Journal of Back and Musculoskeletal Rehabilitation 16 (2002) 39–43 39

IOS Press

Whiplash associated disorders – subjective

complaints vs clinical and objective findings.
A retrospective study of 866 patients
M. Nissan∗, D. Ovadia and S. Dekel
Department Orthopaedics B, Tel-Aviv Sourasky Medical Center, Israel

Abstract. The subjective complaints of 866 WAD (whiplash associated disorders) patients were recorded at a follow-up exam-
ination some 32 months after the accident. The complaints were compared to a number of relatively objective examinations –
X-ray, CT, MRI, EMG, Bone scan, and clinical assessment.
Neck pain and radiating pain to the limbs were the major complaints. The big majority of the X-rays findings, both primary and
late (98%), were found either non-pathological or indicating degenerative changes and old fractures. All positive CT and MRI
findings not related to known degenerative changes and old fractures were considered relevant. Bone-scan and clinical findings
not related to old injuries were considered to be relevant to the WAD. Positive EMG findings were considered relevant except for
those related with incidental CTS. Comparing the various testing modalities, CT and EMG were found positive in 25% and 33%
of the tested sample (11% and 12% of the whole WAD patients), accordingly. Bone-scan and MRI were conducted in a much
smaller sample of the patients, and only 33% and 25% (3% and 2% of the whole population) were found pathologic, accordingly.
Clinically, C-C (chin-chest touch) and RoM tests identified 75 (9%) and 58 (7%) of the pathologic population, accordingly.
Excluding degenerative changes and incidental CTS, only 25% of the patients had any objective supporting findings.

Keywords: Subjective complaints, objective findings, CT, EMG, MRI

1. Introduction and SPECT [10], questionnaires [1,3,6,11] and elec-

Whiplash associated disorders (WAD) or acute neck
sprain injuries are very common, especially following
rear-end car collisions [1]. Many of the WAD pa-
tients complain on a variety of symptoms following the
accident that sustain for a very long period and some
become chronic patients [2–4]. Heavy social and eco-
nomic aspects are often involved, including secondary
gains [5,6].
A variety of methods and techniques are used in
the assessment of whiplash complaints. These in-
clude anamnesis, clinical inspection, various radiolog-
ical tests [7–9] including bone scan, CT and MRI, PET
tromyography (EMG) tests [9]. The clinical inspection
includes tests for Range of Motion [RoM), nerve irri-
tation and muscle strength [12]. The chin-chest touch,
C-C, described and used in this work, is relatively less
known and its use is seldom mentioned.
The subjective complaints are the main cause for
many of the tests including radiological and EMG tests
conducted in WAD patients. Due to the heavy costs,
discomfort and possible risk of the various tests the
relations between the complaints and the findings are
of vital importance. In the present work we tested this
relationships in 866 WAD patients that came to our
clinic for follow-up.

2. Material and methods

∗ Address for correspondence: Dr. M. Nissan, 9, Harduf St., Haifa
34747, Israel. Tel.: +972 4 8371788; Fax: +972 3 6974546; E-mail: Eight hundred and sixty six patients involved in rear-
zmnissan@hotmail.com. end car accidents and complaining of WAD (427 males

ISSN 1053-8127/02/$8.00  2002 – IOS Press. All rights reserved

40 M. Nissan et al. / Whiplash associated disorders – subjective complaints
and 439 females) were examined by the same physician
(S.D) at a mean follow-up of 32 (standard deviation
(sd), ± 18) months. All attended our clinic as a result
of compensation claims. The patients were 38 years
old on average (sd 18 years). All had an X-ray done on
accident day, and the majority of them had a number of
further imaging, bone scan and EMG studies. All the
tests results since the accident were available to us.
At our follow-up all patients had an identical physi-
cal examination by the same clinician, starting by writ-
ing down their subjective complaints. The tests includ-
ed measurement of RoM (in rotation, extension and lat-
eral flexion using goniometers, 13), assessment of the
ability to flex the neck voluntarily and bring the chin
in contact with the chest (the chin-chest touch test, C-
C), and assessment of nerve irritation (NI) and muscle
atrophy (MA) using standard procedures. All imag-
ing data were re-examined by the same clinician, while
EMG tests were conducted and analyzed by a number
of experts. All patients were sent for a follow-up X-ray
in neck flexion and extension that were analyzed by the
same clinician, and those complaining of radiant pain
at follow-up were sent for EMG. The major subjective
complaints are shown in Table 1.
The various tests were classified in 3 categories:
a) The relatively objective radiology tests, which do
not depend on patient cooperation or clinician
longing;
b) EMG which do not depend on patient cooperation
but depends heavily on clinician technique and
expertise; and
c) Clinical tests which depend on both patient coop-
eration and clinician expertise.
The complaints were all subjective by definition.
They were compared to the clinical tests, radiology and
EMG findings, and the percentages of supported com-
plaints were calculated. A further comparison was con-
ducted between the complaints and all objective tests
with positive findings that were considered relevant to
the WAD. These included all X-ray radiographs not re-
lated with existing signs of degenerative processes or
old, healed fractures. All CT and MRI positive find-
ings not recognized as degenerated discs or old frac-
tures by X-ray, all bone scan positive findings, and all
EMG findings not related to CTS were assumed rele-
vant as well. Positive clinical findings were considered
relevant in all cases.
3. Results
The major subjective complaints are summarized in
Table 1. Constant or occasional pain in the neck was
described by 95% of the patients. Radiation to the
limbs and/or shoulders was reported by 64% (553) of
the patients. 19% reported having headache and 12%
vertigo. Tinnitus and movement restrictions were very
rare (5 and 3 patients, accordingly) (Table 1). There
was no significant difference in complaints between the
sexes.
The complaints were related to all clinical and other
findings in 63% of the patients (Table 2). Neck pain –
the most common complaint – was supported in 63%
of the complaining patients. Radiating pain to the up-
per limbs, the shoulder or both was supported by any
findings in 99%, 59% and 82% of the complaining pa-
tients, accordingly. Headache and vertigo were sup-
ported in 62% and 67% of the patients, accordingly.
Movement restriction and Tinnitus were supported in
almost all cases, but due to the small prevalence of these
complaints we cannot rely on this findings statistically.
X-ray (immediately after the accident or shortly af-
terward) was the primary diagnostic tool with positive
findings in 40% of the patients. Other radiology and
EMG tests were conducted only in cases with continu-
ing complaints that justify further investigations. Near-
ly 43% of the patients had CT with 62% of them hav-
ing positive findings, 104 had bone scan (18% positive)
and 66 had MRI (73% positive). All 866 patients were
tested clinically. The chin-chest test (C-C) was found
to be the most indicative test, positively identifying 9%
of patients with neck pain and up to 12% of the patients
with radiating pain. RoM limitations were found in 7%
of the patients. Other clinical tests (nerve irritation NI
and muscle atrophy MA) were indicative only in a little
over 1% of the cases (Table 2).
Disregarding positive radiological findings related
with normal, age related degenerative changes, signs
of fractures that happened long before the accident in
question and EMG findings related to carpal tunnel
syndrome (CTS) changed the picture significantly (Ta-
bles 3, 4). Only 25% of the complaining patients had
any relevant objective finding. Almost all of those pa-
tients with possible relevant findings (99% out of 220
patients) reported having neck pain, 69% (152 patients)
reported radiating pain, 21% had headache, 12% – ver-
tigo and less than 1% reported having tinnitus or move-
ment restrictions.
 M. Nissan et al. / Whiplash associated disorders – subjective complaints 41

Table 1
The major complaints
n Neck pain Radiating pain Vert Tinn Head- Mov.
Perm Occ. Shou Limb Both ache rest
Male 427 283 125 83 138 30 41 3 79 2
Female 439 312 107 104 156 42 61 2 83 1
All 866 595 232 187 294 72 102 5 162 3
Perm, permanent; Occ, occasional; Limb, limbs only; Shou, shoulders only; Both, shoulder and
limb; Vert, vertigo; Tinn, tinnitus; Mov rest, movement restriction. One subject did not have any
complaint at follow-up.

Table 2
Subjective complaints vs. Clinical and Radiological findings
n Σ Clinical findings Radiology
Supp RoM C-C NI MA Pr. X L. X CT MRI B. Sc
n n n n n n n n n n
Neck pain 827 524 37 72 16 12 347 53 216 48 19
Limbs pain 198 195 18 29 11 10 124 18 89 30 6
Shoul. pain 139 82 7 12 0 4 59 7 38 6 3
L & S pain 71 58 2 6 4 4 31 3 24 4 2
Headache 162 101 10 11 2 2 66 14 50 14 6
Vertigo 102 67 5 8 0 1 44 7 32 6 3
Tinnitus 5 4 0 0 0 0 1 1 3 0 0
Mov. Rest. 3 3 0 0 0 0 0 0 3 1 1
All Path. 866 539 58 75 16 12 349 55 230 48 19
All 866 866 866 866 866 866 866 805 369 66 104
RoM, range of motion; C-C, chin chest touch; NI, nerve irritation; MA, muscle atrophy; Pr. X, primary
X-Ray; L. X, late X-Ray, only new findings; prim, primary; B. Sc, Bone scan; Supp, supporting findings; L
& S, limbs & shoulder; Mov. Rest., movement restriction; All Path., all with pathologic findings; All, all
tested.

EMG was tested in 326 of the patients at average
19 (À18) months post trauma, 107 (34%) of them with
positive findings. The test was repeated at follow-up
in 76 patients that were still complaining on radiating
pain, with positive results in 11 (14%) of them (Table 3).
CT identified positively 93 of the patients (or 12%
of all patients and 25% of those tested). MRI and Bone
Scan identified less than 3% of the patients, but they
were conducted in just 8% and 12% of the cases,respec-
tively. Primary X-ray was pathologic in 2%, follow-up
X-ray – in further 2% of the patients (Table 3).
Due to the assumed relevance and importance of the
clinical tests and especially the relative abundance of
positive RoM and C-C findings, the relation between
them and the other objective and relevant tests were
analyzed (Table 4). Fifty-eight patients were found
to have RoM limitation and only in 9 of them there
were no other objective relevant findings. Lack of chin-
chest touch (C-C test) was found in 75 patients, and in
33% of them (25 patients) there was no other objective
relevant finding. The majority of patients had either
RoM limitation or positive C-C test, but 20 patients had
both.
4. Discussion and conclusions
WAD is one of the most common orthopedic con-
ditions, especially after crash accidents. It is a major
burden on the medical, economical and legal systems
in every modern country. However, very little is known
concerning its prognosis and long-term effects and the
existing literature are far from satisfactory [14].
All but one of the 866 WAD patients attending our
clinic and participating in the research reported having
one or more persisting complaints at follow-up, near-
ly 3 years post-trauma on average. This fact has two
possible implications: the first is that our sample might
represent a population with a more severe form of in-
jury than the general WAD population. The other is
that there might be some socio-economic reasons be-
hind some of the patient’s complaints. Considering the
major socio-economic burden of whiplash-associated
disorders (WAD) in the society [1,5,6] the actual re-
lation between subjective complaints and clinical and
objective tests becomes highly important. Our findings
add some data that might help in the assessment of
these relations.
There are a number of typical common subjective
complaints following crash injuries. These include
42 M. Nissan et al. / Whiplash associated disorders – subjective complaints

Table 3
Subjective complaints vs. relevant∗ , radiology and EMG findings
Supported Radiology EMG
complaint F M pr. X L. X CT MRI B. Sc prim late
only n n n n n n n n n
Neck pain 106 111 20 15 91 20 25 105 11
Limbs pain 72 53 8 2 50 14 8 82 8
Shoulder pain 30 26 8 5 27 5 6 28 0
L & S pain 12 17 4 0 15 4 2 19 4
Headache 24 22 2 4 19 4 6 13 2
Tinnitus 2 0 0 0 2 0 0 0 0
Vertigo 16 10 1 2 14 1 3 11 1
Mov. Rest. 1 1 0 0 2 1 1 0 0
No complaint 0 1 0 0 0 0 1 0
TOTAL 107 113 21 15 93 22 26 107 11
All tested 439 427 866 805 369 66 104 326 76
∗ Not including degenerative changes or incidental CTS. F, female; M, male; pr. X,
primary X-Ray; L.X, late X-Ray; L & S, limbs and shoulder; Mov. Rest., movement
restriction; B. Sc, bone scan; Prim, primary.

neck pain, radiating pain to the limbs or shoulders,
headache and vertigo. Other complaints like tinnitus
and movement restrictions are by far less common (Ta-
ble 1). The relationship between the subjective com-
plaints and the objective medical findings are not clear
yet. In the present study our aim was to assess this
relation.
The testing modalities and the technique used in our
study were presented elsewhere [15]. They were all
standard tests except for the C-C test. We followed the
patients on average 32 months after the injury. This
was long enough for the big majority of patients to have
their objective symptoms settled down. Even in cases
with fractures and subluxations, the follow-up showed
a significant recovery. All imaging and EMG studies
that were done along this period were available to us
including up-to-date X-ray in flexion and extension in
all patients and up-to-date EMG tests in patients com-
plaining of radiating pain at follow-up.
Assessing the relative usefulness of the various tests
conducted, one must remember that in our specific sam-
ple we expect a number of un-reliable patients. How-
ever, the lack of accepted “gold standard” test unable
us to discredit any of the complaining patients. All we
could do in this work was do define a subgroup whose
complaints were supported by any of the relevant tests,
the “supported group”.
Only 2% of the primary and follow-up X-rays iden-
tified changes that were relevant to the WAD condi-
tion. The vast majority of positive X-rays were indi-
cating age and work dependent degenerative processes
or old fractures (Tables 2, 3). Pathologic CT and MRI
findings were considered relevant only if they were not
identical with non-relevant changes found in X-rays.
All positive bone scan tests were considered relevant.
The majority of positive EMG findings (107 patients or
about a third of the tested patients) were found relevant,
the rest being related with CTS.
Clinical tests depend heavily on the expertise of the
clinician and the patientfls cooperation, but they were
considered relevant measuring directly the complaints
and disabilities presented. They seem to be as indica-
tive and important as all other tests (Tables 2, 3).
Comparing the relevant findings in the various test-
ing modalities, EMG and CT were found the most use-
ful tests. Assuming all patients with any indication for
it were sent for EMG and CT, they identify 49% and
42% of the “supported group” patients. C-C (chin-chest
touch) and RoM measurements were coming next. X-
ray was positive in just 2% of the “supported” patients
but have a major role in the classification of other ra-
diology modalities relevance. It seems that X-ray, the
main diagnostic tool needed and used at the emergency
room and immediate post trauma period [15], is less
useful in the cases of ongoing symptoms. CT, EMG,
RoM and C-C tests are highly recommended in these
cases.
The lack of gold standard is a major disadvantage in
the work presented here. One can suspect that some of
the positive CT, MRI and EMG findings as well as the
clinical tests including RoM and C-C are not related to
the recent whiplash complaints. At present, there is no
agreed method to distinguish between relevant and non-
relevant findings. We found it logical to assume that
advanced degenerative changes, old healed fractures
and CTS diagnosed at accident day or soon thereafter
were not a result of the accident and hence were not
relevant to the complaints. We assumed that all other
findings are related to the patient’s complaints.
 M. Nissan et al. / Whiplash associated disorders – subjective complaints 43

Table 4
Limited RoM and no C-C touch as related to radiological findings
Sex All Both X MRI CT B.S EMG none
n n n n n
RoM F 23 12 6 3 12 1 3 4
M 35 8 8 10 25 3 2 5
All 58 20 14 13 37 4 5 9
C-C F 41 12 7 4 16 1 7 15
M 34 8 5 5 18 3 7 10
All 75 20 12 9 34 4 14 25
RoM, limited range of motion; C-C, no chin-chest touch; Both, having both
RoM limitation and positive C-C test; B.S, bone scan.

The C-C and RoM tests were found to be highly
related to the radiology and EMG tests. 84% of the
positive RoM tests and 67% of the C-C tests were sup-
ported by some other objective tests (Table 4). Both
C-C and RoM can be easily measured, in a very fast
and simple way which can be easily performed every-
where with no need for any special equipment. The
RoM measurement is a standard test [13], performed
in most cases by most clinicians. The C-C test, on the
other hand, is rarely mentioned nor used and we find
it important to promote its application in all standard
WAD assessments.
5. Conclusions
X-ray is a vital test at the emergency room, but it is
only secondary in cases of continuous complaints.
Clinical tests, CT and EMG are the primary tests in
long-standing complaints.
Chin-Chest touch test is a very useful tool in the hand
of the clinician.
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