic in a large city.

Subjects:   93 patients, 68 female.

Main outcome measure:   Gargan and Bannister grading pre and post treatment.

Results:   Three groups of patients were recognised. Group 1 consisted of patients with isolated neck pain associated with a restricted range of neck movement. Group 2 consisted of patients with neurological symptoms or signs associated with a restricted range of movement. Group 3 comprised patients who described severe neck pain but all of whom had a full range of neck movement. Patients in this group often described an unusual group of symptoms, with a bizarre, non-dermatomal pain distribution. There was a significant difference in outcome between the three groups (p<0.001) with only groups 1 and 2 improving following chiropractic manipulation.

Conclusion:   Whiplash injuries are common. Chiropractic is the only proven effective treatment in chronic cases. Our study enables patients to be classified at initial assessment in order to target those patients who will benefit from such treatment.

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