Original ResearchComparing 2 Whiplash Grading Systems to Predict Clinical Outcomes
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.
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