Original Research
Comparing 2 Whiplash Grading Systems to Predict Clinical Outcomes

https://doi.org/10.1016/j.jcm.2016.04.009Get rights and content

Abstract

Objective

Two whiplash severity grading systems have been developed: Quebec Task Force on Whiplash-Associated Disorders (QTF-WAD) and the Croft grading system. The majority of clinical studies to date have used the modified grading system published by the QTF-WAD in 1995 and have demonstrated some ability to predict outcome. But most studies include only injuries of lower severity (grades 1 and 2), preventing a broader interpretation. The purpose of this study was assess the ability of these grading systems to predict clinical outcome within the context of a broader injury spectrum.

Methods

This study evaluated both grading systems for their ability to predict the bivalent outcome, recovery, within a sample of 118 whiplash patients who were part of a previous case-control designed study. Of these, 36% (controls) had recovered, and 64% (cases) had not recovered. The discrete bivariate distribution between recovery status and whiplash grade was analyzed using the 2-tailed cross-tabulation statistics.

Results

Applying the criteria of the original 1993 Croft grading system, the subset comprised 1 grade 1 injury, 32 grade 2 injuries, 53 grade 3 injuries, and 32 grade 4 injuries. Applying the criteria of the modified (QTF-WAD) grading system, there were 1 grade 1 injury, 89 grade 2 injuries, and 28 grade 3 injuries. Both whiplash grading systems correlated negatively with recovery; that is, higher severity grades predicted a lower probability of recovery, and statistically significant correlations were observed in both, but the Croft grading system substantially outperformed the QTF-WAD system on this measure.

Conclusions

The Croft grading system for whiplash injury severity showed a better predictive measure for recovery status from whiplash injuries as compared with the QTF-WAD grading system.

Introduction

Whiplash injuries impose a substantial public health burden. There are approximately 3 million whiplash injuries in the United States each year.1, 2 The economic burden in the United States has been estimated to be as high as $25 billion, and the comprehensive cost (which includes the costs of Emergency Medical Services, litigation, etc) may be as high as $43 billion annually.3

Researchers and clinicians alike are benefited by grading schemes which foster better communication by providing a coherent common language. In 1983, Norris and Watt4 segmented whiplash patients into 3 groups based upon the type of symptoms or findings with which they presented. Group 1 patients had symptoms only; group 2 patients had symptoms and physical findings; group 3 patients had “objective neurological loss.” Recovery was found to be inversely related to increasing severity grade.

In 1993, a formal whiplash grading system was introduced by Croft,5, 6 and in 1995, a modified version was published by the Quebec Task Force on Whiplash-Associated Disorders (QTF-WAD).7 These grading systems are compared in Table 1. Subsequent reports have indicated some correlation between outcome and grade of severity,8, 9, 10, 11, 12, 13, 14, 15 but most authors have studied only grade 1 and 2 injuries.

The purpose of the present study was to assess the ability of these grading systems to predict clinical outcome using a study population that was part of a separate case-control study.16 To our knowledge, this is the first clinical study to compare these 2 whiplash grading systems and the first study to include a sample with representative proportions of all 4 grades of whiplash injuries.

Section snippets

Methods

Data were taken from a previous case-control study of whiplash patients. In total, 123 individuals were recruited from 12 private clinics in 9 US states. Subjects who had sustained a whiplash injury in the past were recruited and enrolled on an ongoing basis until each clinic had recruited its target number of subjects. Litigating persons were excluded. Five cases were excluded from the present study because of missing data, leaving 118 cases available for analysis. The original case-control

Analysis of 118 Cases and Controls Using the Croft Grading System Definitions

There were 1 grade 1 injury, 33 grade 2 injuries, 53 grade 3 injuries, and 32 grade 4 injuries. χ2 test results were as follows: Pearson χ2 (3 df) = 14.420 (P = .002), likelihood ratio (3 df) = 14.947 (P = .002), and linear-by-linear association = (1 df) 11.390 (P ≤ .001). Symmetric measures, including Cramer V (.350), Spearman correlation (− .322), and Pearson R (− .312), were all statistically significant (P < .001). The negative correlation coefficient resulted from the use of dummy variables

Discussion

To our knowledge, this is the first clinical whiplash study to formally compare 2 published whiplash grading systems as well as to include the entire spectrum of whiplash severity grades. The first whiplash grading system was developed by Croft5 in 1993 and later promulgated in 1995 with some modifications by the QTF-WAD.7 In either form, it provides a means to more precisely characterize whiplash injuries. Several published studies have indicated that the modified grading system has some

Conclusion

This study looked at 118 subjects who had experienced whiplash injuries, 64% of whom had developed chronic pain. Their injuries were classified on the basis of the original Croft whiplash grading system and on the basis of the QTF-WAD modification. Cross-tabulation statistics were used to determine the predictive power of each using the patient’s self-rating of recovery as the outcome of interest. Both grading systems demonstrated predictive power, but the original grading system achieved

Funding Sources and Potential Conflicts of Interest

This study was funded by the Spine Research Institute of San Diego. No conflicts of interest were reported for this study. Dr Croft is the developer of the Croft grading system.

References (41)

  • M Sterling

    A proposed new classification system for whiplash associated disorders—implications for assessment and management

    Man Ther

    (2004)
  • RW Evans

    Some observations on whiplash injuries

    Neurol Clin

    (1992)
  • MD Freeman et al.

    Chronic neck pain and whiplash: a case-control study of the relationship between acute whiplash injuries and chronic neck pain

    Pain Res Manag

    (2006)
  • The economic and societal impact of motor vehicle crashes, 2010

    (2014)
  • SH Norris et al.

    The prognosis of neck injuries resulting from rear-end vehicle collisions

    J Bone Joint Surg

    (1983)
  • A Croft

    Treatment paradigm for cervical acceleration/deceleration injuries (whiplash)

    J Am Chiropr Assoc

    (1993)
  • A Croft

    Proposed classification of cervical acceleration/deceleration (CAD) injuries with a review of prognostic research

    Palmer J Res

    (1994)
  • WO Spitzer et al.

    Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: redefining "whiplash" and its management

    Spine

    (1995)
  • L Hartling et al.

    Prognostic value of the Quebec Classification of Whiplash-Associated Disorders

    Spine

    (2001)
  • A Soderlund et al.

    Acute whiplash-associated disorders (WAD): the effects of early mobilization and prognostic factors in long-term symptomatology

    Clin Rehabil

    (2000)
  • W Hell et al.

    Biomechanics of cervical spine injuries in rear end car impacts: influence of car seats and possible evaluation criteria

    Traffic Inj Prev

    (2002)
  • L Jakobsson et al.

    Whiplash-associated disorders in frontal impacts: influencing factors and consequences

    Traffic Inj Prev

    (2003)
  • LH Pobereskin

    Whiplash following rear end collisions: a prospective cohort study

    J Neurol Neurosurg Psychiatry

    (2005)
  • IA Karnezis et al.

    Factors affecting the timing of recovery from whiplash neck injuries: study of a cohort of 134 patients pursuing litigation

    Arch Orthop Trauma Surg

    (2007)
  • DM Walton et al.

    Risk factors for persistent problems following acute whiplash injury: update of a systematic review and meta-analysis

    J Orthop Sports Phys Ther

    (2013)
  • AC Croft et al.

    Do risk factors for acute whiplash injury also predict non-recovery? A case-control study

    (2015)
  • M Hours et al.

    One year after mild injury: comparison of health status and quality of life between patients with whiplash versus other injuries

    J Rheumatol

    (2014)
  • LJ Carroll et al.

    Pain-related emotions in early stages of recovery in whiplash-associated disorders: their presence, intensity, and association with pain recovery

    Psychosom Med

    (2011)
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