CHIROPRACTIC FOR MOTOR VECHICLE ACCIDENTS

Chiropractic treatment of patients in motor vehicle accidents: a statistical analysist Stephen Dies, BSc, DC* J Walter Strapp, BSc, MSc** Motor vehicle accidents (MVA) are a major cause ofspinal injuries treated by chiropractors. In this study the files ofone chiropractor were reviewed retrospectively to generate a data base on the AMVA cases (n = 149). The effect ofage, sex, vehicle damage, symptoms and concurrent physiotherapy on the dependent variables ofnumber oftreatments, improvement and requirementfor ongoing treatment was computed using an analysis ofvariance. Overall the average number oftreatments given was 14.2. Patients who complained ofheadache or low backpain required more treatments than average. Improvement level was lowered by delay in seeking treatment, the presence of uncomplicated nausea and advancing age. Ongoing treatment to relieve persistent pain was required in 40.2 percent ofthe cases. None ofthefactors studied had a significant effect on this variable. The results ofthis study are comparable to those reported in the medical literature. (JCCA 1992; 36(3):139-145) KEY WORDS: motor vehicle accident, chiropractic, manipulation. Les accidents de voitures representent la cause majeure des blessures de la colonne vertebrale traitees par les chiropracteurs. Dans cette e'tude, les dossiers d'un chiropracteur ont ete revus de maniere retrospective pour creer une banque de donnees de cas d'accidents de la route (n = 149). Les effets de l'dge, du sexe, des degaits du ve'hicule, des symptomes et de la physiotherapie courante sur les variables dependantes du nombre de traitements, des ame'liorations et des besoins de traitement continu ont ete calcule's en utilisant l'analyse de variance. Au total, le nombre moyen de traitements etait de 14,2. Les patients qui se plaignaient de maux de teite et de douleurs du bas du dos ont necessite plus de traitements que la moyenne. Le niveau d'ame'lioration etait inferieur dans les cas ou les patients ont attendu avant de sefaire soigner, en presence de nausee simple et chez les personnes plus agees. Un traitement continu pour soulager une douleur persistante a ete necessaire dans 40,2 pour cent des cas. Aucun desfacteurs etudies n'a d'effet significatifsur cette variable. Les resultats de cette etude sont comparables a ceux rapportes dans la documentation medicale. (JCCA 1992; 36(3):139-145) MOTS CL ES: accident de voiture, chiropratique, manipulation. Introduction Motor vehicle accidents (MVA) are a major cause of spinal injury, with a significant percentage of those injured having persistent pain regardless of treatment. 1-5 Widespread seatbelt use has reduced injury from violent contact but has lead to an increase in soft tissue injuries to the neck.6 Chiropractors are well suited to the management of injury from motor vehicle accidents; however there is little data available on the use of spinal manipulation in this regard. Opinions regarding treatment vary from: early manipulation in less severe injuries,7 manipulation only of areas distal to the injury site until later in the treatment regime8 and no manipulation until at least the post acute stage, if at all.9 One prospective randomized trial of early mobilization using Maitland technique had a significant decrease in pain and increase in movement at four and eight week intervals after the accident when compared to a control group receiving a collar and rest. '0 A retrospective study of chiropractic treatment of patients in MVA is presented. This study was undertaken to assess the treatment outcome where spinal manipulation was the major treatment modality. Materials and methods All patients of one chiropractor from 1981 to 1991 were reviewed individually to identify those files in which patients were involved in car accidents. Files were eliminated if patients did not complete treatment, could not be reached for follow up * Private Practice. ** Atmospheric Environmental Service, Downsview, Ontario. Address reprint requests to: Dr. S. Dies, Box 242, 92 King Road East, King City, Ontario LOG IKO. t Poster presentation. World Chiropractic Congress, May 1991. Toronto, Canada. © JCCA 1992. The Journal of the CCA / Volume 36 No. 3 / September 1992 139 Chiropractic treatment or had seen another chiropractor. This yielded 149 eligible files from a total of 3,224. Treatment consisted mainly of manipulation, begun immediately after examination. If radiographs were taken, manipulation was delayed until the following day. The injured segments were manipulated as well as those distal to the injury site, as determined by motion palpation. In some cases ultrasound, cervical collar, ice or heat were used. Later in the treatment regime, some patients had to begin an exercise program, make changes to work or sleep environment, have foot orthotics fitted or undergo massage therapy. The only treatment received uniformly by all patients was manipulation. Data on age, sex, delay in seeking treatment, pain location and presence of headache were obtained from the clinical notes. Symptoms other than pain were recorded under the heading neurological symptoms. These included nausea, dizziness or vertigo, paresthesia or a combination of symptoms. Symptoms were only included if they were present at the time of examination. Note was also made of patients who had received physiotherapy or were still undergoing physiotherapy. Vehicle damage was determined from patient histories and categorized as: no damage (repairs under one thousand dollars and no police report), some damage (vehicle damage but repaired, police report completed) and written off (damage too extensive to repair the vehicle). Treatment outcome was classified as follows: no improvement (usually referred for orthopedic evaluation), somewhat improved (improvement in pain and mobility but not returned to the pre-accident state) and much improved (returned to the pre-accident state). The patients were classified into three categories on the basis of patient histories, progress notes on reported pain and physical limitations, and on clinical findings such as ranges of motion, orthopedic tests and motion palpation findings. The number of treatments was defined as those completed at the time maximum improvement was realized. For patients who were much improved this would correspond to a symptom free state, while for the no improvement group this would be the point at which treatment was discontinued. For the somewhat improved group the maximum improvement was identified as the point at which the symptoms did not subside any further although treatment continued. After maximum improvement was reached the treatment was gradually eliminated and either discontinued (non-maintenance)- or continued on a periodic basis to maintain the improvement (maintenance). This pattern is illustrated in Figure 1. The maintenance patient is one who had a return of symptoms if treatment was discontinued, and corresponds to the patients reporting persistent pain in other studies. Figure 1 A simple treatment response model. Patients with persistent pain fail to drop down to a zero treatment frequency after reaching maximum improvement. Maintenance/Non-Maintenance Scenaros Maximum improvement Ongoing treatment required to maintain improvement 1 year 2 years Time from initial treatment The Journal of the CCA / Volume 36 No. 3 / September 1992 Daily Weeldy CD Cr 0 .DI 140 S Dies and JW Strapp Table 1 Comparison of similar results in the literature. Table 2 General population statistics. The Journal of the CCA / Volume 36 No. 3 / September 1992 141 Chiropractic treatment Journal entries of data were transferred to a computer data base with improvement levels assigned numbers as follows: I - no improvement, 2 - somewhat improved, 3 - much improved. The data were analyzed using a Multifactor Analysis of Variance.* Output is listed for the individual variables of improvement, treatment numbers and maintenance requirement showing values in the categories of age, sex, delay in seeking treatment and symptoms. F ratios, degrees of freedom and confidence levels were calculated. Interaction between the outcome variables was also tested (e.g. improvement versus maintence), as well as two factor interactions (e.g. improvements vs headache and damage). Results The average age of the sample group was 34.9 years, ranging from 7-74 years, with females constituting 59 percent of the sample. This is comparable to other studies in the literature shown in Table 1. Forty (40) percent of patients had persistent pain (maintenance), again comparable to values reported in the literature. The average number of treatments was 14.2, ranging from 1-70. Improvement was as follows: none 4.0%; somewhat improved, 12.1%; much improved, 83.1%. The general population statistics are presented in Table 2. Over half of the patients were seen less than 4 weeks after the accident and the majority of patients had not had physiotherapy. Neck pain was the most common symptom followed by low back pain and headache. Seventy-five (75) percent did not have any significant neurological symptoms at the time of their first examination. Confidence levels derived from computerized F ratios are shown in Table 3. For simplicity, only the confidence levels are listed. The significant confidence levels of 95% or higher are highlighted. No statistically significant interactions between improvement, maintenance or number of treatments were observed. There was no significant two factor interactions. Improvement was affected by age, delay in seeking treatment and neurological symptoms as shown in Figure 2. There is a trend toward decreasing improvement with increasing age until the 6th decade. It should be noted that the number of patients in the highest age categories was small at n = 3 for 61-70 years and n = 1 for the > 71 group. Delay in seeking treatment resulted in poorer improvement until the 60 day point where average improvement increased again and then declined thereafter. The values all fell midway from somewhat to much improved. Neurological symptoms had very little effect on improvement with the exception of nausea. Those that experienced nausea and pain in the absence of paresthesia, vertigo or dizziness had the worst average improvement of any group in this analysis. The number of treatments required to attain the improvement was affected by pain site only (Figure 3). Patients with headache required more treatments than those without. Patients with combined neck, thoracic and low back pain required substan- * Statistical Graphics Corporation, 2115 East Jefferson Street, Rockville, Maryland, USA 20852. Table 3 Confidence levels (%) for factors affecting treatment outcome.* * Note: No statistically significant two-factor interactions were observed. There were no significant interactions between the outcome variables. 142 The Journal of the CCA / Volume 36 No. 3 / September 1992 S Dies andJW Strapp Figure 2 Statistically significant factors affecting improvement. 0-10 3~~~~~~~~Q I10 11-20 2.8 31-40. 2.76 ~41-.50 27 51-60 2.6.4 I71 + (1.0) I8 -30 2.81 61-90 -2.901 181,365 25 6+.... 7. Neurological symptoms: >99.9 % confidence level Age ( years ) 98.1 % confidence level Delay in Seeking Treatment: 98.3% confidence level 1 no improvement Figure 3 Statistically significant factors affecting treatment numbers. 12.56 18.72 IINo Headache 1 2.91 '7~~~~~~~~9, 16.57 Pain location 99.1% confidence level Presence of headache 95.2 % confidence level The Journal of the CCA / Volume 36 No. 3 / September 199214 somnewhat mpoed much 4 rA012 0 Vl 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Average Number of TPreatments 2.75 n ll"t-ination,:Of I.Vtom -751 143 Chiropractic treatment Figure 4 Factors affecting maintenance requirement that approach significance at the 95% confidence level. I, V 16.7 ~ ~~~~Vehicle Damag III.i1:45.4 89.4% Conienelevel 62.5 NolDrevIOUS Or OngOln~~~~~~- ^ i * i~~5. Phy:: >otherapy si go ar.n~ ~ ~ ~ 1. Physiotherapy 94.9% Confidence level ) 10 20 30 40 50 Patients Requiring 60 70 80 Ongoing Treatment (%) tially more treatments than those that had pain in either location alone. Treatment numbers were unaffected by any other factors studied. There were no factors that significantly affected the requirement for maintenance. Two factors that approached significance were vehicle damage at the 89.4 percent confidence level and previous or ongoing physiotherapy at 94.9 percent, as shown in Figure 4. The percentage of patients requiring maintenance increased with vehicle damage and if there was previous or ongoing physiotherapy. Age, sex, delay in seeking treatment, pain location, presence of neurological symptoms, headache, relative improvement and number of treatments given did not have any discemable effect on the requirement for maintenance. Discussion The results of this study compare with those in the medical literature in regards to the number of subjects, average age, sex distribution and percentage ofpatients who have persistent pain. There appear to be some specific differences in treatment outcome in our data that may be a result of the type of manipulation being employed. Persistent pain as reported in the medical literature is synonomous to a requirement for maintenance in the present study. Patients who required periodic treatment to maintain their improvement had the pain re-ccur if treatment was discontinued, which would have placed them in the persistent pain group in other studies. It appears that manipulation may have a role to play in long term pain relief for these patients. Possibly they have had some form of permanent soft tissue damage as a result of their accident. These patients typically are treated once every 1-3 months to remain pain free. Manipulation has been shown to increase pain tolerance"I and produce a small increase in beta-endorphins, 12 although these are thought to be only short term effects. This is an area which requires further investigation. The improvement rating was employed in this study in an attempt to determine which factors have an effect on manipulative treatment in accident cases. The medical studies quoted have typically relied on pain/no pain classifications, and it was thought in this study that a middle ground between them would generate more useful data. The level of improvement of a patient is not entirely objective or accurate in every case and this may in part be responsible for the variations between categories in the age, delay and neurological groups. There appears to be some rationale for the early use of manipulation after a motor The Journal of the CCA / Volume 36 No. 3 / September 1992 90 100 144 S Dies and JW Strapp vehicle accident. The data indicate the best overall improvement on those who are treated within one week of the accident. Croft and Foreman7 have referred to this time period as the "golden week" because the inflammatory reaction which occurs during this period, if left unchecked, will produce scars and adhesions that make future management more difficult. A general trend toward less improvement with advancing age was observed. Hohl2 and Maimaris et al.5 found that those patients with persistent symptoms had a higher mean age than the symptom free group; while Dean et al.4 did not see a statistically significant correlation between age and persistent neck pain. The presence of nausea without paresthesia or balance disturbances reduced the improvement level greatly. The reason for this observed effect is unknown. The origin of the nausea must be outside structures affected by manipulative treatment. Treatment numbers used in this study are not total treatments given each patient, only those given up to the point at which maximum improvement was achieved. Pain site significantly affected the treatment numbers. Neck and/or thoracic pain or low back pain occurring separately required fewer treatments than when they occurred together in the same patient, which is probably an indication of a more severe injury. The presence of low back pain increased the number of treatments needed. Headache increased the number of treatments required but did not affect improvement or maintenance requirements. Maimaris5 found that the presence of headache was a statistically significant factor in producing a poor prognosis. It may be that the lack of that effect in our data is due to the efficacy of manipulation in the treatment of cervicogenic headache. 13 The requirement for periodic treatment to maintain improvement level does not seem to be affected by any of the factors in this study. Vehicle damage approached significance with more damage seeming to infer an increased need for maintenance. The fact that a patient had or was having physiotherapy may simply indicate that the physiotherapy did not produce symptom relief because of the severity of the injury, causing the patient to seek alternative care. Both instances suggest that some form of permanent soft tissue damage has occurred which makes permanent biomechanical correlation less likely. This cannot be confmned by the present data. Conns The data obtained from this study are comparable to similar studies reported in the medical literature. The inclusion of manipulation in the treatment regime seems to help control persistent pain from injuries due to motor vehicle accidents when continued periodically. Early treatment may improve the treatment outcome; while the results are slightly favourable with advancing age. Nausea in absence of balance disturbances or paresthesia indicated a poor improvement according to our data. Treatment numbers were increased with the presence of headache or low back pain. References 1 Macnab I. The "whiplash syndrome". Orthop Clin Am 1971; 2(2):389-403. 2 Hohl M. Soft tissue injuries of the neck in automobile accidents. J Bone Joint Surg (Am) 1974; 56-A: 1675-1682. 3 Norris S, Watt I. The prognosis of neck injuries resulting from rear-end vehicle collisions. J Bone Joint Surg (Br) 1983; 65-B:608-61 1. 4 Deans G, McGalliard J, Rutherford W. Incidence and duration of neck pain among patients injured in car accidents. Br Med J 1986; 292:94-95. 5 Maimaris, Barnes M, Allen M. "Whiplash injuries" of the neck: a retrospective study. Injury 1986; 19:393-386. 6 Allen M. Barnes M. Bodiwala G. The effect of seatbelt legislation on injuries sustained by car occupants. Injury 1985; 16:471. 7 Croft A, Foreman S. The cervical acceleration deceleration syndrome: a proposal for management algorithms. ACA J Chirop 1989; June:59-72. 8 Fitz-Ritson D. The chiropractic management and rehabilitation of cervical trauma. J Manipulative Physiol Ther 1990; 13:17-25. 9 Ameis A. Cervical whiplash: Considerations in the rehabilitation of cervical myofascial injury. Can Fam Physician 1986; 32:1871-1876. 10 Mealy K, Brennan H, Fenelon G. Early mobilisation of acute whiplash injuries. Br Med J 1986; 292:656-657. 11 Terrett A, Vernon H. Manipulation and pain tolerance. Amer J Phys Med 1984; 63:217-225. 12 Vernon H, Dhami M, Howley T, Annet R. Spinal manipulation a 

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