Physical Examination 213: The Whiplash Patient

The examination of the patient who presents after a motor vehicle collision, from the first question to the deposition. It opens with whiplash as a cervical acceleration/deceleration injury and the history that drives everything after it — mechanism, awareness of the impact, seat position, seat belt, body contact, loss of consciousness, symptom onset and what the emergency department already imaged. Concussion is documented with the Acute Concussion Evaluation form, its red flags and the risk factors for a protracted recovery. The physical examination covers cranial nerve screening I–XII, spinal and extremity evaluation with the orthopedic and neurologic tests, documentation that names the anatomy and side, and the Balance Error Scoring System. Imaging covers CT as first-line in acute head injury, the hematomas it finds, brain MRI with SWI, DTI and NeuroQuant at six weeks, the cervical series with flexion-extension views, MRI when radicular signs are reproducible, fractures, subluxation, disc herniation and ligament laxity, and DXD motion analysis with AMA Guides impairment ratings. Three rear-end collision cases carry the protocol through radiology reports, impairment ratings and treatment, and the course closes with deposition.

Dennis O'Hara, DC, DACBSP — sports medicine chiropractor, Diplomate of the American Chiropractic Board of Sports Physicians, ACBSP concussion certified, former chiropractor for D.C. United and MMA ringside physician — teaches the 2-hour course. It is written for Doctors of Chiropractic who see collision patients: the first-visit examination, the documentation that will be read by an attorney, the imaging to order and when, and the treatment plan that follows.

The course's answer is in two parts, the neck and the head. For the neck, a cervical series with flexion and extension stress views — the neutral films in all three cases were read as unremarkable for alignment, and it was the stress views and the DXD motion analysis that showed the ligament laxity: interruptions of George's line, translational and angular alteration of motion segment integrity, and in two of the three patients a listhesis that appeared or worsened in flexion or extension. Reproducible radicular signs on the examination are the indication for cervical MRI; in the second case it found posterior central herniations at C4–5 and C5–6 with an annular fissure and cord impression, which the emergency CT had not shown. For the head, CT is the right first-line study in the acute setting because it is fast and sensitive for skull fracture and hemorrhage, but it lacks sensitivity for diffuse axonal injury, the most common injury in concussion. When concussion symptoms persist, brain MRI with susceptibility-weighted imaging, diffusion tensor imaging and NeuroQuant volumetrics is ordered about six weeks after the accident; in the second case the standard MRI was grossly unremarkable while SWI showed a frontal microhemorrhage, DTI showed decreased fractional anisotropy in four of twelve regions and NeuroQuant showed decreased volume in 17 segments.

Physical Examination 213 is online and on-demand: you start immediately after checkout and work at your own pace. When you pass the post-course assessment your completion is recorded electronically and your certificate is issued right away. CCEDseminars is PACE Provider #34015544 and the course is co-sponsored by Texas Chiropractic College; completions are reported to CE Broker for the states served. Approved states are listed at the bottom of this page, and confirming your own board's requirements remains your responsibility.

Physical Examination 212: Clinical Pearls in Uncommon Cases, whose fourth case is a rear-end collision with whiplash and concussion, and Physical Examination 202: Neck and Upper Extremities for the cervical examination itself — any three of Dr. O'Hara's Physical Examination courses are 6 CE hours, where the automatic 10% multi-course discount starts ($108 instead of $120). The personal-injury side continues in his Whiplash 207: Personal Injury Case Management, Whiplash 203: Treatment & Documentation and Whiplash 204: Deposition & Trial Preparation, and the concussion material in Sports Injuries 258: Concussion Update. New Physical Examination titles are released as faculty complete them; the current list with pricing lives on the category page.