Dr. Christopher Quigley Presents on Chronic Whiplash Pain

Dr. Christopher Quigley Presents on Chronic Whiplash Pain

In this entry of his Zoom Webinar series, Dr. Christopher Quigley presents on a recent study regarding chronic whiplash pain. In this webinar, Dr. Quigley shows:

• What you need to know about long-term whiplash case
• The factors you cannot miss that worsen whiplash and help prove your client’s injuries
• Which diagnostic tests can – and cannot – prove whiplash damage to your client
• How to counter common attempts by insurance companies to disprove or diminish chronic whiplash – and why pain management alone does not stop the effects of whiplash
• How to show the real long-term effects of whiplash on your client to win your cases and get larger settlements

Dr. Christopher Quigley:
Again, the article, is Whiplash Real or Not Real? A Review of a New Concept. They state chronic whiplash’s symptoms that persist for six months or longer. 50% of those who are injured in whiplash develop chronic symptoms. Classic chronic whiplash symptoms include neck pain, headaches, interscapular pain, parasthesias in arms and hands, dizziness, TMJ pain, visual symptoms, vestibular symptoms, cognitive problems, emotional stress, psychological disturbances.Dr. Christopher Quigley:
In some patients who experienced unexpected rear-end collision, symptoms persist for years. That is a key point. We’ve talked about this multiple times. Getting hit when you’re unaware of the crash is the worst thing that can happen to you. The surprise is what gets you. An essential factor in chronic whiplash. Whether or not the driver in a rear-end car crash is aware of the pending collision is extremely important. The awareness or expectancy of the incoming collision is crucial in the whiplash process. 70 to 80% of the patients that suffer from chronic whiplash were unaware of the incoming collision. Correlation exists between being unaware of the incoming collision and a full recovery. A crucial factor in determining the extent of whiplash and the extent of the injury is the expectancy of an incoming collision.

Dr. Christopher Quigley:
Another key point. More women suffer from whiplash trauma than men, 1.5 to 1. More women develop chronic whiplash symptoms than men, 1.54:1. The literature says a lot of that can be from the diameter of the neck. In a woman, it’s going to be smaller than a man’s. There were lines of investigation of documenting the following injuries from whiplash mechanisms. Number one for set joint capsular ligaments. That’s a really big one. Paravertebral ligaments, including the ligament, intervertebral disc, dorsal root ganglion. The dorsal root ganglion is the little relay center. The nerves exit the spine.

Dr. Christopher Quigley:
The nerves exit the spinal cord, and that bump right there is going to be your dorsal root ganglion. Relay center for the nerves. Can you see that?

Attendee:
Yes.

Dr. Christopher Quigley:
All right. Neck muscles. Fatty infiltration of the muscle is considered an indicator of pseudohypertrophy, as extensively demonstrated in the chronic stages of whiplash by MRI studies. Very important point here. Current diagnostic techniques cannot detect tissue damage in chronic whiplash patients. This means your typical stuff. This is like in a plain MRI, plain CAT scan, plain x-rays. But there is something called a stress x-ray where you can see this injury. A stress x-ray is when you take the x-ray with the head fixed forward and the head back, and you do a measurement. If those bones slip in the cervical spine more than 3.5 millimeters, that is going to give you documentation of ligament injury there.

Dr. Christopher Quigley:
Now, the research says one millimeter is normal. So anytime you have more than one millimeter of slippage, you have an injury. You can document the injury very well. That’s one of the things that makes docs in my group special, and it really focuses on this injury because the powers that be know that this is an important injury because what happens is the spine is never going to recover from that injury. These injuries do not heal. They wound repair, and they wound repair with scar tissue. Scar tissue gets in there and it causes all sorts of problems. The bones don’t move properly, creates abnormal loading, creates abnormal stress in the air, instability, and that area’s never going to be the same, and it’s going to speed up the degenerative process. The literature is clear that once you get one of these injuries, the degeneration in your spine accelerates by over 50%. This is the long-term sequela.

Dr. Christopher Quigley:
Now, the other part about this is that if you look in surgical guidelines for the spine, you will find that if you still see that 3.5 millimeter slippage, that’s a surgical case. You can go to any spine center and look and say, “What’s an indication for cervical spine surgery?” This is it, when you have 3.5 millimeters worth of slippage. In the lumbar spine, it’s four millimeters. In the rest of the spine, I think 4.5 millimeters at the base of the spine. This is a very common procedure, but it’s been missing in the literature for whiplash. That’s what these people in my group are good at.

Dr. Christopher Quigley:
The other measurement they take is they do what’s called angular rotation, which is how the bones angle from one another. The normal degree of measurement is seven degrees, normal angulation. If it’s more than 11 degrees, that’s going to give you an instability. More importantly for your case is the impairment rating. The computer algorithms that they use, the Colossus program, which you’re familiar with, I’m sure. There’re four parts to an insurance sum. There’s the injuries, there’s the impairment rating, there’s duties under duress, as what you can do when it hurts, and then there’s functional loss of what you can’t do. It’s very difficult to unlock the bottom two, so the impairment rating is a key thing to get maximum value in your cases.

Dr. Christopher Quigley:
All right. Moving right along. Standard imaging techniques, such as radiography, computed tomography, CT, or MRI are inconclusive to the prognosis of the symptoms after whiplash trauma. PET imaging, P-E-T, positron emission tomography, and inflammatory markers show chronic whiplash patients have persistent inflammation around the neck muscles as compared to controls. Now, this is not a standard test we would probably order in most cases. The initial whiplash injury is an inertial reaction creating a non-physiological estate cervical spinal curvature occurring when the entire cervical spine column is under compression. Whiplash injury appears around the [inaudible 00:06:40] base. It usually involves a subject who is unprepared for the incoming collision.

Dr. Christopher Quigley:
Pass me that book. I’ll just grab one. I got one right here. All right.

Dr. Christopher Quigley:
Just to review. You guys are experts in this, but just to show the picture. You can see the four phases of a whiplash injury. All right. Phase one is in my right hand side. You can see the occupant of the car. What happens is the car slips underneath the person here, and your head and body start to rise up. At some point, you stop rising up and then the car moves the torso forward and the head goes back. This is where the injury occurs, because one part of the spine is going forward and the head is going backwards. The head’s staying in place, but the body’s moving out from under it. Then, everything starts going backwards and everything slips forward. So, there’re your four phases of a whiplash crash. That number two, this guy right here, that’s where the injury occurs. That S curve.

Dr. Christopher Quigley:
Symptoms after a whiplash injury result in disturbed proprioceptive information from the neck. All right, another key point. When you move, your spine has these receptors called proprioceptors, and it basically gives the brain information where your body is in space. So, if everything’s healthy, you get a proper flow of this information to the brain. When you get a whiplash injury, that message is going to get static to it. That’s going to cause imbalances in the musculature, imbalances in the rest of the spine and nervous system, and it’s going to create a vicious cycle of bad stuff.

Dr. Christopher Quigley:
There was a close interaction between neck proprioception and mechanoreception, where the brainstem controls the vision, vestibular, and somatosensory functions. So, vestibular is going to be your balance. Vision is obvious. Somatosensory is, again, where the body is in space. Anybody need any clarification on that? Everybody with me so far?

Speaker 3:
Yep.

Dr. Christopher Quigley:
All right. Good. Chronic whiplash symptoms are a result of mismatch between aberrant information from the cervical spinal cord and the information from the vestibular and visual systems, all in which are integrated in the mesencephalic periaqueductal gray in joining regions. That’s just a big word for the gray nervous system inside the brainstem. The upper cervical whiplash injury derives the alteration in proprioception. Mechanoreception result in altered pain, altered pain perceptions, depressive-like symptoms, headaches, TMJ symptoms, dizziness, visual disturbances, alterations in postural control. More than 30% of the spinal periaqueductal gray fibers originate in C1, C3 spinal segments.

Dr. Christopher Quigley:
All right. That top of the spinal cord is where the mother load of these receptors live. The researcher who really did this was a lady by the name of Candice Kurt. She was at Georgetown and she was actually a psychiatrist. In her research, she figured out a lot of these receptors, not only for proprioception and mechanoreception, she found there’s a big emotional component for those receptors. The [inaudible 00:10:28] located in the periaqueductal gray are involved in a number of individual and species’ vital functions, including pain modulation and duration, makes you go to bathroom, blood pressure, fight or flight response, sympathetic nervous system, vocalization, respiration, and maybe behavior. There is no clear evidence that compensation and related processes are involved in the health of whiplash injury patients.

Dr. Christopher Quigley:
Number 18. These authors propose that chronic whiplash symptoms, nausea, dizziness, headache, neck pain, are due to an injury-induced mismatch in the midbrain and other structures by the upper cervical cord. It’s in the middle of the brain, and on one hand, in the intact information on the vestibular and visual symptoms to the midbrain. On the other hand, the subsequent continuous imbalance may create a permanent hyperarousal to the brain, depending on the strength of the cervical damage.

Dr. Christopher Quigley:
This is why the chiropractor has a big leg up in these cases, because the chiropractor is the one provider who can rebalance these receptors. The study supports the evidence that concentrating on pain control with drugs is misplaced in the whiplash injury patient. The evidence continues to support that chronic whiplash occurs as a bunch of consequences of poor quality proprioceptive and mechanoreceptive input on the injury of soft tissues into the central neural axis. The management should be directed towards improving mechanical function of the injured and often already repaired soft tissues. This very much supports the chiropractic approach to the management of chronic whiplash patients. That’s why literature says that going to the chiropractor is the best thing since sliced bread for these injuries. Unless you can get these guys moving again, you just can’t get them back. All right. Questions? I know there were a lot of big words in that one, so shoot.

Attendee:
When you talk about receptors, I don’t know what those are. Is that something you find in a muscle? Is it something you find in a ligament? What is it?

Dr. Christopher Quigley:
All of the above. You find it everywhere. Essentially, what would be a good sensor is a thermostat. Your thermostat in your office there is a sensor for the temperature. Your body has these sensors for movement. Your body has these sensor for feel and for touch. They have receptors in your ears to hear when you stop using your eyes to see. These receptors are numerous in the body and have all sorts of applications. Now, in this case, we’re talking about mechanoreceptors in the muscles, the ligaments, the joints, the disc. These mechanoreceptors are what allow you to stand in space, allow you to move.

Attendee:
Can you see damage to a receptor on any kind of a film?

Dr. Christopher Quigley:
Really, really, really, no. You can’t. They’re really, really, really tiny. Tip of a pin kind of thing. You’re not going to see those. If you really wanted to, what you could do is you could take the tissue and stain it, put it underneath a microscope, and can see them. But again, not something we do.

Dr. Christopher Quigley:
But you can test that. You can test it. You have someone stand in place, close their eyes, and just stand there. Now you’ve tested the mechanoreceptors because you’re taking the visual cues out, and now you’re just dealing with the body’s ability to balance. That’s one of the tests you do. It’s called Romberg’s test. Have the patient stand up, close their eyes, and you put your arms around them. If these receptors are shot, they go and tumble right over. This is a test that I use for concussion patients. That’s the same kind of thing. It’s called the sway test, and it documents the level of proprioception function in the body. The passing score on a sway test is an 80. Typically, my concussion patients are 50 and below.

Dr. Christopher Quigley:
The Romberg’s test is just a test you do with the person standing there. Sway test is an app on my phone and it measures the movement of the patient. But it’s a great test to document concussion. The NFL is using it now, and it makes my life a lot easier because every checkup, I do my checkup and then I do the sway test, and I can effectively document how that patient’s brain is recovering from their injuries.

Dr. Christopher Quigley:
Yes, very objective. Kevin says, “An app on a phone, nice, and objective tests that you can graph the patient’s recovery.” Had a young lady come in just about four months ago. She was coming up on a four month checkup. She, during a celebration with some alcohol involved, fell and gave herself a concussion. She’s seen a whole bunch of other providers. She came and did sway testing, and what was interesting in her case was that she was doing well, progressing but slowly, and I happened to come across an article that said that blood pressure is a big determinant on brain function. Especially if you have low blood pressure, your brain is not going to function as well. So, people who have low blood pressure have a tendency towards Alzheimer’s. So, I’m thinking this lady has really low blood pressure. She was like 90 over 70. Typically, those numbers are 120 over 80. So, I’m like, hmm, let’s try something.

Dr. Christopher Quigley:
I tell her to go home and I have her do half an hour of cardio every single day for a week. What does cardio do? It’s going to get your heart pumping, get that blood up to the brain. Sure enough, when we got out of the week, she was feeling 20% improved in one week because we located that one area of weakness with her and snapped right back. She felt so much better after one week of doing cardio 30 minutes a day, just because we got the blood pressure back up. Cool little clinical tidbit there. Any other questions?

Attendee:
Early on, you mentioned that you could diagnose damage to the ligaments doing those flexion extension x-rays. Of the people that have whiplash that you treat, what percentage would show up as 3.5 or greater?

Dr. Christopher Quigley:
My guesstimate is about 70% of your female patients, about 50% of your male patients. It’s a big percentage.

Attendee:
So, it’s definitely worth having them tested with that.

Dr. Christopher Quigley:
Absolutely.

Attendee:
Do you have to do it soon after the accident, or would that show up even if they’ve been treating with physical therapists and other kinds of things?

Dr. Christopher Quigley:
The way it works is this. Again, it depends on the patient. If you’ve got a patient that’s really sore and stiff after an accident, not best to do it then because they’re sore and stiff, they’ve got muscle spasms, splinting going on to protect the movement. Typically, a patient like that, I work on for two months, and then I do the test and send it in. Two months to get the muscle spasm out of there so you get a real good picture. If they don’t have that, I’ll do that right away.

Dr. Christopher Quigley:
I had a young lady. She was sitting in her pickup truck and a guy slammed into her pickup truck. I did it on her right away because she didn’t have that muscle spasm splinting. She was the one we sent it in. We already sent the test in. She was a new patient last week. That’s because, again, like I said, the onset, these ligaments do not heal. They tissue repair with scar tissue, just like any scar, and they don’t allow proper movement, create instability, and that’s why you have that advanced degeneration. That’s why you get that big impairment rating. With the fifth edition impairment, when you’ve got that 3.5 millimeter slippage, it’s a 25% whole body impairment. That’s worth real money in a legal case.

Dr. Christopher Quigley:
I had a judgment in a trial. $60,000 for a ligament injury case with no other medical professionals. Now, I wouldn’t do that on a regular basis. It just happened to work out with that particular patient. No warp speed of care. No MRIs. Just that ligament test gets $60,000 on a rear-end impact. That’s the number that the insurance companies reserve when they see that diagnosis. If you’ve got that ligament injury and the proper testing. Obviously if you can get other testing on it, great. But the fact is, that alone is a big finding. How many cases have you had where you didn’t have that test? Have it in your pocket and go deal with that insurance agent.

Dr. Christopher Quigley:
Kevin’s on the call. I had a case with him. We used that, and we got a good result out of that case. I think he’s just settled that one, if I’m not mistaken. But in his whiplash cases, that is the key finding. You can get that test. Then you throw an MRI on top of that. You got some good documentation on the injuries. Now you’re talking real money for these whiplash cases. You don’t have to worry. Take those low-ball offers and tell them to stick it, quite frankly.

Dr. Christopher Quigley:
Good. Any other questions? Great questions, guys.

Dr. Christopher Quigley:
Kevin’s asking if this is in After the Car Crash. It is not. Jacks just sent around a copy of the article in an email, but it’s from PET and SPECT in neurology, 2014, pages 947 and 963. Obviously, these guys like to use big words, so if you have any questions about the translation into English, I’ll be happy to do that for you.