DEMOGRAPHIC CHARACTERISTICS OF 38 PATIENTS INJURED IN MOTOR VEHICLE ACCIDENTS REFERRED BY CHIROPRACTORS TO PHYSIATRISTS

Adam L. Schreiber, DO, MA,a and Guy W. Fried, MDb

ABSTRACT
Objective: The purpose of this study is to describe the demographic profile of patients in the New Jersey area who are involved in motor vehicle personal injury lawsuits and who are referred from chiropractors to physiatrists. Methods: The study design was a prospective chart review of patients (N = 38) referred to a private physiatric practice from 5 chiropractic practices. Patient data collected at initial consultation included age, employment status, emergency department consultation, time since accident, visual analog score, neck pain and back pain, review of systems, and functional limitations. Results: The average patient was 37.1 years old, with male-to-female ratio nearly 1:1, and presenting 4.5 months after the accident; 81.6% were employed before the accident, 25.8% of which stopped working. The average pain score was 6.6 on a visual analog scale. Neck and back pain were common at 84.2% and 89.5%, respectively. Other complaints included headaches, sleeping difficulties, dizziness, depression, and anxiety. Limitations in function was reported in most patients. Conclusions: In this study, patients referred to a physiatrist from doctors of chiropractic had neck and low back pain not requiring hospital admission. Patients referred tended to have complicated cases with a variety of medical, legal, and psychological factors that are associated with delayed recovery. Physiatrists may be uniquely suited to assist chiropractors in management of complicated patients who have been involved in motor vehicle personal injury lawsuits and who have multidisciplinary needs. (J Manipulative Physiol Ther 2009;32:772-775) Key Indexing Terms: Whiplash Injuries; Physical Medicine; Accidents; Traffic; Chiropractic; Low Back Pain; Neck; Pain

T
a

he manifestations of low-impact car accidents are major public health problems.1 Because of the myriad of symptoms, the injuries sustained after such an accident are termed whiplash-associated disorders (WAD). These are well described in the literature and include neck pain, neck stiffness, arm pain and paresthesias, temporomandibular dysfunction, headache, dizziness, visual disturbances, memory and concentration problems, and psychological distress.2 Along with describing WAD, the

Assistant Professor, Department of Rehabilitation Medicine, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Penn. b Chief Medical Officer, Magee Rehabilitation Hospital, Philadelphia, Penn; and Associate Professor, Department of Rehabilitation Medicine, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Penn. Submit requests for reprints to: Adam L. Schreiber, DO, MA, Associate Professor of Rehabilitation Medicine, Thomas Jefferson University Hospital, Department of Rehabilitation Medicine, 25 South 9th Street, Philadelphia, PA 19107 (e-mail: adam.schreiber@jefferson.edu). Paper submitted September 17, 2008; in revised form September 20, 2009; accepted September 25, 2009. 0161-4754/$36.00 Copyright 2009 by National University of Health Sciences. doi:10.1016/j.jmpt.2009.10.004

Quebec Task Force (QTF) also created a classification system based on severity of signs and symptoms (Table 1). Many people in the United States obtain legal council after low-impact car accident resulting in QTF grades I-III and thereafter consult a chiropractor as the primary health care practitioner to manage the personal injury case. Because of the complexity of WAD, chiropractors consult a myriad of health professionals to help in the patients care. This includes but is not limited to orthopedists, spine surgeons, neurologists, otolaryngologist, ophthalmologists, clinical psychologists, acupuncturists, physical therapists, interventional spine specialists, and physiatrists to assist in care. To our knowledge, there are no reports of typical demographic characteristics and complaints of litigant patients with WAD under the care of a chiropractor consulting a physiatrist. The purpose of this study is to describe the demographic profile of motor vehicle personal injury lawsuit patients referred from chiropractors to physiatrists in the New Jersey area.

METHODS
This prospective study was approved by the Institutional Review Board Jefferson Medical College of Thomas

772

Journal of Manipulative and Physiological Therapeutics Volume 32, Number 9

Schreiber and Fried Motor Vehicle Accidents

773

Table 1. The QTF's classification system predicting WAD a

Grade 0 I Definition No complaint about the neck; no physical sign(s). Neck complaint of pain, stiffness, or tenderness only. No physical sign(s). Neck complaint and musculoskeletal sign(s). Musculoskeletal signs include decreased range of motion and point tenderness. Neck complaint and neurologic signs include decreased or absent deep tendon reflexes, weakness, and sensory deficits. Neck complaint and fracture or dislocation. Adapted from Spitzer et al.2

Table 2. Common complaints secondary to motor vehicle accidents

Complaint Headaches Loss of sleep Dizziness Depressive symptoms Anxiety Gastrointestinal complaints Memory loss Vision difficulties Hearing difficulties % (N = 38) 47.37 31.58 13.16 13.16 13.16 10.53 10.53 2.63 2.63

II

III

IV
a

Jefferson University, Philadelphia, Pa. Data were collected from patients presenting to a physiatric private practice referred from 5 private chiropractic offices. The inclusion criteria composed of new patients referred from the chiropractors with pending personal injury cases from a motor vehicle accident with QTF I-III grading. The recorded epidemiologic data included age, location in the car, sex, ethnicity, pre- and postaccident employment, time since accident, visual analog scale (VAS), neck pain (occurrence and distribution), low back pain (occurrence and distribution), common other complaints (review of systems), 10 different functional problems (bed transfer, car transfer, exercise, heavy chores, play with children, shopping, sleep, stairs, take care of family, and work), consultation of other osteopathic and allopathic physicians, and usage of over-thecounter and prescription medications. All questions were recorded via intake form with interview confirmation by the principle investigator (ALS). A total of 38 consecutive patients referred to a private physiatric practice after being involved in a rear-end motor vehicle crash, obtained legal counsel, and were under the care of a chiropractor.

inferiorly to the superior interscapular region, localizing to midline or just paramidline, whereas radiating pain was described as in shoulder girdle and distally in the upper limb.3 Back pain was limited to axial involvement in 53.9%, whereas including radiating complaints in 47.1%. Besides neck and back pain, the most common complaints were headaches, sleeping difficulties, dizziness, depression, and anxiety (Table 2). Limitations in function were most common in activities such as heavy choirs, exercising, and work (Table 3). Besides seeing emergency physicians and chiropractors, 58.0% consulted primary care physician, orthopedists, or neurologists; 34.2% were either taking a prescription or over-the-counter medication for pain.

DISCUSSION
Most patients referred for physiatric consultation from a chiropractor had complaints consistent with WAD. This subgroup of patients are generally stable; none of which were hospitalized nor had the complications of severe injury from an automobile accidents more likely to be a QTF grade IV, such as fractures, weight-bearing precautions, respiratory failure, enteral or parenteral nutrition, wound and pin care, bowel and bladder issues, or spinal orthosis. The common chief complaints were from soft tissue injuries associated with WAD, which do not necessarily have straightforward recovery patterns. There are complex interactions of medical, legal, and psychological issues. Whiplash-associated disorder is generally considered a favorable prognosis2 but unpredictable1 with some nonclinical factors contributing.4,5 All patients in this study retained a lawyer, which is also associated with delayed recovery and lack of meaningful improvement7 with a chance of compensation decreasing prognosis.4 All patients lived in North America, which is also associated with slower recovery.6 Besides the legal implications, there are studies documenting guarded prognosis for recovery. Sturzenger et al7 found that neck pain and headache intensity within the first 7 days after the collision were predictive of chronic whiplash disorders. Radanov et al8 found that baseline neck pain intensity, headache intensity, and radicular signs and symptoms are associated with delayed recovery. Malanga

RESULTS
The average patient was 37.1 years old, with male-tofemale ratio nearly 1:1, and presenting 4.5 months after the accident. Most patients were drivers (76.3%) and reported to the emergency department (73.6%); none of which were admitted. All patients had grade I-III WAD. There were 81.6% who were employed before the accident, 25.8% of which stopped working since the accident. The average overall pain score was 6.6 on a VAS. Neck and back pain were common at 84.2% and 89.5%, respectively. Neck pain was described as axial 34.3% and radiating in 68.8% neck pain patients. Axial neck pain was described as occurring in all or part of a corridor extending from in the inferior occiput

774

Schreiber and Fried Motor Vehicle Accidents

Journal of Manipulative and Physiological Therapeutics November/December 2009

Table 3. Patients reported decrease in function secondary to motor vehicle accidents4

Task which is affected by injury Heavy chores Exercise Sleep Work Shopping Play with children Car transfer Bed transfer Stairs Take care of family % (N = 38) 63.16 44.74 39.47 34.21 28.95 23.68 23.68 21.05 21.05 18.42

and Peter9 state that residual effects of whiplash at 45 days are considered a warning sign for developing chronic symptoms in the future. Barnesly et al10 report that patients destined to recover will do so in the first 2 to 3 months after injury, after which the rate of recovery then slows to become asymptomatic with no further changes in symptoms after 2 years. The average VAS for this patient population remained 6.6 despite the average time since injury being 4.5 months. Both this score and persistent symptoms reveal therapeutic challenges for a physician. With the average age of 37.1 years, the older the patient is associated with poorer outcome.11 Although female sex is associated with delayed recovers, our study shows equal ratio of men to women. A comparison of pre- and postaccident employment data revealed that 81.6% were employed before the accident, and 25.8% of which stopped working since the accident. One fourth of people employed before accident were not employed at time of consultation. In regard to symptoms, most patients in this group had neck and back pain. Neck pain was divided into general categories of axial and radiating. Theoretically, this should give the clinician information on potential pain generators and treatment strategies. There were 34.4% of patients with neck pain who described it as axial, whereas 68.8% had symptoms that were radiating, which may necessitate further electrodiagnostic and imaging workup to evaluate for thoracic outlet syndrome, brachial plexopathy, ParsonageTurner syndrome, radiculopathy, or entrapment neuropathy. Of this population, 89.5% complained of lower back pain, and 47.1% of patients with low back pain described their pain as axial, whereas 53.9% had symptoms that were radiating, which may also necessitate further electrodiagnostic and imaging workup to evaluate of radiculopathy, lumbosacral plexopathy, or entrapment neuropathy. In both cervical or lumbosacral radiating complaints, myofascial trigger points can also be implicated in a radiating pattern. Although there are various diagnosis that could cause radicular-like symptoms, the simple presence of these signs and symptoms are associated with delayed recovery.1 Aside from neck, shoulder, low back pain, and associated paresthesias and weakness, consistent symptomatology

reported in previous studies include headaches, dizziness, visual problems, tinnitus, memory, or concentration impairment.10 This patient population had similar complaints of sleeping difficulties, dizziness, depression, anxiety, gastrointestinal complaints, memory loss, vision difficulties, and hearing difficulties (Table 2). Duckworth and Iezzi12 found significant correlation between high levels of posttraumatic stress symptoms and greater physical injury and impairment, greater psychologic distress, and greater use of maladaptive pain-coping strategies. Sterling et al13 suggest that pain symptoms that do not decrease cause patients to be concerned with long-term suffering and disability, leading to depression, anxiety, and fear avoidance behavior. Once the pain complaint is resolved, the psychologic distress commonly disappears.13 Schmand et al14 report that cognitive complaints of nonmalingering postwhiplash are more likely a result from chronic fatigue or depression, not brain damage. Depending on severity, cognitive and psychological complaints raise several concerns in regard to diagnosis, which may require for workup and treatment. Furthermore, these components are associated with poorer prognosis. Workup and treatment may require consultation of a myriad health practitioners including psychology, neuropsychology, neurology, psychiatry, otolaryngology, and ophthalmology with concordant testing such as brain magnetic resonance imaging and/or electroencephalography and psychological testing. These reported symptoms reinforce that WAD is a syndrome and a much more mechanical musculoskeletal injury. Of our study population, 58.0% had already been seen by other osteopathic and/or allopathic primary care physician, orthopedists, or neurologists after seeing an emergency physician and their primary chiropractor. One third of patients had also been taking prescription or over-thecounter medication for pain. Despite previous medical consultation and chiropractic and pharmacologic treatment, there were still significant complaints requiring further physician consultation, workup, and treatment strategies. Manifestation of WAD can also be measured by difficulties in function and loss of work. This population most commonly had difficulties in heavy chores, exercising, and work (see Table 3); 25.8% of patients who were employed preaccident were not working at time of consultation. Patients involved in low-impact automobile accidents who retained a lawyer for a personal injury lawsuit are quite complicated. There are many risk factors for a guarded prognosis. Some of the risk factors are higher age, continued severe complaints and symptoms despite 4.5 months' time since accident, radiating neck and/or back pain, and non spine-related complaints. Their complaints are persistent despite consultation from several health practitioners as well as pharmacologic and chiropractic treatment. They also have nonmusculoskeletal complaints, which are disruptive and may heighten musculoskeletal problems. Functionally, their

Journal of Manipulative and Physiological Therapeutics Volume 32, Number 9

Schreiber and Fried Motor Vehicle Accidents

775

lives were affected by difficulties with activities of daily living and missing or difficulty performing work. The WAD population may benefit from early physiatric consultation. Physiatric training is focused on patient function at the acute, subacute, and chronic states with exposure to a wide complex spectrum of disease including, but not exclusive to, nonoperative musculoskeletal and spine care, neuromuscular disease, traumatic brain injury, anxiety, and depression. As primary care givers to this population, chiropractors should consider early involvement of physiatric consultation, which may improve outcome. Physiatrists may assist in nonoperative musculoskeletal care by ordering diagnostic tests and prescribing/performing treatments such as anti-inflammatory, antispasmolytic, and analgesic medications and muscle/joint/nerve injections; detecting and treating brain injury via supervising treatment with medications, therapy, and appropriate referrals; and evaluating radiculopathy or other peripheral nerve injury by performing electrodiagnostic tests early to initiate treatment sooner. Although the interventions listed here are not inclusive, early input from physiatrists may help with treatment and workup, which potentially may maximize patient function. Early physiatric consultation may also assist if loss of function persists into more difficult subacute or chronic states.

these patients have been shown to be related to prolonged recovery. Physiatrists may be uniquely suited to assist chiropractors in management of these complicated patients with multidisciplinary needs.

FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST

No funding sources or conflicts of interest were reported for this study.

REFERENCES
1. Conte P, Cassidy JD, Carroll L, Frank JW, Bombardier C. A systematic review of the prognosis of acute whiplash and a new conceptual framework to synthesize the literature. Spine 2001; 26:E445-58. 2. Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, et al. Scientific monograph of the Quebec Task Force on whiplash-associated disorders: redefined whiplash and its management. Spine 1995;20(suppl 8):1-73. 3. Depalma MJ, Slipman CW. Treatment of common neck problems. In: Braddom RL, editor. Physical medicine and rehabilitation. Philadelphia: Elsevier; 2007. p. 795. 4. Cassidy JC, Carroll LJ, Cote P, Lemstra M, Berglund A, Nygren A. Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury. N Engl J Med 2000;342:1179-86. 5. Dufton JA, Kopec JA, Wong H, Cassidy JD, Quon J, Mcintoush G, et al. Prognostic factors associated with minimal improvement following acute whiplash-associated disorders. Spine 2006;31:E759-65. 6. Ferrari R. Whiplasha review of commonly misunderstood injury letter to the editor. Am J Med 2001;112:162-3. 7. Sturzeneger M, Radanov BP, Di Stefano G. The effect of accident mechanism and initial findings on the long term course of whiplash injury. J Neurol 1995;242:443-9. 8. Radonov B, Sturzeneger M, Di Stefano G. Long-term outcome after whiplash injury: a 2-year follow-up considering features on injury mechanism and somatic, radiologic and psychosocial findings. Medicine 1995;74:281-97. 9. Malanga G, Peter J. Whiplash injuries. Curr Pain Headache Rep 2005;9:322-5. 10. Barnsley L, Lord SM, Bogduk N. The pathophysiology of whiplash. In: Malanga GA, Nadler SF, editors. Whiplash. Philadelphia: Hanley and Belfus; 2002. p. 66. 11. Radanov BP, Sturzenger M. Predicting recovery from common whiplash. Eur Neurol 1996;36:48-51. 12. Duckworth MP, Iezzi T. Chronic pain and posttraumatic stress symptoms in litigating motor vehicle accident victims. Clin J Pain 2005;21:251-61. 13. Sterling M, Kenardy J, Jull G. The development of psychological changes following whiplash injury. Pain 2003;106: 481-9. 14. Schmand D, Lindeboom J, Schagen S. Cognitive complaints in patients after whiplash injury: the impact of malingering. J Neurol Neurosurg Psychiatry 1998;64:339-43.

LIMITATIONS
There are several limitations to this study. The small sample size and geographic area limit generalizability. Although there were multiple chiropractic practices utilizing physiatric consultation, there was a single physiatrist referred to in this study. It is possible that chiropractors in other areas of the country would have different referral patterns. Data gathered from multiple physiatric practices with several allopathic or osteopathic physicians and from other areas of the country would help provide more generalizable information. Future research should include timing and outcomes of collaborative treatment and of the timing of chiropractic and physiatric cooperation in the management of this patient population.

CONCLUSIONS
In this study, patients who were referred to a physiatrist from 5 chiropractors were involved in a personal injury case from motor vehicle accident are QTF grade I-III type injuries with additional nonspine-related complaints resulting in difficulty with function and work. Many characteristics of