Prognosis, Chronic Pain, and Treatment Options

A Review of Studies by Martin Gargan, MD and Gordon Bannister, MD

Two of the most published physicians on the topic of outcomes from whiplash trauma are Martin Gargan and Gordon Bannister from the University of Bristol in the United Kingdom. Dr. Gargan is a specialist in pediatric orthopedic surgery. Dr. Bannister is also an orthopedic surgery specialist who has published 127 peer reviewed papers and 2 books.

A recent PubMed database search of the National Library of Medicine shows that Drs. Gargan and Bannister have published 15 studies pertaining to whiplash injuries, 11 of which they appeared together. Their first study was published in 1990 and their most recent study was published in July 2009. A review of their studies pertaining to prognosis, chronic pain and treatment options follows:

In 1990, Drs. Gargan and Bannister published a long-term follow-up study on whiplash-injured patients in the Journal of Bone and Joint Surgery (British), titled (1):

Long-Term Prognosis of Soft-Tissue Injuries of the Neck

In this study, Gargan and Bannister reviewed 43 patients who had sustained soft-tissue injuries of the neck after a mean 10.8 years. Of these, only 12% had recovered completely and 88% suffered from residual symptoms. Of these residual symptoms, 28% were intrusive and 12% were severe. Pain in the neck and lower back was the commonest complaint. Older patients had a worse prognosis for recovery. After two years, symptoms did not alter with further passage of time.

Gargan and Bannister subdivided the patients into four groups on the basis of their symptoms, as follows:

Group A (12%) were free of any discomfort and considered that they had made a complete recovery from their accident.

Group B (48%) were left with mild symptoms which did not interfere with their work or leisure activities.

Group C (28%) complained of intrusive symptoms which handicapped work and leisure and caused them to seek relief by frequent intermittent use of analgesia, orthoses or physiotherapy.

Group D (12%) suffered from severe problems, had lost their jobs, relied continually on orthoses or analgesics, and had undergone repeated medical consultations.

This indicates that in this study, 40% of whiplash-injured patients continued to suffer from significant residual symptoms more than a decade after being injured.

The specific residual symptoms found at follow-up (10.8 years) were:

Neck pain	74%
Paraesthesia	45%
Lower back pain	42%
Headache	33%
Dizziness	19%
Auditory symptoms	14%
Dysphagia	2%
Visual symptoms	2%

Other interesting finding in this study by Gargan and Bannister were:

1) 35% of those injured in motor vehicle collisions experienced a delay in symptoms, meaning they did not suffer from immediate symptomatology following the collision.

2) Seat-belts did not offer protection against hyperextension whiplash injuries.

3) Injured patients tended to reach their final level of improvement by two years after injury.

4) Patients with objective neurological signs and restriction of neck movement were more likely to experience continuing symptoms.

5) The fact that symptoms do not resolve even after a mean 10 years supports the conclusion that litigation does not prolong symptoms; all litigation had resolved by the follow-up analysis.

••••

In 1991, Drs. Gargan and Bannister and colleague (Watkinson) published their second long-term follow-up study on whiplash-injured patients, but this time included a detailed radiological analysis of their patients. This article was published in the journal Injury and was titled (2):

Prognostic factors in soft tissue injuries of the cervical spine

In this study, the authors clinically and radiographically reviewed 35 patients presenting with soft tissue injuries of the cervical spine after an average of 10.8 years. Symptoms persisted in 86% and were intrusive or worse in 23%. On presentation, paraesthesia, thoracolumbar back pain and multiple symptoms were predictive of continuing symptoms and their severity. Degenerative changes of the cervical spine were present in 68% of the patients, of whom 87% were symptomatic. Of those with normal radiographs, 80% were symptom-free. Degenerative changes occurred significantly more frequently in patients who had sustained soft tissue injuries than in the control population.

Once again, the severity of symptoms was graded using the same classification used in their 1990 study (1):

A asymptomatic

B nuisance

C intrusive

D disabling

These authors found that continued complaints usually occurred in those who had radiographically proved degenerative disease of the cervical spine. In contrast, most of those who had recovered did not show degenerative changes in their cervical spines. The authors concluded:

“The increased symptomatic degenerative changes after 10 years suggests that the complaints of patients with whiplash injuries are organic. The condition does not recover with time and its prevention and treatment merit further consideration.”

••••

In 1993, Drs. Gargan and Bannister and colleagues (Hamer and Nelson) published a study pertaining to whiplash injury and surgical cervical disc pathology. The study was published in the journal Injury and titled (3):

Whiplash injury and surgically treated cervical disc disease

In this study, the authors reviewed the incidence of a previous whiplash injury in 215 patients who underwent an anterior cervical discectomy and fusion. The rate of this disc surgery was found to be twice that of a control population of 800 general orthopaedic outpatients. The mean age at which the whiplash injury occurred in the surgical group was 37 years and in the control group 36 years. The mean age at operation of those patients with a previous whiplash injury (45 +/- 12 years) was significantly less than those patients without a previous whiplash injury (55 +/- 14 years). These authors concluded:

“This study provides further evidence that whiplash injury causes structural changes predisposing to premature degenerative disc disease.”

“These data suggests that the symptoms and signs of whiplash injury cannot be attributed solely to psychological factors and the organic pathology is a more constant explanation.”

••••

In 1994, Drs. Gargan and Bannister published a study pertaining to whiplash injury recovery rates. The study was published in the European Spine Journal and titled (4):

The rate of recovery following whiplash injury

In this study, Gargan and Bannister prospectively studied 50 consecutive patients with soft-tissue neck injuries following rear end collisions to assess their rate of recovery. Patients were seen within 5 days of the accident, after 3 months, 1 year and 2 years, and their symptoms were classified into one of four groups (A, asymptomatic; B, nuisance; C, intrusive; D, disabling) as was done in their earlier studies. Their findings were:

• 93% of patients who were asymptomatic after 3 months remained symptom-free after 2 years.
• 86% of patients with symptoms after 3 months remained symptomatic after 2 years.
• After 1 year, 52% stated that they had recovered completely, but after 2 years this had fallen to 38%.
• 60% of the patients who had improved between 3 months and 1 year deteriorated to their previous status, or worse, between 1 and 2 years.

They concluded:

“In asymptomatic cases, a prognosis that is 93% accurate after 2 years can be given after 3 months, and 86% of patients who are symptomatic after 3 months will remain so after 2 years. However, the severity of their symptoms will change during this period and will be at the same degree of severity in less than 50%.”

••••

In 1996, Drs. Gargan and Bannister and colleague (Squires) published a 15-year study pertaining to whiplash injury recovery. The study was published in the Journal of Bone and Joint Surgery (British) and titled (5):

Soft-tissue Injuries of the Cervical Spine
15-year Follow-up

In this study, 40 patients with a whiplash injury who had been reviewed previously 2 and 10 years after injury were assessed again after a mean of 15.5 years by physical examination, pain and psychometric testing.

Twenty-eight (70%) continued to complain of symptoms referable to the original accident. Neck pain was the commonest, but low-back pain was present in half. Women and older patients had a worse outcome. Radiating pain was more common in those with severe symptoms. Evidence of psychological disturbance was seen in 52% of patients with symptoms. Between 10 and 15 years after the accident 18% of the patients had improved whereas 28% had deteriorated.

Once again, the severity of symptoms was graded using the same classification used in their prior studies:

A asymptomatic

B nuisance

C intrusive

D disabling

At follow-up (15 years after injury):

30% of the patients were asymptomatic (group A)

28% had mild symptoms (group B)

33% complained of intrusive symptoms (group C)

10% were unable to work and relied heavily on analgesics or alternative therapy (group D)

At the 15-year follow-up, neck pain was present in 65% and low-back pain was present in 48%. 80% of women and 50% of men continued to have symptoms at 15 years. Patients with continued symptoms had stiffer necks. Paraesthesia occurred in 35% of patients. Radiating pain was eight times more common in patients with intrusive or severe symptoms.

Once again these authors found that degenerative changes of the cervical spine were associated with a worse prognosis for recovery, stating:

“80% of the patients who had deteriorated in the last five years had degenerative changes, compared with 67% of those whose symptoms had stayed the same and 50% of those who had improved.”

Key points from this article include:

• At a mean of 15.5 years post whiplash trauma, 70% of patients continued to complain of symptoms referable to the original accident.
• Long-term symptoms from whiplash injury include neck pain, arm paraesthesia, back pain, headache, dizziness, and tinnitus.
• At the 15-year follow-up, neck pain was present in 65% and low-back pain was present in 48%.
• 80% of women and 50% of men continued to have symptoms at 15 years after whiplash injury.
• Degenerative changes are associated with a worse prognosis for recovery from whiplash injury.
• 60% of symptomatic patients had not seen a doctor in the previous five years because the doctors were unable to help them.
• 18% of these patients had taken early retirement due to health problems which they related to the whiplash injury.
• Whiplash symptoms do not improve after settlement of litigation.
• In this study, 100% of patients with severe ongoing problems had cervical spinal degeneration.

••••

In 1997, Drs. Gargan and Bannister published a long-term follow-up comparison study of whiplash-injured patients to a group of matched controls. This study appeared in the Journal of Orthopedic Medicine, titled (6):

The Comparative Effects of Whiplash Injuries

This study is a cross-sectional age and sex-matched comparison of the clinical signs and radiographic features of 41 patients 10 years after whiplash injury, with 80 clinical and 100 radiographic controls. Specifically, the symptoms and signs of 41 patients who had sustained a whiplash injury 10 years previously were compared with 80 age-matched controls and their radiographs with 100 age-matched controls. Their findings in the whiplash-injured group include:

Neck pain was 8 times more prevalent than in the control group.

Paraesthesia was 16 times more prevalent than in the control group.

Headaches were 11 times more prevalent than in the control group.

The combination of both back pain and neck pain was 32 times more prevalent than in the control group.

Importantly, the x-rays showed that radiographic degenerative changes in the cervical spine appeared 10 years earlier in the whiplash group as in the control group, leading Gargan and Bannister to conclude:

“The prevalence of degenerative changes in the younger cervical spine [of the whiplash group] suggests that the condition has an organic basis.”

“After soft tissue neck trauma, degenerative change presented over 4 times as frequently in those aged between 31 and 40 and twice as often between 41 and 50.”

“Only one of the 24 patients with degenerative changes after soft tissue injury was symptom free.”

“Patients with degenerative changes had more restricted neck movements than controls.”

“Degenerative change and its association with neck stiffness support an organic basis for the symptoms that follow soft tissue injuries of the neck.”

••••

In 2000, Drs. Gargan and Bannister published a long-term follow-up comparison study of whiplash-injured patients to a group of matched controls. This study appeared in the Journal of Orthopedic Medicine, titled (6):

Prognosis following a second whiplash injury

In this study, Gargan and Banister note that 43% of whiplash-injured patients suffer long-term symptoms. They undertook a retrospective study of 79 patients who had suffered two whiplash injuries. The severity of each patient’s symptoms was assessed after the first and second injuries using the Gargan and Bannister classification (A, B, C, and D, as noted above).

Overall, 84% of patients reported increased symptoms following the second injury. Ninety-seven percent of patients who had been symptom free before the second injury reported persisting discomfort. This indicates that nearly all patients who are involved in a second whiplash injury will develop chronic symptoms.

Gargan and Bannister explain their findings in this study with the following comments:

“The increased severity of residual symptoms following a second whiplash injury may result from an increased vulnerability to trauma caused by the first injury.”

“This suggests that whiplash injury appears to cause structural damage to the neck, rendering it more vulnerable to subsequent trauma, which results in more severe symptoms and a poorer prognosis.”

The authors end by noting that the differences in neck pain shown in this study, as compared to studies reporting neck pain in the general population “are greater by many multiples suggesting that our observations are not confounded by age-related neck pain.”

••••

In 2007, Drs. Gargan and Bannister and a colleague (Tomlinson) published a long-term prospective study of recovery rates in whiplash-injured patients. This study appeared in the journal Injury, titled (8):

The fluctuation in recovery following whiplash injury:
7.5-year prospective review

In this study, 42 patients with a whiplash injury were assessed at the time of injury, after 3 months, after 2 years and after a mean of 7.5 years. Patients were assessed using both physical and psychometric tests.

Once again, the severity of symptoms was graded using the same classification used in their earlier studies:

A asymptomatic

B nuisance

C intrusive

D disabling

In this prospective study, 7.5 years after sustaining whiplash injury:

• 29% of the patients had no symptoms.
• 48% had mild symptoms that did not interfere with work or leisure.
• 21% had intrusive symptoms that interfered with work and leisure and required continued treatment and drugs.
• 2% had severe problems that required ongoing medical investigations and drugs.

This means that 71% of patients had symptoms 7.5 years after being injured, and these symptoms were clinically significant in 23%.

Their data shows that it takes 2 years for whiplash symptoms to stabilize, stating:

“Between 3 months and 2 years symptoms fluctuate significantly and during this time any estimation of patients’ prognosis will be unreliable.”

The cause of this fluctuation is “important in medico-legal reporting since patients’ outcome can only be predicted at 3 months and not confirmed until 2 years.”

••••

In July 2009, Drs. Gargan and Bannister and colleagues (Amirfeyz, Kelley) published a study pertaining to whiplash injuries. This study appeared in the Journal of Bone and Joint Surgery, (British), titled (9):

Whiplash Injury

This review article has 100 references. These authors make the following key points:

• Patients who sustain low-velocity whiplash injuries often will have more pain than those who sustain a fracture.
• Patients who sustain low-velocity whiplash injuries often will have more psychological distress than those who sustain a fracture.
• 90% of all road-traffic collisions occur at speeds less than 14 mph and “it is in these that whiplash occurs.”
• “Since the mid 1950s it has been recognized that the disability from whiplash is associated less with tire skid marks or the degree of vehicle damage than the effect of differential velocity on the head and upper torso.”
• Being rear-ended by a larger/heavier vehicle increases inertial injuries.
• Because women have a thinner less rigid neck they have twice the whiplash-injury rate as men.
• All human volunteer rear-end crash tests at collision speeds of 5 mph have produced neck pain in a proportion of their subjects.
• The most common whiplash-injury symptoms are:

Neck pain

Neck stiffness

Occipital headache

Thoracolumbar back pain

Upper limb paraesthesia

• Symptoms are more prognostic than signs. [Important]
• Signs that have prognostic value are, in order of severity:

Neck tenderness < neck stiffness < neurological deficit.

• In reviewing 15 studies on whiplash-injury outcomes:

Fewer than 50% of all patients made a full recovery; 4.5% were permanently disabled.

• Whiplash-injured patients are 5 times more likely to suffer from chronic neck pain than control populations.
• The view that a whiplash-injured patient’s symptoms will improve once litigation has finished “is unsupported by the literature.”
• “Patients whose necks are spondylotic at the time of their accident have an incidence of pain of 53% after two years.”
• “Patients who sustain a whiplash injury in their third decade and undergo radiography ten years later show a level of cervical spondylosis which is typical of necks 15 years older.”

••••

Drs. Gargan and Bannister have authored two studies pertaining to the management of chronic whiplash injury pain. Both articles evaluated the effectiveness of chiropractic spinal manipulation on these chronic patients.

Their first chiropractic study was published in 1996 in the journal Injury, and titled (10):

Chiropractic treatment of chronic ‘whiplash’ injuries

In this study, the authors note that 43% of patients will suffer long-term symptoms following ‘whiplash’ injury, for which no conventional treatment has proven to be effective. Therefore, they completed a retrospective study to determine the effects of chiropractic in a group of 28 patients who had been referred with chronic ‘whiplash’ syndrome. The severity of patients’ symptoms was assessed before and after treatment using the Gargan and Bannister classification as noted above.

These author also note that if whiplash patients are still symptomatic after 3 months then there is almost a 90% chance that they will remain so, and that no conventional treatment has proven to be effective in these established chronic cases. However, they did not consider chiropractic to be “conventional treatment.”

The 28 chronic whiplash patients in this study were treated by chiropractor J. Cook, using “specific spinal manipulation, proprioceptive neuromuscular facilitation, and cryotherapy.” The treatment was evaluated by an independent orthopedic surgeon, M. Woodward, who was blinded as to the treatment. “Spinal manipulation is a high-velocity low-amplitude thrust to a specific vertebral segment aimed at increasing the range of movement in the individual facet joint, breaking down adhesions and stimulating production of synovial fluid.” The 28 patients in this study had initially been treated with anti-inflammatories, soft collars and physiotherapy. These patients had all become chronic, and were referred for chiropractic at an average of 15.5 months after their initial injury. Following chiropractic 93% of the patients had improved. These authors concluded:

“The results of this retrospective study would suggest that benefits can occur in over 90% of patients undergoing chiropractic treatment for chronic whiplash injury.”

••••

Their second chiropractic study was published in 1999 in the Journal of Orthopaedic Medicine, and titled (11):

A symptomatic classification of whiplash injury and the implications for treatment

In this study, the authors retrospectively reviewed 93 consecutive patients seen in a chiropractic clinic for whiplash injures. They documented that 74% of the patients being treated by chiropractic improved. They concluded:

“The results from this study provide further evidence that chiropractic is an effective treatment for chronic whiplash symptoms.”

“Chiropractic is the only proven effective treatment in chronic [whiplash] cases.”

••••

In summary, the studies by Gargan and Bannister indicate that a substantial number of individuals injured in whiplash trauma will develop chronic pain, lasting more than a decade; this chronic pain is organic, often involving joint degeneration, and is not related to litigation. Chiropractic management of these chronic whiplash cases, including specific joint manipulation to reestablish normal joint motion, is often effective in helping these patients, especially when other treatment approaches have failed.

References:

1) Gargan MF, Bannister GC. Long-Term Prognosis of Soft-Tissue Injuries of the Neck. Journal of Bone and Joint Surgery (British); Vol. 72-B, No. 5, September 1990, pp. 901-3.

2) Watkinson A, Gargan MF, Bannister GC. Prognostic factors in soft tissue injuries of the cervical spine. Injury. 1991 Jul;22(4):307-9.

3) Hamer AJ, Gargan MF, Bannister GC, Nelson RJ. Whiplash injury and surgically treated cervical disc disease. Injury. 1993 Sep;24(8):549-50.

4) Gargan MF, Bannister GC. The rate of recovery following whiplash injury. Eur Spine J. 1994;3(3):162-4.

5) Squires B, Gargan MF, Bannister CG. Soft-tissue Injuries of the Cervical Spine: 15-year Follow-up. Journal of Bone and Joint Surgery (British). November 1996, Vol. 78-B, No. 6, pp. 955-7.

6) Gargan MF, Bannister GC. The Comparative Effects of Whiplash Injuries. The Journal of Orthopaedic Medicine, 19(1), 1997, pp. 15-17.

7) Khan S, Bannister G, Gargan M, Asopa V, Edwards A. Prognosis following a second whiplash injury. Injury 2000 May 1;31(4):249-251.

8) Tomlinson PJ, Gargan MF, Bannister GC. The fluctuation in recovery following whiplash injury: 7.5-year prospective review. Injury. Volume 36, Issue 6, June 2005, Pages 758-761.

9) Bannister GC, Amirfeyz R, Kelley S, Gargan MF. Whiplash Injury. Journal of Bone and Joint Surgery (British). July 2009, Vol. 91B, no. 7, pp. 845-850.

10) Woodward MN, Cook JCH, Gargan MF, Bannister GC. Chiropractic treatment of chronic ‘whiplash’ injuries. Injury. Volume 27, Issue 9, November 1996, Pages 643-645.

11) Khan S, Cook JCH, Gargan MF, Bannister GC. A symptomatic classification of whiplash injury and the implications for treatment. The Journal of Orthopaedic Medicine 21(l) 1999, 22-25.