Answers to Frequently Asked Questions About Whiplash
Dr Barry Marks, Chiropractor
Car Accident Injury Specialist
Patients often have many questions regarding whiplash injuries that arise over time. Often they may have pressure from an insurance adjuster or attorney or a well-meaning friend with remarks such as “shouldn’t you be better by now?”
Here are some common questions about whiplash injuries and answers from the experts in spinal trauma research. I hope this answers any questions you may have. If not, please let me know.
“My neighbor says I should be done with treatment now. It’s been 2 months already, how long will this take?”
The truth is, most whiplash injuries are very complex and take time. Sure some people get hit and don’t feel a thing or receive treatment a few times and then feel great. This definitely happens, but only in very mild cases with little injury. Even doctors fall prey to “short sightedness” and treat for minimal periods and then release patients prematurely. Make no mistake, under treatment is just as bad as no treatment at all. Until a spine is functioning properly and relatively free of subluxations (dysfunction) it will eventually revert back to where the pain began.
Duration of treatment for whiplash injuries is a heavily researched area. Numerous studies have been done to determine how long treatment may last for an injury. The consensus among researchers is that any injury that resolves within 3 months is a “mild” injury. Anything longer than 3 months is a “moderate to severe” injury that probably involves extensive damage, particularly to the discs or joint surfaces of the spine.
According to Bogduk and others in the current medical literature, “uncomplicated, mild “whiplash” type injuries require 2 to 3 months to heal, often without any residual impairments or pain.” The same authors note that 25% of whiplash victims suffer chronic pain. These patients are said not to spontaneously heal, but may improve over a period of 2 years. Another study in 1994 indicated that the average treatment period for whiplash type injuries is 7 months, 1 week; and that tough cases may require up to 108 wks. (About 2 years) until they became stationary.
Therefore, treatment of 2-3 months in more mild collisions is reasonable, while several months to 2 years of care can be required for more extensive injuries.
The key to remember is that each case is individual and must be assessed on that basis. I do not have a cookbook that I can fit each patient into. Ameis in his book Cervical Whiplash, states it clearly, “Each accident must be analyzed in its own right. Auto speed and damage are not reliable parameters.”
“My accident wasn’t all that severe, but I’ve been under care for 4 months and still need more. Why?"
There are several factors in each case that can indicate the possibility of increased injury and a worsened prognosis, which necessitates several months of care.
1. The patient was unaware of and surprised by the collision. Medical researchers have identified an increased chance of injury and a 15 times higher risk of chronic symptoms in patients who were “unaware” of the impending collision.
2. Pre-existing degenerative changes in the spine at the time of the accident. This leads to increased injury and a worsened prognosis. , , Other authors have noted that previously asymptomatic degeneration may become “decompensated” and symptoms occur following minor trauma.
3. Another complicating factor is when the patient’s vehicle is struck by another vehicle at an angle and not completely straight, or a side impact collision. The same applies if the patient had their head turned on impact or if the front wheels were turned. This causes asymmetrical loads to be applied to the spine causing increased injury and a worsened prognosis.
4. Females suffer more injury and longer treatment times due to smaller frame structure and increased nerve and blood supply in the neck and upper back.
5. Seat belts and airbags save lives, but in less than fatal accidents, they increase your chance for injury. Seat belts anchor the torso to the seat and allow your head to move around more thus creating increased sheer force to the neck and upper back. Airbags shoot out at 200 mph and have been shown to cause head injuries and increase the chance of neck and upper back injuries. Wear seat belts in conjunction with the airbag to save your life, but remember it won’t reduce your chance for sub-fatal injury.
6. Loss of consciousness on impact is an ominous sign. This means that so much neurological stress was suffered that your brain temporarily “shut down”. Loss of consciousness or “L.O.C.” is a certain sign of concussion or brain trauma. Particular attention must be paid to any neurological signs that may arise over the ensuing weeks to months that indicate the existence of “Post concussion syndrome” or “mild traumatic brain injury”. Treatment duration is often dramatically extended in these cases.
7. Multiple impacts, such as a rear end collision that pushes you into another vehicle in front involves more damage to the spine and therefore more treatment is required.
8. Previous accidents cause damage to the soft tissues of the spine. Subsequent accidents cause further damage, which accumulates over time. The more accidents you have the more likely you are of suffering from chronic whiplash.
9. Head injuries are common even in fairly low speed collisions. Unknown to many crash victims, is that the head restraint above their car seat strikes them in the back of the head on impact. This often causes a mild concussion that the patient, ER and family doctors often miss. Concussion may also occur without direct head trauma, from the head being shaken quickly in the collision. These injuries take longer to heal.
“My uncle says I should hire a lawyer. Do I really need one?”
The choice to consult an attorney is a personal one and depends on many factors. In the case of a low speed, minimal vehicle damage crash, good luck finding an attorney who will take your case. Although the research is clear that people are injured in low speed collisions, the truth is attorneys will not take a case they feel will not produce a certain level of income to them.
Another factor is, whether the attorney can assist in receiving certain benefits, services and compensation that you cannot get on your own. If an insurance company is refusing to pay for car repairs, negotiate fairly with you or you cannot obtain proper medical treatment or other services you need, such as an MRI, etc, then an attorney may be necessary.
We work with many patients without attorney representation. This is unusual for a doctor’s office. Most will not feel comfortable delivering $3,000 to $10,000 worth of medical services to someone without the protection of an attorney signed lien. We do, however we will refer you to a competent trustworthy attorney if we feel you would be better served by legal representation. We base all of our decisions on what is best for you and your particular situation.
Another point to keep in mind is that if your accident was fairly recent and you are still under treatment, an attorney cannot do anything to help you until you are done with all treatment and ready to settle. So if you are still under care, relax. You have time to make that decision later.
“My lawyer wants me to switch to his doctor or therapist. Do I have a choice?”
Of course you have a choice. You are the boss. You decide which lawyer to hire and which doctor to hire. It is your welfare at stake here, so you must make choices that are in your best interest. The reason many lawyers prefer you see their doctor is because they have a relationship with that doctor. The relationship is usually financial; meaning they cross refer and scratch each others backs. This isn’t necessarily bad unless the lawyer is referring to a typical car accident mill type doctor or clinic that gives mediocre treatment with poor service, builds up a bill and then releases you after a magic dollar amount has been reached. Each case to these lawyers and doctors are exactly the same. This is called "churning" and unfortunately it is the norm rather than the exception. Lawyers often don’t really care who treats you medically, they are more concerned over the fact of whether the doctor will cooperate financially when it comes to settling your case.
Your concern should be to get the best medical treatment possible and have your attorney represent you once your treatment is done. In this office you are always assured of being treated as an individual, with respect and using the most advanced methods and procedures in the industry. You have every right to treat in this office despite your attorney’s wishes and it will have no negative impact on your case. We will cooperate with your attorney fully and supply him or her with everything they need to achieve a successful settlement. Once a lawyer sees our reports and how we do business, they are very happy with the results.
“Shouldn’t I get checked by my medical doctor? Can I treat exclusively with a chiropractor or do I need a referral?”
No current medical literature can be found in peer reviewed, refereed journals to support the use of medications, surgery or other “traditional” methods of treatment that would be rendered by a medical doctor, neurologist or orthopedist to be effective at treating “whiplash” type injuries.
On the other hand, several current articles have appeared in the last few years indicating that spinal manipulation is effective at treating this condition. Woodward, Cook, Gargan and Bannister found in 1996 that “Following chiropractic treatment, 93% of the patients had improved. The results of this retrospective study would suggest that benefits could occur in over 90% of patients undergoing chiropractic treatment for chronic ‘whiplash’ injury”. These authors also noted “The accumulated literature suggests that 43% of patients will suffer long-term symptoms following ‘whiplash’ injury. No conventional treatment has proven to be effective in these established chronic cases.”
Therefore, if your condition is documented and treated and it responds favorably to care in a reasonable amount of time, without the need for surgical intervention, there would be no medically sound reason to send you out to another physician.
Of course if you do not respond as expected in a reasonable amount of time, another health professional would be consulted for a second opinion. We have an extensive network of medical specialists (neurologists, neuro-psychiatrists, orthopedists, pain management, and others) that we make referrals to for second opinions and specialized treatments when it is medically appropriate.
Remember that many times an insurance adjuster may say that your case should have been treated by an MD or orthopedist, but this same person will also tell another patient that they just “racked up a bill” by seeing another doctor for a “soft tissue-only” injury. Their reasoning isn’t based on medical science; they attempt to have their way at all costs. (It’s usually all about costs to them.)
Doctors of Chiropractic (D.C.’s) like their Medical Doctor (M.D.) counterparts are “Primary Health Care Providers”. This means that they are equipped to evaluate any type of medical condition, render a diagnosis and then order the appropriate treatment. Therefore, no referral is necessary.
“My family medical doctor says to discontinue chiropractic care or he/she doesn’t want my neck adjusted.”
This is a statement made out of ignorance on your medical doctor’s part. Your MD has no professional knowledge of chiropractic or chiropractic manipulation. He/she does not know when it is appropriate or not, just as Dr Marks as a chiropractor who does not perform surgery or prescribe drugs will not give you advice on those specialized areas.
Chiropractic treatment has been proven through research performed by MD’s and other research scientists to be the most effective form of care for your particular condition.
Further, your medical physician will have very little knowledge of how to manage an auto accident case. Your MD may treat whiplash cases, but he or she has no real formal training in this field and only a handful of MD’s in the entire country have the amount of specialized training as Dr Marks does. The model of medications, rest and physical therapy has been soundly refuted as a viable treatment option in the medical literature. That form of care results in chronic pain, disability and a much higher chance of arthritis in the spine later on.
“I have a concussion or mild traumatic brain injury (MTBI) shouldn’t I see a specialist? ”
The good news is, whether you realize it or not, you already are seeing a doctor who is a specialist in Mild Traumatic Brain Injury. Dr. Marks is one of a handful of doctors, chiropractic or medical, who have undergone specialized training in whiplash and brain traumatology from the prestigious Spine Research Institute in San Diego, CA.
Advanced graduates such as Dr. Marks have extensive training in how to diagnose brain injuries, especially hidden ones that your medical physician or ER doctor may have not noticed, and also the most advanced forms of care to resolve your head injury as quickly and completely as possible. Rest assured if your particular problem is outside the scope of our practice here, you will be referred to another specialist for further testing.
When a loved one or lawyers tells you, you need a specialist, they are under the impression that Dr Marks is just a general chiropractor. What they do not understand is that Dr. Marks is a highly qualified specialist in spine trauma and brain injury as well as disability evaluation and physical rehabilitation. Review Dr. Marks' credentials here.
“I know I’m really hurt, but many people say I can’t be because my car is only slightly damaged. How can I be hurt if my car wasn’t?”
This is an outmoded manner of thinking; "No Crash, No Cash" First, anyone at any age can be injured in a low impact collision. Statistically, females suffer more injury, longer periods of treatment and poorer prognoses than do males. The elderly are more susceptible to injury than younger drivers. There are several factors that make it more likely to be injured as compared to an “average” person.
Next, the correlation between vehicular damage and occupant injury has been soundly refuted by the medical literature. Some of the world’s most renowned researchers have found absolutely no correlation between the two. Macnab, Ameis, Hirsh, Emori, and many others, independently reached the same conclusion. As Macnab puts it, “The amount of damage sustained by the car bears little relationship to the force applied (to the occupant).” These researchers and authors made these observations with collisions as low as 2.5 mph. This now has become the universally accepted standard in the objective medical literature. Humans have been found to have a threshold for injury up to 2.5 mph. anything above this threshold is likely to induce injury. The way newer cars are constructed, the rear bumpers may not even show any damage until they are hit at speeds exceeding 5 mph. A recent study conducted in Germany found that the average automobile parking lot accident occurred with speeds between 7 and 12 mph and that many of the cars did not show any damage. Therefore, if the vehicle was damaged at all, it is an indication that enough force was generated to injure the occupant.
Rather than vehicle damage, the number one prognosticator for injury cited by the literature is “awareness”. If the occupant is surprised by the impact, they suffer more damage and a worsened prognosis. It has been found that “surprised” patients are 15 times more likely to suffer injury. Teasel in Spine: State of the Art Reviews, states that injury is greater “when the impact is unexpected and the victim is unable to brace”.
It’s often curious how insurance companies put a dollar amount on vehicle damage and then extrapolate that to how badly a person is injured. The threshold for them is usually $2,000. Let’s look at this more closely. $2,000.00 in damage to a Geo Metro is a lot different than $2,000.00 damage to a Jaguar or Mercedes. Who is hurt the worst in this scenario? All other things being equal, the Geo Metro driver probably got the worst of it as that car is close to being totaled, while the Jaguar or Mercedes bumper was probably just scratched. Equal vehicle repair bills in unequal cars cannot be compared.
The cost to sand, paint and polish an expensive luxury auto is steep, so a thousand dollars means very little. This is a graphic illustration of why vehicle damage is meaningless in terms of predicting bodily injury.
“My insurance adjuster says your fees are too high. How much does my treatment cost?”
First, our fees are dictated by what is considered appropriate by the insurance industry at large and what are known as “Current Procedural Terminology” (CPT) codes by the American Medical Association. In other words, I do not set the fees; the market and the profession set them for me. There is a narrow range that I can place my services into. I cannot expect to get paid over this amount and for business purposes; I would not want to fall below this level either. The cost for an average treatment consisting of an adjustment, and 2 therapies (heat and electrical stimulation) costs $130. Exercises, soft tissue/stretching and traction are additional. The same services performed in a therapy clinic under the direction of an MD or orthopedist would cost 30 to 50% more.
Certain visits, re-exams for example, are much more. That’s because they include an examination, a computerized range of motion analysis, and surface EMG studies of the entire spine, a comparative x-ray and treatment. Exams can be costly, but are needed to objectively “prove” your injury. Without them insurance adjusters routinely dismiss cases as “minor soft tissue injuries”.
When the adjuster states that our charges are “excessive for this loss scenario” he is being less than genuine. The costs may be more than what he “thinks” they should be, and certainly more than what he “wants” to pay, but when you go down the list, everything is within normal limits for our area and the type of work being done. Everything is to “code”. Our fees are dictated by the insurance industry and are within PMIC’s “Medical Fees in the United States” guidelines.
Our office takes great pride in delivering very upscale and thorough treatment as specialists, but the cost of our care is moderately priced, therefore treatment in our office is a great value.
We have many examples to show how each of the major auto insurers routinely pay our bills at 100%.
“I feel great one day and bad the next. What’s going on?”
Many tissues are injured in an accident. These injuries result in “inflammation” which is the body’s opening act at trying to rebuild damaged tissues. We want some inflammation to exist in order for your tissues to heal, but too much causes pain and stiffness. Inflammation is always changing; it rises and falls in response to your body’s needs for repair. Think of your body as a construction zone inside. Lots of work has to be done to repair stretched and torn tissues. Some days your construction crew inside is working hard and so inflammation will rise and you will feel more pain or stiffness. Other days, your body is taking it easy and rebuilding at a low level and therefore inflammation and the resultant pain is low. Our treatment aids in the restructuring of torn and damaged tissues. Sometimes this actually increases inflammation. It’s an unfortunate but necessary part of recovery that we try to control with electrical stimulation, alternating heat and ice and nutritional supplements.
The important thing to remember is that the overwhelming percentage of patients will recover with our help. During this time you will enjoy good days and have to cope with bad days. The amount and duration of bad days should decline over time, but it is an erratic process and looks more like peaks and valleys rather than a smooth glide. Be patient and follow our recommendations and you will get better.
“Why do I need to be adjusted--have my neck cracked? Why can’t I just have physical therapy and do exercises?”
Remember, the current medical literature indicates that chiropractic is more effective than any other form of care for whiplash injuries. What is unique about chiropractic care? The spinal adjustment. Spinal adjustments restore proper function and break down bad neurologic reflex patterns that become established when the spine is injured. No amount of exercise or therapy will do the same thing. They are complimentary treatments, but cannot be substituted for an adjustment. Woodward, et al., found improvement in chronic symptoms in 93% following chiropractic treatment. Khan, et al., in a recently released study stated “The results from this study provide further evidence that chiropractic adjustments are an effective treatment for chronic whiplash symptoms.” In the early stages of care you may feel more pain afterwards. If you do, discuss this with Dr. Marks. Sometimes your adjustments may be postponed until inflammation has died down and you are more comfortable. If you absolutely do not want to be adjusted just say so and we will make other treatment recommendations to suit you.
“How safe is Chiropractic?”
Chiropractic has been found to be one of the most effective and safest treatments available. Researchers found that chiropractors performing spinal adjustments have 1/6 the amount of adverse reactions as compared to physical therapists performing spinal manipulation. In a 1992 study, Shekelle found that the incidence of serious neurologic problems due to spinal manipulation of he lower back is approximately 1 in 100 million. Similar studies by insurance companies have found an incidence rate in neck adjustments to be approximately 1 in 10 million.
These incidence rates show that chiropractic spinal adjustments are quite safe if done by a competent doctor of chiropractic.
Another measure of safety is professional malpractice rates. Insurance companies charge riskier professions more for their premiums than less risky professions for obvious reasons. Surgeons have exorbitantly high insurance rates because they pose a risk if a mistake occurs. Premiums can reach the tens of thousands of dollars for these professionals. General medical physicians have lower premiums than surgeons because there is less risk, but they still pay thousands and thousands for their coverage. Doctors of Chiropractic enjoy extremely low malpractice premiums in line with their low risk treatment. Adequate coverage will cost less than many auto insurance policies.
One more thought about safety. Chiropractic is known to be safe. Other medical interventions that many patients assume to be safe are not. The CEO of Johnson and Johnson stated in the January 12, 1998 Forbes magazine that prescription anti-inflammatory medications manufactured by their company (Tylenol) resulted in 20,000 deaths annually. Add to this number another 16,000 deaths from over the counter Tylenol and you can see how this seemingly safe medical intervention has many risks associated with it. The British Medical Journal found 180,000 deaths each year in hospitals due to staff mistakes. This does not include the many thousands of people who die from adverse reactions to “proper” care. The CEO of Kaiser Permanente recently stated that medical care results in 400,000 deaths each year. Medical intervention is now the number 3 cause of death in the U.S. behind only heart disease and cancer. Keep these figures in mind next time you question an adjustment and reach for an Advil or Tylenol.
“The insurance adjuster says my children couldn’t be hurt.”
It has been a great curiosity to not only me, but the entire medical community concerned with whiplash-type injuries, that insurance companies do not believe that children can be hurt in an accident. It is a position taken by most insurance companies and I cannot explain it. They seem to think that because children are more flexible, they resist the same forces that damage older spines. While it is true a younger more flexible spine is more resilient than an older stiffer spine, it defies logic to state that younger passenger absolutely cannot be injured. This excuse is raised for 2 years olds, but also for 19 year-olds. At what age does a spine become capable of being injured? The truth, obvious as it is, is that spines of every age can be damaged in an accident even in a relatively minor collision. It all depends on the dynamics of the accident; the speed of the vehicles, the angle of the impact, the size differential between the vehicles, the type of seat belts used, the health of the occupants, history of pre-existing damage or injuries, these must all be considered. Each accident is unique.
The best advice is this; children generally do not fake automobile accident injuries. If they have been in an accident and they say they are hurt, give them the benefit of the doubt and treat them as if they are injured until proven otherwise. A proper examination by a doctor with whiplash experience will uncover any injuries.
The good news is that children have amazing recuperative powers and usually make quick recoveries with proper chiropractic treatment.
“The accident wasn’t my fault, why are you asking me for my insurance information?”
Ultimately, the person (their insurance company) who caused the accident is responsible for your medical bills. Unfortunately, they will not pay for treatment as you go. They will only pay when you have completely settled your case and then will only send payment to you, the patient. You are then responsible to pay the doctor out of the settlement funds.
The standard procedure is for your doctor to bill any and all insurance policies you have in effect at the time of the accident so that they will be paid as treatment progresses. Personal health insurance, automobile accident medical payments coverage or other accidental injury policies will pay for your care up to your policy limits. This allows the doctor to stay in practice. Otherwise he or she may have to wait 6 months to over 2 years to be paid.
IMPORTANT NOTE: It is a law in California that your auto insurance rates cannot be raised if the accident is not your fault. Therefore, you have no worries of repercussion should you use your policy.
Whatever is paid out by your insurance policies goes towards your account and any remaining balance is held until your case settles and then you are responsible for it at the end. Your insurance company will be reimbursed through negotiations with the responsible insurance company if your policy has that provision.
“What if I have no insurance coverage?”
If you do not have automobile medical payments or health insurance coverage, then you will be asked to sign a lien. A lien is an agreement that the doctor will provide treatment to you up from but not charge you until your case ends. You get the treatment you need now and pay later when your case settles. Therefore, you will not pay for your treatment out of your own pocket. We will even help guide you as to how to settle your case to make sure you get a fair settlement.
Your doctor however, is not working on a contingency basis; you are expected to pay for your care regardless the outcome of your case. The good news is, if you do your part and show up for proper treatment and follow directions, you will alwasy receive enough settlement money to pay your bills and have enough left over as compensation for your pain and suffering. You will not have to pay out of your own pocket as long as you handle your case appropriately.
“Do I have to sue the other driver?”
In the vast majority of cases you are not suing anyone. Most cases are negotiated between you and the insurance of the person who hit you. It is a negotiated settlement that does not involve the courts or law suits. As long as the other party has auto insurance, you will most likely resolve your matter without a lawsuit. And if you’re concerned about not hurting the other driver legally, please realize that accidents happen and when they do we should all have insurance, it is the law. And insurance is there to protect us. An occasional accident will not have an adverse affect on the other person, but repeated negligent driving or driving without insurance will and that is fair.
“What if the other person is uninsured? How will I get treated then?”
In this scenario, which is common in Orange County since almost 1 in 3 cars are uninsured, your own “uninsured motorist’s” coverage will cover your medical expenses and possibly your car damages. Check your policy. Make sure you have both uninsured motorist (UM) for medical as well as vehicle. This coverage will take care of you in the event the other driver has no coverage. If you don’t have it, get it added.
I hope this information has been useful to you.
I have taken the time to cite the current medical literature in hopes that the more you learn about this problem, you will be better able to make important decisions about your health.
If you have any questions that are not covered here, please let me know so that I may address the issue with you and include it in future articles for our patients.