Whiplash is a puzzling injury and 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.”
Now researchers believe that during a rear-end collision that the lower neck goes into hyperextension [jerked backwards], while the upper goes into flexion [jerked forward]. “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 Dan Murphy, DC an ACA member who teaches whiplash throughout the world, including a certification course on spine trauma. “This sequence of events has been captured with cineradiography [the making of a motion picture record of successive images appearing on a fluoroscopic screen or simply an “x-ray movie”], 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 should 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.”
This information was first observed by researchers using human cadavers in cars, but those who thought live humans would respond differently were skeptical of data gathered by this method. 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 (video fluoroscopy). 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 [center] 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 [disparaging or belittling expression] 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 single largest contributor to chronic neck pain and overall spine pain is motor vehicle accidents. Of the 6 million injuries per year due to motor vehicle crashes, about three million of whiplash-type injuries and 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 worsened by the fact that the treatment of whiplash, unlike other conditions, is often entangled with typical motor vehicle crash legal action. Lawyers and insurance-company representatives salivate over 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 chronic symptoms 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 studies1 [&] 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 [accreditation board], 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. 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.”
New research in the future 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 in journals such as the January 1999 issue of Archives of Physical Medicine and Rehabilitation6 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;27:643-645.
- Kahn S, Cook J, Gargan M, Bannister G. A symptomatic classification of whiplash injury and the implications for treatment. Journal of Orthopaedic Medicine 21(1) 1999, 22-25.
- Freeman MD, Croft AC, Rossignol AM, Weaver DC. “A review and methodologic critique of the literature refuting whiplash syndrome.” Spine 1999;24(1):86-98.
- Freeman MD, Croft AC, Rossignol AM: “Whiplash associated disorders (WAD): redefining whiplash and its management” by the Quebec Task Force: A critical evaluation. Spine1998, 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 1995;20(8S):1S-73S.
- 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, 80(1): 20-5).
- Saal JS, et al. “Nonoperative management of herniated cervical intervertebral disc with radiculopathy.” Spine. 1996 Aug 15;21(16):1877-83.
- ACA (American Chiropractic Association) Article, February 2000.
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 101“Whiplash: a Patient’s Guide to Recovery.” 83-page booklet explains whiplash, exercises, nutrition, etc.
- Spine Research Institute of San Diego at 800/423-98600
- 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.