Crash Course in Chronic Whiplash Cases Webinar
Dr. Christopher Quigley Presents Crash Course in Chronic Whiplash Cases Webinar
- Get practical and reliable information to understand chronic whiplash, including its prevalence and outcomes that helps you win more cases.
- Learn how what documentation you need to avoid low ball settlement offers.
- Discover valuable information about different factors which may affect your client’s condition, including how to turn pre-existing degeneration to your advantage!
- Learn the relationship between vehicle damage and passenger injury.
- Gain the knowledge needed to combat misconceptions about chronic whiplash, so you can better protect your clients
Dr. Quigley:
So, today’s article is the positive findings in neck injuries from the American Journal of Orthopedics and this is a 1964 publication. This is a article by Dr. Ruth Jackson. Dr. Jackson is a pioneer. She was the first female orthopedic surgeon in the United States, and she had to retake the boards to join the American Academy of Orthopedic Surgeons.
Dr. Quigley:
So, she was a practicing surgeon, then this academy of orthopedic surgeons came in and they said, “Oh, you’re a woman. You need to take the board again to get in.” So, that was quite a slap in the face, but she obviously did it. And this is a summary article of 5,000 patients with spine disorders, particularly the cervical spine.
Dr. Quigley:
And so, Dr. Jackson writes here, 90% of neck disorders are caused by trauma. Of the trauma cases, 85% are caused by motor vehicle collisions, which means that 77% of those with disorders of the neck are caused by motor vehicle collisions. Having been in practice for 31 years, I would completely agree with that statement.
Dr. Quigley:
The author also notes, in head-on vehicle collision, or when a vehicle collides with a stationary object, the resistance of the muscles and capsules of the ligaments of the cervical spine stop the forward momentum of the head and the neck, but not without some degree of injury to them. When a vehicle is struck from the rear, the resulting acceleration of the vehicle with the body of the occupant will cause injury to the cervical spine because of Newton’s Laws. Noting that when the cervical spine instructors are forcibly stretched beyond the functional capacity, they suffer injury, of variable degree. The forces which are imposed in the cervical spine to the passengers of colliding vehicles are tremendous, and if one attempts to calculate mathematically, the amount of such forces, the results are unbelievable.
Dr. Quigley:
In as much as rear-end collisions outnumber by far other types of collisions, the greatest percentage of neck injuries are the acceleration type. So, what she means by that is that you’re sitting at your car at a stop light, and you get rear-ended. So, the car accelerates, so your body is attached to the seat, via the seatbelt. So, your body accelerates but your head does not accelerate. Your head stays in place because Newton’s Law says, that if you’re at rest, you’ll stay at rest until something moves you. I don’t know if that’s the exact law, but you get the idea.
Dr. Quigley:
Jack will help me out with that.
Jack:
The object at rest tends to stay at rest, right?
Dr. Quigley:
So, your head stays at rest while your body accelerates. Well, the issue is your neck. It’s got to balance that force. So, the damage to the vehicles involved in collisions is no indication of the extent of the injuries that’s posed by the passengers. So, in your career Dave, how many times have you heard that? The car didn’t break, so the patient must not have gotten injured.
Participant:
Right.
Dr. Quigley:
That’s the mantra of the defense industry. Motor vehicle collisions to the cervical spine often go unrecognized or ignored for many months. Speaking from my own experience, I was rear-ended three times my senior year in college, and I had no clue about what to do. And so, my neck is never going to be as good as it should be.
Dr. Quigley:
Now, the injuries: This is a key component here. Listen, this is a top 10 kind of thing here.
Dr. Quigley:
Strains. When joint motion is slightly beyond normal passive mobility, a strain occurs, which leaves no permanent damage. These injured joints may be painful for a few days to three weeks. So, how many IMEs have you seen in your career where the patients had pain for six months, they go for an IME and they say, “Oh, they had a strain.”
Dr. Quigley:
How often does it happen? What do you think Dave?
Participant:
Not often.
Dr. Quigley:
In my IMEs, every single one comes back with a strain.
Participant:
Oh really?
Dr. Quigley:
Sometimes not even the area of the complaint. I have one particular case. Lady had obvious, severe ligament damage and instability in her cervical spine. She went for the IME, he came back with a thoracic sprain. I think this is a case I might even have sent to you. I worked on it with Matt.
Participant:
Yeah, I see sprain a lot. I’m sorry did you say strain or sprain?
Dr. Quigley:
Strain. Strain is what the IMEs write? It’s like they all went to the same training or something like that. So, the lady has a severe sprain of her neck and the IME comes back with thoracic strain because she’s got muscle spasm in the upper back. The injury is to the neck, so the spasm was compensation for the neck injury and that was his diagnosis.
Dr. Quigley:
So, I actually knew the surgeon who did the IME. I called him up and I said, “Doctor, you should look at the x-rays.” And at first, he got a little bent out of shape from me, “How dare I call them up?” And then a half an hour later, he calls me back and says, I’m sorry. And then he says, all right, send me the x-rays, I’ll take a look at him. So, he takes a look at him and he comes back with the same diagnosis.
Dr. Quigley:
It’s like, come on dude, this lady’s neck is a wreck. So, that is a great thing to have when you’re dealing with IMEs because they, for the last 10 I’ve seen, for record reviews, comes back with thoracic strain or cervical strain or lumbar strain. Strain. If it’s a strain, it resolves, according to Dr. Jackson, in a few days to three weeks. So, by definition, if it’s four weeks or five weeks, it’s probably not just a strain, it has the sprain component.
Dr. Quigley:
Got it? All right, moving right along. The forces which are imposed on the cervical spine of the passengers colliding vehicles is tremendous. And if one attempts to calculate mathematically, the amount of such forces are unbelievable. Damage to the vehicle in collision is no indication of the extent of the injuries posed in the passengers. Healing a sprain ligamentous structures take place by the formation of scar tissue, which has less elastic and less functional than normal ligamentous tissue.
Dr. Quigley:
So, this is why every sprain injury is permanent. Every sprain results in scar tissue, results in fibrosis, results in stiffness. Every single sprain is a permanent injury. Sprain’s the result, therefore in some degree, a permanent injury. Injuries to other tubal disc structures are frequent and these may vary from a slight rent in the annulus fibrosus to a complete avulsion of the disc from its attachments. Any entry of the disc causes disturbance in the dynamics of the motor unit, which is, the disc is apart. This leads to degeneration of the disc and the proximate joints. That’s a huge point as well. The nerve, the cervical sympathetic nerves and the spinal cord may suffer injuries of varying degrees. The tubal arteries in the transverse foramen may be contused or stretched. So, somewhere in your career, you may have heard of a chiropractor getting blamed for a stroke. Have you heard about that Dave?
Participant:
Yeah, I have heard that. It comes up occasionally when I’m talking to defense friendly counsel.
Dr. Quigley:
Right. So, the vast majority of patients who are blamed via chiropractic for a stroke, they’ve already had the stroke when they got to the chiropractor’s office. The research is emphatic that the chiropractic work, unless they’re really doing something really stupid, is not going to affect a stroke. They’ve done the literature; they’ve done thousands of patient studies. But we do find that people who’ve been in car accidents, 80% of those people who had strokes were in a car accident in the last six months.
Dr. Quigley:
So, car accidents are highly correlated to strokes and patients seek chiropractors for strokes. So, I mean, not for strokes, for car accidents. So, it makes sense that sometimes we get blamed for it, but actually it happened already.
Dr. Quigley:
The vertebral arteries and the transverse foramen may be contused or stretched. Trauma of the arteries initiates a vasospasm, which may well extend beyond the site of trauma and give rise to vascular insufficiency in the spinal cord and the posterior portion of the brain. The location of some mental problems can be verified by lateral radiographs of the cervical spine in maximum flexion and extension.
Dr. Quigley:
So, anytime you have a case that you’re dealing with, as the primary case, not the PIP collect side, that those x-rays are minimal standard. So, any physician you work with, you’ve got to make sure they take those x-rays. That’s the flexion extension. So, that’s the one where you tilt down and tilt up. If you go to the ER and they take x-rays, they typically do a seven-x-ray series, it’s called a Davis series, and that’s part of it. So, anybody who does not take those x-rays in a car crash case, is not up to the standards.
Dr. Quigley:
Upper extremity, deep tendon reflexes may be hyperactive immediately following neck injury, but after a few days, they may become hypoactive. Superficial sensation may be hyperesthesia, but after a few weeks may become hypo aesthetic.
Dr. Quigley:
Grip strength. Grip strength should be measured by a dynamometer and should be performed four times in sequence to look for muscle fatigue. Normally each of the readings should be essentially the same. So, what happens is, is that as they do their grip strength, even though they can lose their grip strength. Number two is, as you do more of them, the person gets weaker, so that’s a sign of nerve injury. Unilateral dilation of the pupil indicates irritation of the sympathetic nerves.
Dr. Quigley:
Whiplash-caused partial deafness may be improved with cervical traction. Irritation to the cervical sympathetic nerve supply may give rise to vasoconstriction of the arteries, which are supplied by the sympathetic fibers. Blood pressure in the two arms often varies by as much as 10 and 20 points following neck injuries. This is a completely objective finding.
Dr. Quigley:
So, I don’t do that test, but maybe it’s something I should be doing. An adequate radiograph examination of the cervical spine is essential for a diagnosis. Pre-existing pathological additions to the cervical spine when injured result in more damage than would be anticipated in a so-called normal cervical spine. That’s a key point. Very, very, very important. Three stars next to that one.
Dr. Quigley:
It just makes perfect common sense. If you have some arthritis or pre-existing damage, and then you get a second injury, of course, you’re going to get hurt more. So, whenever you see that, that’s something you can hang your hat on. You can say, this person has some pre-existing arthritis, there’s some degeneration, and now this car accident has aggravated that or has an inactive condition become active? So, the aggravation is the key term there.
Dr. Quigley:
The inflammatory response to trauma, at least to post-traumatic fibrosis and adhesions. Dr. Jackson represents eight x-rays exposed from following whiplash hammering trauma, including an ADP cervical, a quoted angle view, so that’s like looking up. This view may show fractures of the lamina and other intraarticular isthmuses, which may or may not be demonstrable in any other view.
Dr. Quigley:
The alar ligaments of the upper cervical spine are also vulnerable to injury. David, those alar ligaments, that’s a big one. In your cases where people have headaches post whiplash, a couple of months later, they most likely have alar ligament damage. The alar ligaments are at the top of the spine and they attach the first couple of bones here up to the head. So, they are critical.
Dr. Quigley:
They’re easily tested. All you do is you have the person open their mouth and you take an x-ray, over this side and take the x-ray so you can see those bones and then go the other side. And when you have that kind of movement, you can see any abnormal movement. Initial x-ray is maybe normal, but subsequent x-rays may reveal multiple problems, therefore repeat x-rays are essential. X-rays showing any segmental instability, any segmental restriction of motion and any segmental angulation may indicate severe injury.
Dr. Quigley:
The intervertebral foramina may still suffer from encroachment as well as the result of hemorrhage swelling or hypoplasia of the proximal capsular ligamental structures, even in the presence of normal oblique x-rays. All radiographs should be repeated periodically. Subsequent findings may be very revealing. The extent of the damage to the vehicles in no way proportional to the extent of damage imposed in the cervical spine of the passengers. To ascertain injuries adequate radiographic examination is essential and repeated. Physical and radiographic examinations are necessary for a final analysis.
Dr. Quigley:
So, from your viewpoint, if you work with a physician and they do not take x-rays of the trauma case, they are not practicing up to the standard. So, unfortunately, it’s a trend in the chiropractic profession not to take x-rays. You do not want to work with those people in a trauma case. Personally, I wouldn’t work with any of them for a non-trauma case, but still, for a trauma case I think it’s essential. Questions.
Participant:
I did have a question. You had said earlier that with regard to the patients having a correlation issue between car accidents and strokes, do you know of any research that has linked those two things? That a car accident tends to lead to strokes? I think that’d be useful to bring up in a, go ahead-
Dr. Quigley:
I can track that down, sure.
Participant:
Okay. Yeah. And you had said in just the last piece that you really can’t correlate the physical damage to the vehicle, to the damage to the person. And can you elaborate on that a little bit, about how you can tell that or why that is?
Dr. Quigley:
Well, there’s several favorite examples. The first one would be an egg carton. Drop a carton of eggs on the floor, and you’ll see that the carton doesn’t really get damaged, but the eggs do. If you look at a football injury. You can have the football helmet not break, but the brain still gets injured.
Dr. Quigley:
So, the container has nothing to do with the force that results to the victim. So, they’re trying to say that the container, the car or the person, it’s proportional. The damage is proportional. But that’s ridiculous. Cars are made of metal, people are not.
Dr. Quigley:
So, anybody says that to you, they are woefully under informed.
Participant:
I often get it with adjusters that say, look, there’s only a couple of hundred dollars’ worth of repair damage to the vehicle. So, how injured could this person really be? That’s kind of like the tone.
Dr. Quigley:
The research is this. The research says that if you’ve been injured in a car accident, that if there’s no damage to the car, you can get injured more because all the forces are directed into the passenger compartment where the person is. So, not only is it inaccurate, it’s actually the opposite of what the research shows? You have my book, right?
Participant:
Yes.
Dr. Quigley:
So, there’s an article by Hijoka. H I J O K A, and it is chapter four. The car damage is not related to the severity of your injuries.
Dr. Quigley:
And page 48, car damage is another important factor. There is no relationship between the severity of the collision and disability. The fascinating research in the 2001 archives of orthopedic trauma and surgery by Hijoka found many important findings. They studied risk factors for long-term treatment of 400 patients with whiplash injury in Japan. And they show a chart. Can I switch them around?
Jack:
Yeah.
Dr. Quigley:
How do we do that?
Jack:
Look on your picture.
Jack:
Yeah. Right side, the little pin. I think click ‘pin’.
Dr. Quigley:
There we go. So, you can see the chart in here. Oh there it is, nice. Obviously, it’s backwards, but they rate six grades of destruction to the car. So, grade zero is no damage to the car. Grade one is slight damage, grade two is bumper damage, grade three is one third damage to the car or the trunk. Grade four is half a car damage and grade five is total destruction of the car. Now the average duration of treatment for the no damaged car was 110 days. The slight damage was 80 days.
Dr. Quigley:
Bumper damage, 80 days. Grade three, one third damage to the car, 80 days. Now, only when you get to half-damage to the car, grade four, did the number get back to 110 days. And then total destruction of car was actually a little less, a hundred days. So, what happened here is that the car dissipated some of the energy. It slowed down the acceleration.
Dr. Quigley:
So, what the car does when it breaks, it slows down the acceleration, and all injury and car accidents is time dependent. So, the quicker the impact, the quicker it happens, the more injury that happens. So, when the car breaks or crushes, it slows down the acceleration of the body. The inertia is lessened. Inertial injury is lessened. Make sense?
Participant:
Yeah.
Dr. Quigley:
It’s all about the time.
Dr. Quigley:
Time is the denominator. So, if you have lots of time, your forces are going to be less. If you have a shorter period of time, your forces are going to be much, much more. That’s a key point. Can’t go over that enough. Great question. What you got next?
Participant:
I just want to appreciate what you had said about the pre-existing injury, the arthritis. The collision actually exacerbating the underlying injury. Because that’s another piece that I always get into with people. So, where they say, “Oh, well they already have these injuries.”
Participant:
So, how can you separate out the accident from their previous injured state? And I always have to come back with, well, they were already injured from the arthritis or the degeneration and this made it all much worse.
Participant:
It’s actually impacted them more than if they were good and healthy.
Dr. Quigley:
Yes, as you say, is an arthritic spine stronger or weaker than a healthy spine? What do you think?
Participant:
Right. So, it’s obviously more prone to injury.
Dr. Quigley:
If my 20-year-old son gets in a car accident and my 78 year old dad gets in a car accident. Who’s going to get hurt worse. And it’s just basic common sense. I think a jury would get that.
Participant:
For sure.
Dr. Quigley:
It’s complete lunacy to say anything else. Bring it on, I would love to teach the jury about that. Bring that on.
Dr. Quigley:
Taking out a piece of paper towels and we’ll bring an egg carton in and then we’ll drop the carton on the floor and see what happens. Good. Great stuff, dude. Good. Any other questions?
Participant:
Nope, I’m all set. Thank you so much.
Dr. Quigley:
Good. Now the one thing in here, that we didn’t get hit in the questions, was that these injuries, these sprain injuries, are permanent. Healing of sprain ligament structures take place by the formation of scar tissues, have less elastic and less functional than normal ligamentous tissue. Sprains result therefore in some degree of permanent injury. That is a key concept. You have to get that because that’s going to lead you to damages. When you can talk about, this is a permanent injury, this is always going to be weaker. It’s going to be unstable and they’re going to have arthritis and pain. That’s where the meat and potatoes is when it comes to the damages. Did you hear me tell a story about the case we had in front of the judge? Where we had a $60,000 settlement?
Participant:
No.
Dr. Quigley:
So, we go through this hearing and I testify. At the end of my testimony, the judge says, “Doc, tell me about these injuries. How is this going to affect her later in life?” And I said, “Your Honor, this reminds me of a case, I just recently had.”
Dr. Quigley:
Young lady, 60 years old comes into my office, maybe 61, 62. Comes in, in agony. Level 10 type pain. The pain is radiating down her arm. She’s literally in tears in my office and we get to talking a little bit. And it turns out, 20 years ago to the day almost, she was rear-ended at pretty high speed. And then she said she walked away. 10 years go by, no pain at all, nothing. About 10 years after the car accident, she starts getting some neck pain. It gets a little worse, a little worse, a little worse, then culminates 10 years later with her showing up in my office.
Dr. Quigley:
Now, when you look at her x-rays you could see where the injury was from that car accident 20 years ago. It was plain as day. Everything looked great and there’s one spot, she looked like a 90-year-old. One small section of the spine.
Dr. Quigley:
That’s where this injury, this now 25-year-old client, a rear-end victim, that’s where she’s going to be in 40 years. The arthritis is going to accelerate. She’s going to be in rough shape. In 10 years, she’ll probably get a lot of pain. Right now, she felt fine. She was 25 years old and still living her life, didn’t even come in to see me for maintenance care. She’s just doing some home exercises. She says, “Whenever my neck gets tight, I just do the exercises and I feel better.” What the key was, is the permanency. The key was, this is where the rubber meets the road. This is where the end result of these injuries is going to cause problems.