demographic characteristics of 38 patients injured in

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DEMOGRAPHIC CHARACTERISTICS OF 38 PATIENTS INJURED INMOTOR VEHICLE ACCIDENTS REFERRED BY CHIROPRACTORSTO 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 afterthe 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

The manifestations of low-impact car accidents aremajor 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

Quebec Task Force (QTF) also created a classificationsystem 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, neurolo-

gists, otolaryngologist, ophthalmologists, clinical psycholo-

gists, acupuncturists, physical therapists, interventional spine

specialists, and physiatrists to assist in care.

To our knowledge, there are no reports of typicaldemographic 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

a Assistant Professor, Department of Rehabilitation Medicine,Jefferson Medical College of Thomas Jefferson University,

Philadelphia, Penn.b Chief Medical Officer, Magee Rehabilitation Hospital, Phila-delphia, Penn; and Associate Professor, Department of Rehabilita-tion Medicine, Jefferson Medical College of Thomas JeffersonUniversity, Philadelphia, Penn.

Submit requests for reprints to: Adam L. Schreiber, DO, MA,Associate Professor of Rehabilitation Medicine, Thomas JeffersonUniversity Hospital, Department of Rehabilitation Medicine, 25South 9th Street, Philadelphia, PA 19107(e-mail: [email protected]).

Paper submitted September 17, 2008; in revised form September20, 2009; accepted September 25, 2009.

0161-4754/$36.00Copyright 2009 by National University of Health Sciences.doi:10.1016/j.jmpt.2009.10.004

772
mailto:[email protected]:[email protected]://dx.doi.org/10.1016/j.jmpt.2009.10.004http://dx.doi.org/10.1016/j.jmpt.2009.10.004mailto:[email protected]


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Jefferson University, Philadelphia, Pa. Data were collected

from patients presenting to a physiatric private practicereferred 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 distribu-

tion), 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 otherosteopathic and allopathic physicians, and usage of over-the-

counter 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.

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. 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

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 com-

plaints 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. Thissubgroup 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 disor-

der 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 docu-

menting 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

Table 1. The QTF's classification system predicting WADa

Grade Definition

0 No complaint about the neck; no physical sign(s).

I Neck complaint of pain, stiffness, or tenderness only.

No physical sign(s).

II Neck complaint and musculoskeletal sign(s).

Musculoskeletal signs include decreased range of

motion and point tenderness.

III Neck complaint and neurologic signs include

decreased or absent deep tendon reflexes, weakness,

and sensory deficits.

IV Neck complaint and fracture or dislocation.

a Adapted from Spitzer et al.2

Table 2. Common complaints secondary to motor vehicle accidents

Complaint % (N = 38)

Headaches 47.37

Loss of sleep 31.58

Dizziness 13.16

Depressive symptoms 13.16

Anxiety 13.16Gastrointestinal complaints 10.53

Memory loss 10.53

Vision difficulties 2.63

Hearing difficulties 2.63

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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 after2 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 notemployed 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, Parsonage-

Turner 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 electrodiagnos-

tic 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 com-

plaints of sleeping difficulties, dizziness, depression, anxi-

ety, 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 r esolved, 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 con-cerns 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, oto-

laryngology, and ophthalmology with concordant testing

such as brain magnetic resonance imaging and/or electroen-

cephalography 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-the-

counter 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

Table 3. Patients reported decrease in function secondary to motor

vehicle accidents4

Task which is affected by injury % (N = 38)

Heavy chores 63.16

Exercise 44.74

Sleep 39.47

Work 34.21

Shopping 28.95

Play with children 23.68

Car transfer 23.68

Bed transfer 21.05

Stairs 21.05

Take care of family 18.42

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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 physia-

tric 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 medi-

cations and muscle/joint/nerve injections; detecting and

treating brain injury via supervising treatment with medica-

tions, 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.

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 physiatristreferred 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.

CONCLUSIONSIn 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

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.

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