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benefits of early rehab &
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MEDICAL-LEGAL RESEARCH

30% of Disk Herniations are Missed on MRI

5 MPH Bumper Damage Myth

A
Active Range of Motion

Arthritis & Accidents

Arthritis & Whiplash

B
Biomechanics of Whiplash

Brainstem Injuries as a Result of Whiplash

C
Car Accidents Cause Extra-Cervical Injuries

Cervical Fusion & Injury

Cervical Fusion Accelerates Disc Degeneration

Cervical Range of Motion Predicts Disability

Confronting Secondary Gain Issues

Cord Compression vs. Abutment

Carpal Tunnel Syndrome (CTS)

Conditioning Facts & References

D
Degenerative Intervertebral Discs Are Innervated

Diagnosing Head Pain After Whiplash

Directional Disc Displacements


Disc Herniation and Causal Relationship

Disc Herniation MISSED by Medical Radiologist

Disc Herniation TRAUMATIC; Disc Bulge DEGENERATIVE


Disc Injury and MRI Findings

Disc Injury Causes Chronic Headache


Disc Protrusion

Dizziness & Vertigo Linked to Whiplash

E
Event Data Recorders (EDR) Prove Injury Risk

F
Facet Joint Syndrome

Findings in Patients After Whiplash

Fracture Types

H
Herniation of the Nucleus Pulposus (HNP)

I
Injury Rates in Low Speed Collisions Predicted

Intervertebral Disc and Pain Patterns

Intervertebral Discs are Injured in Whiplash

J
Jaw Pain After Whiplash

L
Ligament & Tendon Injury

Litigation Does Not Influence Whiplash Recovery

Low Speed Rear End Collisions & Neck Injury

Low Velocity Impacts Cause Whiplash

M
Minimal Vehicle Damage

Missed Disc Herniation at the Emergency Room

Long Term Symptoms in Low Velocity Crashes (MIST)

MRI Documented Muscle Injury in Whiplash Disorder

MRI Parameters

Myelopathy


N
Neck Injury Increased with Head Turned

Neck Muscles Injured in Whiplash

Neck Pain in "Minor" Traffic Accdients

Neck Trauma Causes Headaches


Normal Range of Motion in the Cervical Spine

O
Objectifying Ligament Injury in the Cervical Spine

P
Pre-existing Conditions INCREASE Bodily Injury

Pre-existing Injuries Increase Bodily Injury


R
Rear End Collisions

Recurrent Meningeal Nerve


Rehabilitation & Conditioning

Rib Fractures

S
Shmorl's Nodes

Shoulder Injury Commonly Missed in Whiplash Victim

Spinal Cord Injury W/O Radiographic Abnormalities

Spinal Stenosis Increases Bodily Injury

Spondylolysis

Sprains are Permanent

Steering Wheel Injuries

Stenosis

Strain/Sprain & Permanency

Structures Injured Generate Pain & Functional Loss


T
Thoracic Outlet Syndrome

Trauma and Activation of Pain

Traumatic Brain Injury & Whiplash

U
Undetected Neck Injuries

W
When Working with Traumatically Induced Clients

Whiplash

Whiplash & "Slight" Bumper Damage

Whiplash & Cervical Ligamentous Instability

Whiplash & Chronic Headaches

Whiplash & Disc Herniation Stats

Whiplash Causes Instability in the Cervical Spine

Whiplash Causes Nerve Injuries


Whiplash Causes PTSD

Whiplash Causes Stenosis


Whiplash Causes Working-Disability in 58% of Cases

Whiplash Injures Intervertebral Discs

Whiplash Injuries Made Worse By Cervical Stenosis

Whiplash Injury is More Than Neck Pain

Whiplash Most Common Injury

Whiplash, Brain Injury and Concussion

 

30% of Disk Herniations are Missed on MRI

It has been shown in prior studies that in patients with a suspected intervertebral disc herniation, on physical examination 30% are not confirmed by traditional MRI. Zou et al. (2008) studied lumbar disc herniation with functional loading or with weight bearing in flexion-extension views. This is important, as it puts “functional stress” on the spine, particularly in the position that produces symptoms. The results of the study showed that a significant increase in intervertebral disc herniation was diagnosed when additional flexion-extension views were added. Intradiscal pressure also changes with lumbar spine position. Flexion and extension MRI views provide added information when assessing patients for lumbar disc herniations, and may be especially useful in situations where symptomatic radiculopathy is present with unimpressive conventional MRI studies. In this study it was found that there was approximately a 14% increase of herniated discs compared to conventional MRI during extension views, rendering a more accurate diagnosis.

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5 MPH Bumper Damage Myth

It has been widely reported that the majority of automobiles deform or crush, as per the manufacturers rating at 5mph, and as a result, occupants can not be hurt at such a low velocity of impact. The Spine Research Institute of San Diego who crashed dozens of cars in an independent study, found a flaw in the manufacturer’s rating. As you can see by the late model car in the graphic (which is only one of many models crashed), the car withstood multiple crashes beyond 5mph, therefore invalidating the manufacturer’s report. Their research showed that “cars can withstand speeds of 8-12mph without sustaining crush damage.” Richter et al. (2000) showed in their research that occupants sustained injuries beginning at 6.8 MPH, proving that a large percentage of occupants get injured in no damage crashes.

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Active Range of Motion

In cases involving patients that are traumatically injured, documentation of the injury from the beginning is paramount to determining causal relationship. One critical aspect of this assessment is the proper measurement of ranges of motion in the joints that were injured. In a recent article by Kaale, Krakenes, Albrektsen, & Wester (2007), the authors studied the efficacy of active range of motion in the cervical spine as a way to objectify soft tissue injury. They stated, “WAD [Whiplash Associated Disorder] patients had on average a shorter range of active motion for all movements compared with the control group” (p. 715). The authors went on to say, “The difference was statistically significant for all measures considered…” (Kaale et al., 2007, p. 715). When working with the traumatically injured, assessing the initial injury is essential to understanding the short and long term consequences of the injury. This study also discussed chronic symptoms and the possibility of the condition worsening over time. This paper demonstrates that active range of motion is an objective method to diagnose soft tissue injuries.

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Arthritis & Accidents

Arthritis causes more bodily injury in accidents. It has often been said that if an accident patient/client has pre-existing arthritis (degenerative joint disease- sponylosis), that the ensuing bodily injury was most likely pre-existing. That couldn’t be further from the truth. As an example, if a 22-year-old body builder and a 90-year-old man that is 4’2” and riddled with arthritis are both in the same accident, who will be hurt more, the person with no arthritis or the person with a significant amount of arthritis? The answer is, the 90-year-old man with a significant amount of arthritis.
1) Rao et al. (2005) 2) Ehara et al. (2001) 3) Kaale et al. (2005)
4) Regenbogen et al. (1986) all conclude in their research that
pre-existing arthritic degeneration causes more bodily injury then a person with no arthritis.
Beyond the research, common sense dictates the same.

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Arthritis & Whiplash

Pre-exisitng arthritis leads to increased cervical damage in whiplash. In Trauma Series #15 we established that pre-existing arthritis renders the whiplash victim more susceptible to bodily injury in trauma. We further find in a rear-impact victim without arthritis, there may be nerve root compression. However, when there are spondylolytic changes (arthritis) in the foramina (hole between the vertebrate), the ‘injury risk greatly increases and spreads to include both multiple cervical ganglia (bundles of nerves) and nerve roots.”This was concluded by Panjabi et al. (2006), who also concluded that these ‘injuries may lead to permanent structural damage causing chronic radicular symptoms.’ Radicular symptomatology includes pain, weakness and numbness in the upper extremities. It should be noted that since spondylolytic changes in the foramen are present in most arthritics, this is a very common finding.

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Biomechanics of Whiplash

Understanding the mechanics and consequences of whiplash injuries are an important part of any medical-legal practice. In a recent article published in 2009, the authors Hai-Bin, Yang, & Zheng-guo state, “Despite a large number of rear-end collisions on the road and a high frequency of whiplash injuries reported, the mechanism of whiplash injuries is not completely understood. One of the reasons is that the injury is not necessarily accompanied by obvious tissue damage detectable by X-ray or MRI” (p. 305).

The authors go on to state the following, “It was estimated that the annual incidence was 3.8 per thousand populations in the US…The rate continued to increase even after the introduction of mandatory seatbelts…A proportion of victims will be left with a significant disability that may interfere with jobs, everyday activities, and leisure-time pursuits…Most studies on the natural history of WAD have suggested a proportion between 6%and 18%with long-term disability” (Hai-Bin, Yang, & Zheng-guo, 2009, p. 305).

The authors report, “According to an extensive review of whiplash injury, the structures most likely to be injured in whiplash were the facet capsule, the intervertebral discs and the upper cervical ligaments” (Hai-Bin, Yang, & Zheng-guo, 2009, p. 305).

When working with healthcare experts in the medical area, it is critical that the practitioners understand the very latest trends in research. Having a working knowledge on how injuries happen, how to document them and how to offer accurate prognoses for long-term disability have never been more important than they are today.

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Brainstem Injuries as a Result of Whiplash

When eliciting a history from a victim of a traumatic injury, cognitive questions regarding concentration, changes in emotion and difficulty sleeping can be indications of a serious underlying condition. Wenngren et al. (2002) stated that, “Attention and concentration deficits, emotional changes and sleep disturbances are findings explained by possible damage to the basal frontal and upper brain/brainstem structures” (p.122). In this case study, 5% of the patients were labeled with “severe clinical symptoms and cognitive problems” Wenngren et al., 2002, p. 121). Specific neurological testing utilizing Brainstem Auditory Evoked Response, MRI or PET Scans, can be ordered to ensure a traumatic brain injury has not been overlooked. The importance of a precise clinical history and ordering specific objective tests are imperative to properly diagnose and treat patients with possible brainstem lesions due to trauma. These types of patients are often seen in minimal damage accidents and can occur in a single car, no-crash scenario creating a coup-contrecoup injury, which will be the focus of our next educational fax.

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Car Accidents Cause Extra-Cervical Injuries

A recent study was carried out to determine the significance of trauma to the upper body, in the development of injury to the nerves of the upper extremity. Many times trauma patients present with feelings of “heaviness,” numbness and tingling, along with easy fatigability of the upper limb. Kai et al. (2001) state, “The frequency of occurrence, the long period of convalescence, the financial loss through disability, and the inevitable medical–legal complications all make NTOS (Neurogenic Thoracic Outlet syndrome) one of the most prevalent and important posttraumatic problems faced by the medical profession” (p. 493). When examining the traumatically injured, highly trained astute clinicians will look at all areas of the body, including the thoracic outlet, for objective findings to explain causality and persistent functional losses. This is often confused with other maladies and the chronic condition goes undiagnosed.

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Cervical Fusion & Injury

There are many instances of clients having had a history of cervical fusion (single or multi-level) that predated an automobile accident. How do you quantify bodily injury and ensuing functional loss in this situation? It has been hypothesized that the inflexibility of the fused segments will result in increased injury to the levels above and below the fusion. Prior to March 2008, there had been no studies documenting this occurrence. Dang et al. (2008) reported injury to the anterior longitudinal ligaments during 8g simulated crashes in single and double level fusion. It was determined that the mean peak increase in strain to the anterior longitudinal ligament in single level fusion was 15.5% and in double level fusion was 40.8%. The results of this study show that damage to the soft tissue structures are increased in the adjacent motion segments due to the necessity for compensation with the acquired loss of flexibility.

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Cervical Fusion Accelerates Disc Degeneration

When a client requires surgical intervention after a traumatic event, a very recent article AGAIN confirms what has been published in the past; it’s NOT OVER after the surgery.

In a study by Matsumoto, et al. (2009), a 10-year follow up MRI of patients who underwent anterior cervical decompression and fusion (ACDF) compared to healthy controls was conducted. The authors state, “There have been few studies which investigate incidence of progression of degenerative changes at adjacent segments in patients treated by ACDF comparing healthy control subjects…However, ACDF is associated with several peri and postoperative problems, one of which is adjacent segment degeneration” (Matsumoto, et al., 2009, p. 36).

Later on in the research paper, the authors report, “However, clinical symptoms including neck pain, shoulder stiffness, and numbness in the upper extremities were significantly more frequent in ACDF group than in control group. This suggests that adjacent segment degeneration might be in part associated with the patients’ symptoms” (Matsumoto, et al., 2009, 42).

That means that surgical correction is not the end of the claimant’s injuries. Future care is required in ALL FUSIONS to ensure the progression of degeneration and the reactivation of sensitive structures is monitored. Doctors that are trained properly in triaging and treating the traumatically injured not only understand the necessity of future care, but also how and when to properly document it.

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Cervical Range of Motion Predicts Disability

Whiplash may result in chronic, long-term symptoms in certain trauma victims known as Late Whiplash Syndrome. Predicting which segment of the whiplash population is a useful tool early on in the care of the traumatically injured whiplash victim. A recent study by Kasch et al. (2001) showed that long term handicap after whiplash injury is predictable by measuring neck mobility in a standardized manner. The accuracy of this assessment was increased by the addition of clinical assessment. The sensitivity of this type of testing was 73% and 91% respectively. Accurate and valid scientific testing of range of motion in the cervical spine is a MANDATORY part of the diagnosis, prognosis and treatment plan for whiplash victims.

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Confronting Secondary Gain Issues

In the medical legal arena, the term secondary gain or malingering is an important concept to understand as it has changed over time with increased academic scrutiny. Clinically, there are a group of “signs” that were associated with secondary gain concepts and were initially designed to “catch” a patient that was faking or exaggerating symptoms. This is an important topic and these concepts continue to be overused and incorrectly applied.

We are actually reviewing two separate articles that comprise the most recent research on this topic. In the first paper, the authors provided a review of 16 studies related to Waddell signs and listed a comparison of the results as well as an analysis of their practical applications. The authors state that the purpose of this manuscript was, “…to determine if any evidence exists for the interpretation of WS [Waddell signs] as being associated with secondary gain and thus possibly malingering and to evaluate the strength of that evidence through an evidence-based structured review process utilizing Agency for Health Care Policy Research (AHCPR) guidelines for review of research evidence”(Fishbain, Cutler, Rosomoff, & Steele, 2004, p. 400). They go on to discuss the basic premise with WS and whether they should change or not during treatment by stating, “If an individual was malingering WS, then those signs should not change, improve or disappear with treatment” (Fishbain et al., 2004, p. 406). They also report, “This is the rationale for using the studies presented Table 4. Here all 8 reports indicated that WS improved with treatment. This evidence was extremely consistent” (Fishbain et al., 2004, p. 406). In conclusion, the authors state in relation to WS, “Although inconsistent, the research evidence indicates that there is little evidence for an association between WS and secondary gain and, thereby, malingering. The preponderance of the evidence points to the opposite conclusion: no association” (Fishbain et al., 2004, p. 408).

In the second article, the objective was, “To determine what evidence, if any, exists for the various interpretations for the presence of WSs on physical examination” (Fishbain, Cole, Cutler, Lewis, Rosomoff, & Rosomoff, 2003, p. 141). This review also provided some insight into the WS by stating the following, “1) There was consistent evidence for WSs being associated with decreased functional performance, poor nonsurgical treatment outcome, and greater levels of pain; 2) There was generally consistent evidence for WSs not being associated with psychological distress, abnormal illness behavior, or secondary gain; 3) There was also generally consistent evidence that WSs are an organic phenomenon and that they cannot be used to discriminate organic from nonorganic problems; 4)There was inconsistent evidence that WSs do demonstrate inter-rater reliability, do not correlate with the neurotic triad of the MMPI, are associated with poor surgical treatment outcome, and are associated with non-return to work; 5) There was little or no evidence that WSs demonstrate test-retest reliability, or reliable factors, and are associated with self-esteem problems, catastrophizing, or the nonorganic pain drawing” (Fishbain et al., 2003, pp. 141-142).

In conclusion, it is important to understand that using Waddell signs when determining organic versus non-organic conditions in relation to secondary gain and medical legal issues is no longer valid. In fact, these articles were published approximately 4-5 years ago and it is important to work with clinicians that understand changes that have taken place with these very important concepts.

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Cord Compression vs. Abutment

Spinal Cord Compression vs. Spinal Cord Abutment: When a space occupying lesion (something that doesn’t belong in a space, i.e. splinter, bullet or tumor) in the form of a herniated disc (by definition always from trauma), goes beyond the borders of the disc/vertebrate into the spinal canal, it can touch and/or push the spinal cord. If it pushes the spinal cord against the back of the spinal canal in a “pincer” fashion, with pressure both in front and back of the spinal cord, the result is a cord compression. When the herniated disc simply touches, or is against the spinal cord, leaving space behind the spinal cord, the result is a cord abutment. The difference is dramatic in symptomatology and necessity for treatment, where the cord compression is a much more serious condition, often necessitating surgery. Trauma Series #9 will detail the differences.

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Carpal Tunnel Syndrome (CTS)

Pressure on the median nerve causing numbness, tingling and loss of motor function (power) in the thumb, forefinger and middle finger over time. There are many causes for CTS, however, trauma plays a major role in causality when the transcarpal ligament overstreches and compresses the median nerve. Symptoms can be instant or develop over time and can also be caused by a problem in the neck, where a clinical evaluation correlated with an EMG/NCV are the most accurate tools to differentially diagnose carpal tunnel syndrome. In the EMG/NCV, the patient does not actively participate, making the results highly accurate. From trauma, therapy or surgery are required, as this problem is usually progressive over time.

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Degenerative Intervertebral Discs Are Innervated and Cause Pain

Many clients present with pain after a traumatic event. This is because there are pain generating structures in the spinal column and surrounding musculature. One of the most commonly injured structures after a traumatic event is the intervertebral disc.

In a recent study by Edgar (2007), “The anatomical studies, basic to our understanding of lumbar spine innervation through the sinu-vertebral nerves, are reviewed” (p. 1135). This paper addresses the innervation patterns of both the healthy and degenerative intervertebral discs.

The author goes on to say, “Sensory nerve endings in the degenerative lumbar disc penetrate deep into the disrupted nucleus pulposus, insensitive in the normal lumbar spine. Complex as well as free nerve endings would appear to contribute to pain transmission” (Edgar, 2007, p. 1135). This has profound implications on the understanding of how clients with degenerative discs can be injured with less trauma than those with healthy intervertebral discs.

The author also proposes an additional theory of disc pain that is gaining more and more evidence as the procedures associated with studying this phenomenon improve. He states “…there is growing evidence to support a ‘visceral pain’ hypothesis, unique in the musculoskeletal system. This mechanism is open to ‘peripheral sensitization’ and possibly ‘central sensitization’ as a potential cause of chronic back pain” (Edgar, 2007, p.1135). What this means is when a client gets injured as a result of a traumatic event, not only can the disc produce pain at the level of injury, but it can also effect the extremities or entire regions of the body. The nerve supply that accounts for this is outlined in the paper.

If you have clients that have pain due to a traumatic event, it is important that you work with doctors that understand the most current and scientific explanations of disc anatomy and pain patterns.

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Diagnosing Head Pain After Whiplash

Many victims of whiplash injury complain of headache immediately following the trauma. Clinicians and researchers have documented persistent headaches occurring years after the initial trauma. Pain in the head can be a difficult finding to correlate clinically and this is even more important in head pain caused by whiplash. In a recent publication in a premier headache medical journal, Becker (2010) wrote about neck injury causing headache. The name of the headache that is caused by an injury to the neck is called cervicogenic headache and is different from migraine or tension headache.

The author states, “Although the concept of headaches originating from the cervical spine was described as early as 1860, and the term ‘cervicogenic headache’ was coined over 2 decades ago in 1983, a firm clinical diagnostic paradigm that most clinicians can use with confidence is still lacking” (Becker, 2010, p. 699). This paper is about that protocol and how to objectify this condition. The author continues to describe the diagnostic dilemma by stating, “Neurologists are the specialist to whom headaches patients are referred to most often, and neurologists are often not expert in the examination of the neck” (Becker, 2010, p. 701). Examination by a clinician that has expertise in headaches, whiplash trauma and the cervical spine is critical.

A MAJOR feature of this pain is “…posterior onset of the headache pain…” (Becker, 2010, p. 700). The author concludes, “Its existence [cervicogenic headache] should not seem surprising, given that the upper neck has many pain sensitive structures, and that the innervation of these structures is such that pain referral from these structures, even to the orbit [eye], is possible” (Becker, 2010, p. 704).

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Directional Disc Displacements

When a disk disrupts through external forces causing internal derangement, like when you step on a balloon and it pops from the internal pressure secondary to outside forces, it first tears the annular (outer) fibers. As a result, the derangement of the disk is focal or directional, and this is indicative of trauma. When a disc degenerates, it does so circumferentially, or over a region of the disc, and is called a bulge, with the understanding that in some instances, a bulge can also be traumatically induced. When you see a medical report and there is a disc pathology associated with a directional displacement (i.e. lateral or anterior), then it is a herniation according to medical literature and is secondary to trauma.


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Disc Herniation and Causal Relationship

Objectifying intervertebral disc pathology and, most importantly, a disc herniation can be a critical component of personal injury practice. Using the information found on MRI to correlate bodily injury to causality is a common task for the clinician working with the traumatically injured.

MRI is a tool to help OBJECTIFY the causally related injury, so how can you date a disc herniation? The key lies in the body’s response to mechanical changes in the vertebrae/intervertebral disc complex, specifically formation of the osteophyte.

In a recent study, He and Xinghua (2006) stated the objective of the research was, “To extend the quantitative prediction of the external shape of bone structure to the simulation of osteophyte formation on the edge of vertebral body” (p. 95). Basically, what resulted was a VALIDATED mathematical formula that predicts the location and timing of the formation of a vertebral osteophyte.

Understanding the adaptive power of bone (the body’s response to changes in mechanics) helps to put a timeline to disc pathology and determines whether the disc herniation was recent or was produced in the past. The authors report, “In this paper, the osteophyte formation process on the edge of a vertebral body in its mid-sagittal plane was simulated numerically” (He & Xinghua, 2006, p. 96). This has NEVER been done before. The paper goes on to say, “Osteophytes are defensive reactions of the bone to the adjusted mechanical environment” (He & Xinghua, 2006, p. 98). This is a reaction to degeneration of the intervertebral disc and therefore will identify degenerated disc vs. newly formed causally related disc herniations. The research goes on to say, “The formation of osteophytes appears to halt the process of disc slipping [that is its purpose]” (He & Xinghua, 2006, p. 98).

The paper finally reports, “However, in clinics it will actually take about more than half a year to observe the bone morphological changes to evaluate whether these changes are beneficial for the bone in the long run [when compared to the mathematical model]” (He & Xinghua, 2006, p. 101).

In conclusion, osteophytes will NOT BE PRESENT in an injury that is LESS than 6 months old. Using this timeline along with good MRI technical parameters, thorough physical examinations and proper history taking are the ONLY way to ensure that causality, bodily injury and persistent functional losses are properly identified and linked together.

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Disc Herniation MISSED by Medical Radiologist

2009 - Research conducted at Dartmouth Medical School, Department of Orthopedics

In a VERY recent publication in SPINE, Lurie, Doman, Spratt, Tosteson, & Weinstein (2009) sought “[to] compare the interpretation of lumbar spine magnetic resonance imaging (MRIs) by clinical spine specialists and radiologists in patients with lumbar disc herniation” (p. 701). The goal of this study was to determine whether the standardized guidelines for the description of disc pathology where being following in clinical practice. In other words, was the information being transferred from the academic world to the clinical arena?

“The Spine Patient Outcomes Research Trial (SPORT) is a clinical trial with both randomized and observational cohorts conducted at 13 sites with multidisciplinary spine practices across 11 states. Using patients with disc herniation from the randomized cohort of this study, we compared the interpretation of a radiologist and a clinician reading the same image” (Lurie et al., 2009, p. 701).

The results of this study showed the following:
1. “…the specific morphology of the herniation was not reported by the radiologist in 42.2% of cases” (Lurie et al., 2009, p. 703).
2. “…the radiology dictation did not provide enough detail to classify the herniation as a protrusion, extrusion, or sequestered fragment” (Lurie et al., 2009, p. 704).

The authors have made the following recommendations regarding interpretation of spine MRI:
1. “Transitional vertebrae may lead to confusion between vertebral levels” (Lurie et al., 2009, p. 705).
2. “Disc morphology should be described as per the guidelines….” (Lurie et al., 2009, p. 705).
3. “Also, left/right confusion must be considered a potential reason for discrepancy between lateralization of clinical symptoms and lateralization of a herniation on a radiology report” (Lurie et al., 2009, p. 705).

It is critically important to work with clinicians who have extensive knowledge in the interpretation of spine MRI when representing the traumatically injured. Clinicians who read their own films and do not rely on the interpretation of the radiologist ensure the proper diagnosis, prognosis and triaging of those that have sustained a traumatic injury.

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Disc Herniation TRAUMATIC; Disc Bulge DEGENERATIVE

There continues to be significant debate in the medical-legal arena in relating imaging findings to CAUSALITY. When there is a traumatic event and clinical findings indicate the need for MRI, correlating those objective findings to the event is what causality is all about. A paper by Fardon and Milette (2001) sought to unify the naming (nomenclature) of disc pathology. They went to great lengths to include every possible type of disc appearance and what they looked like on MRI. The problem is that radiologists are only concerned with how things “look,” also called morphology. The academic side of radiology has names for every possible configuration of disc pathology, but in the medical-legal world, we are concerned with only ONE thing…If there is disc pathology present, is it related to the traumatic event or was it pre-existing? That is it…the problem is that many in the medical-legal community continue to try and find answers about how the disc pathology “looks” (morphology) instead of how it was “caused” (etiology). Think of it this way; morphology is the noun and etiology is the verb. You can spend an eternity reading radiology research, but it is only focused on morphology. That is why there is so much debate. We are trying to turn a noun, morphology, into a verb, etiology, and it is causing confusion.

When we get down to the foundation of indentifying and documenting causality related to the intervertebral disc, there is a special set of circumstances that needs to be identified and learned; how the intervertebral disc “responds” to biomechanical forces. What that means is what marker is associated with a single burst of energy through the disc such as in a car accident or fall, and what marker is present when the disc is subjected to forces a little at a time over a long period, as in a degenerative disc? The marker we are looking for is a tear in the annulus fibrosis. This can be identified either by seeing the tear on MRI or discogram or by how the disc behaves in the presence of a tear. Any type of tear can change the shape of the disc. If we look at etiology, there are two main causation categories of annular tearing, traumatic and degenerative. When we look at morphology, there are many.

The two types of etiological tears in the annulus fibrosis are radial and circumferential. Radial tears are produced by a burst of energy through the disc causing a tear through the many layers or bands of the annulus fibrosis. These result in a DISC HERNIATION. A circumferential tear occurs when the disc is exposed to sustained forces and there is a separation of the layers of the annulus fibrosis. This causes a DISC BULGE. This is a key factor in the association of clinical relevance to determining causality. In a study by Fazzalari and Manthey (1997) an investigation into the nature of annular tearing is done. The authors state, “No correlation was found between radiating tears and other types of anulus disease, such as rim lesions or concentric tears, indicating that these three types of anulus tears are independent pathological processes.” (Vernon-Roberts, Fazzalari, & Manthey, 1997, p. 2643). The concept that a radial tear resulting in disc herniation is not related to degenerative changes was substantiated by the authors stating, “Importantly, the proposition that concentric tears enlarge and coalesce to form radiating tears was not substantiated by our results” (Vernon-Roberts, Fazzalari, & Manthey, 1997, p. 2643).

When correlating causality to bodily injury, clinicians that understand how the disc responds to traumatic forces are the key to proper triage and care of the injured.

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Disc Injury and MRI Findings

Correlating a single causative event to objectified bodily injury is one of the most important aspects of handling complex medical legal cases. There are many types of tests that can be used to assess the client’s injury but without causal correlation they have little value. The mechanism of injury, the client’s history and the physical examination give clues as to the location and type of injury sustained. It is only then that the findings on MRI, for example, carry “causative weight.” In recent years, identification of a “high intensity zone,” or HIZ, on MRI has been identified as a means to visualize tearing of the rear portion of the annulus fibrosis. In a study by Saifuddin, Braithwaite, White, Taylor and Renton (1998) and in a more recent paper by Peng, Hou, Wu, Zhang and Yang (2006), the authors discuss the reliability of visualizing a high intensity zone on MRI. Diagnostic criteria to visualize annular tearing on MRI were initially established by Aprill and Bogduk in 1992.

In the 1998 study, the authors state that the objective of the study was to “To determine the sensitivity of magnetic resonance imaging in the detection of painful anular tears manifested by the high-intensity zone” (Saifuddin, Braithwaite, White, Taylor, & Renton, 1998, p. 453). They continued by saying, “Anular tears were identified in magnetic resonance images by the presence of a high-intensity zone in the posterior annulus” (Saifuddin et al., 1998, p. 453). The study also pointed out a very important aspect of MRI physics and slice thickness reporting, “The ability to identify an HIZ on T2-weighted MRI scans has also been related to slice thickness. Most current MRI sequences employ a 4- or 5-mm slice thickness. A small tear may therefore not be identified using such slice thicknesses because of partial volume averaging with the surrounding hypointense annulus” (Saifuddin et al., 1998, p. 457). The authors also recommend that the parameters of the study should not include a gap between slices. It should be noted that the slice thickness parameters, as published by the American College of Radiology in 2006, were outlined in chart form in Bimonthly #74, MRI parameters.

In the study published more recently in 2006, the authors also reported, “The current study suggests that the HIZ of the lumbar disc on MRI in the patient with low back pain could be considered as a reliable marker of painful outer annular disruption” (Peng, Hou, Wu, Zhang, & Yang, 2006, p. 583). This again confirms the findings of Aprill and Bogduk in 1992. Proper history taking, documentation of causal relationship and knowledge of how to order and properly read MRI studies is critical in the medical legal world. Clinicians that have the credentials and are current with the research literature are required to properly render causality, a proper diagnosis and prognosis in personal injury cases.

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Disc Injury Causes Chronic Headache

There are cases in which traumatic injuries cause head pain without evidence of disc herniation or nerve root impingement. How does a chronic headache develop from a neck injury? The term cervicogenic headache describes a headache that is caused by structures in the neck. It is well established that intervertebral discs are innervated and in Trauma Series #12 we discussed the recurrent meningeal nerve. Schofferman et al. (2002) report that a single trauma can cause tears in the annulus fibrosis “which can lead to mechanical stimulation of annular nociceptors… In the middle and lower cervical spine, these structural problems can cause neck pain. In the upper cervical spine, they can cause headache” (p. 2242). When evaluating traumatic injuries, it is important to consider cervical sources of chronic headache in structures other than a herniated disc and the nerve root.

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Disc Protrusion

A generic term for a disc disorder that sticks out past the margin of the vertebral endplates and encompasses both disc herniation and bulging. This term is best used when the data from the imaging studies is insufficient to discriminate between a herniated and bulging disc. Historically, when MRI was called NMR (nuclear magnetic resonance), almost 2 decades ago, the term protrusion was used exclusively. This was before further definitions of herniations were used to describe tears in the disc from trauma, and bulges were used to describe a degenerative process.


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Dizziness & Vertigo Linked to Whiplash

When eliciting a history from an accident victim, symptoms such as dizziness, vertigo and depression are often overlooked. Many victims experience these types of symptoms immediately or shortly following an impact. Some even describe lack of concentration and lack of energy. Whiplash symptoms can be very complex and many professionals overlook the Vestibular System (responsible for balance/equilibrium) when evaluating injuries.

Of 262 patients investigated 6 months to 5 years after a whiplash injury, 85% complained of persistent dizziness. Tinnitus was presented in 14% of patients, and unilateral or bilateral hearing loss was reported in 5% of cases. 25% of cases reported visual disturbances, such as blurred vision and focusing impairments.

According to Vibert et al. (2003), “Lesions of the vestibular organs…..after whiplash injuries are probably underestimated by attributing dizziness and vertigo symptoms mainly to cervical damage and lesions of the central nervous system” (p. 250). Following a traumatic event, symptoms such as those mentioned above need to be evaluated by a neurologist and can be diagnosed with tests that include V-ENG (vestibular-electronastagmography) or BAER (Brainstem Auditory Evoked Response). Clear definitions of these and other specialized neurologic tests can be obtained from the medical legal educator below.

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Event Data Recorders (EDR) Prove Injury Risk

Event data recorders (EDRs) are similar to “black boxes” in airplanes, as they record information in the event of a highway collision. Of particular interest to this study was the EDRs ability to record the vehicle velocity profile during a collision event (Gabauer & Gabler, 2008).

The purpose of this study was to use EDR data to compare the effectiveness of the OIV (Occupant Impact Velocity) and ASI (Acceleration Severity Index) and to compare these metrics to the standard crash severity metric, delta-V. The study found that the more computationally intensive OIV and ASI offer no statistically significant advantage over the simpler delta-V crash severity metric in discriminating between serious and non-serious occupant injury (Gabauer & Gabler, 2008). Delta-v continues to be the best measurement of injury risk in real world collisions.

The most important aspect of the study states, “Belted occupants have very different kinematics than unbelted occupants” (Gabauer & Gabler, 2008, p. 557). This has major clinical implications, as although EDRs show the forces necessary for injury have occurred (Delta-v), how they exert their physics on the occupant takes a proper trauma oriented work up, correlating bodily injury with demonstrative evidence and persistent functional loss.

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Facet Joint Syndrome

Facet joint syndrome is a condition that affects the facet joints in the spine and causes pain. The facet joints are the areas where the vertebrae join together (see arrow to the left). They are designed to impart strength, flexibility and spinal integrity, as well as offer a range of defined movement for each spinal level.

Facet joints can cause pain in the cervical, thoracic and lumbar spine, and can also refer pain to the upper and lower extremities, and the chest wall and head, thereby making this a very important clinical finding. The International Association for the Study of Pain (Merskey & Bogduk, 1994) found that approximately 50% of all chronic spinal pain sufferers had facet joint involvement.

According to Manchikanti et al. (2004), 54% of all whiplash patients reported the prevalence of facet joint pain. The ratios were cervical 60%, thoracic 48% and lumbar 22%-45%, thereby making facet joint pain a very significant portion of the patient’s complaints. The authors also reported that only 15% of back pain sufferers can be diagnosed from a clinical examination alone, and facet joint syndrome falls into that category. An accurate diagnosis requires x-rays and often MRI’s in conjunction, to rule out additional pathology. Therefore, in the absence of disc pathology or other demonstrable findings, facet joint syndrome, traumatically induced, can be the cause of chronic pain for a lifetime.

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Findings in Patients After Whiplash

Patients that are involved in motor vehicle accidents often complain about headache, brachialgia (pain radiating into 1 or both arms), vertigo or dizziness, chewing and swallowing problems, visual-motor disturbances, such as blurred vision and reduced coordination, fatigue and reduced energy, neuropsychologic dysfunction, depression, irritability, and sleep disorders. On clinical examination, reduced range of motion of the cervical spine is prevalent. One can distinguish between the mobility of the upper cervical spine and the mobility of the lower cervical spine by using an inclinometer as a visual finding. However, this is not deemed the method of choice by the American Medical Association.

Ettlin et al. (2008) concluded that patients with whiplash disorders would display more trigger points in the upper neck, on the basis of the biomechanics of the injury and the findings by Barnsley and Lord and colleagues. The results showed 85.1% of the patients with whiplash had positive trigger points in the upper cervical spine at the base of the skull when compared to the control groups. The paper concluded that whiplash syndrome showed a distinct pattern of muscle spasm distribution that differed significantly from other patient groups and healthy subjects, establishing a causal relationship to the accident.

It is critical that each patient undergo a thorough clinical examination to correlate causality to bodily injury and persistent functional loss. There is no “canned” algorithm for whiplash patients that have stood the test of academic and clinical scrutiny necessitating an individual examination.

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Fracture Typess

 

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Herniation of the Nucleus Pulposus (HNP)

Herniation of the nucleus pulposus (HNP) through an annular defect causes focal protrusion of disk material beyond the margins of the adjacent vertebral end plate. (Any directional displacement of the disc is a herniation/)

In layman's terms, a disc herniation occurs when the inside of the intervertebral disc (nucleus pulpous) tears its way through the outer portion of the disc (annulus fibrosis) and into the space where the delicate neural structures reside. This can only be caused from trauma.

 

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Injury Rates in Low Speed Collisions Predicted

There are many structures in the neck that can be injured as a result of trauma, the most common being the intertervertebral disc, spinal nerve root or the facet joints (the joints in the back of the spinal column). The facet joints in particular are often overlooked since diagnosis is highly clinical in nature. Intervertebral disc injuries are visualized on MRI and nerve injuries are correlated with electrodiagnostic testing. The facet joint injuries are often seen in chronic pain patients with limited findings on MRI and/or diagnostic testing.

Over the last decade, the research has shown that in low speed collisions, the facet joints are included in disc and nerve injury fairly often. Although we see these clinical presentations often, to date there has been little research helping us to “predict” whether it is probable in a given situation that the facet joints will be involved, UNTIL NOW! In a study published in 2010, Stemper and Storvik sought to develop a model to predict these injuries. This does two important things. First, it firmly establishes that the facet joints are a source of pain and disability and second, it helps clinicians understand how and when to look for injuries to these very sensitive spinal joints. The authors state “…considerable evidence exists in clinical and experimental literature to implicate lower cervical facet joints in the injury mechanism resulting from low-speed automotive rear impacts…” (Stemper & Storvik, 2010, p. 306).

The authors also report, “The present study was successful in demonstrating the utility of lower neck loads for predicting soft-tissue injuries in low velocity rear impacts” (Stemper & Storvik, 2010, p. 306). This is very important research and the astute trauma clinician understands the different structures of the cervical spine and how and when they are injured. This is imperative to be able to properly identify the bodily injury and correlate it to persistent functional loss.

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Intervertebral Disc and Pain Patterns

Determining the source of pain in a traumatically injured patient/client is one of the most important aspects of medical-legal practice. Objectifying what is wrong, how it relates to the injury and what the patient/client cannot not accomplish as a result, is what we do in medical-legal practice. There are many sources of pain in the body following a traumatic injury and these can be influenced by accident physics and co-morbidities (prior injuries, diabetes, and patient physiological age). This is certainly true when it comes to pain emanating from the intervertebral disc.

In a recent study in Spine, by O'Neill, Kurgansky, Derby, & Ryan (2002), the authors looked “To determine the pattern of pain response to noxious [painful] stimulation of the intervertebral disc" (p. 2776). The main issue was the difference between radicular pain and referred pain.

The following definitions may be helpful in understanding this information. "Radicular pain [a.k.a. radiating pain] results from irritation of axons of a spinal nerve or neurons in the dorsal root ganglion" (O’Neill et al., 2002, p. 2776). This means that the nerve is either being compressed or irritated. This follows a dermatomal pattern down the arm or leg. This is very specific to each nerve level coming out of the spine. This is where you see POSITIVE EMG testing.

"In contrast to radicular pain, referred pain results from activation of nociceptive free nerve endings (nociceptors) in somatic or visceral tissue, a common example being upper extremity pain from cardiac ischemia [heart attack]" (O’Neill et al., 2002, p. 2766). This is where you get NEGATIVE EMG results.

The authors used the IDET procedure to heat the intervertebral disc thereby activating pain fibers. In a healthy disc, pain sensation is provided to the outer 1/3 of the annulus fibrosis [outer ring]. Research has shown that as the disc degenerates, these nerve endings grow farther and farther into the middle of the intervertebral disc and is some cases, pain fibers have been found in the nucleus pulposus (center). This is why pain patterns can be so intense in degenerative discs.

The results of this study were very interesting. The authors stated, "Noxious stimulation of the intervertebral disc may result in low back and referred extremity [pain] in patients presenting with these symptoms. The distal [away from the body] extremity pain produced depends on the intensity of stimulation" (O’Neill et al., 2002, p. 2776).

In conclusion, pain in the lower back that goes to the legs may not necessarily be a radiculopathy at all. Using this knowledge will be very helpful in developing a proper diagnosis, prognosis and treatment plan in patients with discogenic and referred pain patterns.

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Intervertebral Discs are Injured in Whiplash

The whiplash-related response of the cervical ligaments and discs have been quantified for frontal, side, and rear impacts in many different studies to date. In a very recent article by Siegmund, Winkelstein, Ivancic, Svensson, & Vasavada (2009), it was demonstrated that “spinal ligaments and annular fibers encapsulating the discs can partially or completely rupture when stretched beyond their physiological limit” (p. 104).

The C5/C6 disc was found to be at highest risk of injury during both frontal and rear impacts. Excessive strains were observed in superior discs, including C2/C3, during frontal impacts. Injuries to the ligaments of the upper cervical spine were reportedly more severe in individuals who had their head rotated at impact.

When evaluating the traumatically injured, it is critical to work with health professionals that understand the mechanisms of injury, how to objectify bodily injury and the correlation between causality and persistent functional loss.

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Jaw Pain After Whiplash

Reduced or painful jaw movement is more common in individuals with Whiplash Associated Disorder (WAD) than other collision realted disorders, such as pedestrian, bicycle or motorcycle injuries. This study included comments from the Quebec Task Force on Whiplash Associated Disorders, revealing that painful jaw movement is a common symptom of Tempromandibular Disorder. This condition also clinically correlates to whiplash and often leads to permanent disorders that can be symptomatic for a lifetime. Carroll et al. (2007) determined that reduced or painful jaw movment is an important aspect of WADs, and jaw symptoms also coorelated with difficulty swallowing and ringing in the ears. They also found that, “Reduced or painful jaw movement is an important aspect of [whiplash]...” (p. 86).

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Ligament & Tendon Injury

Ligaments and tendons are structures that are often injured as a result of a motor vehicle accident. When intact and healthy, these structures are responsible for allowing normal joint motion and stability. When injured, ligaments and tendons heal with inferior tissues (wound healing) or do not heal at all. Woo et al. (1999) state that, “Injury to these structures can cause significant joint instability, which may lead to injury of other tissues and the development of degenerative joint disease.” (p. 212-213). When evaluating a trauma victim, special tests can be ordered to evaluate for ligament and tendon damage. The most important aspect of the evaluation is to determine permanency in creating a final diagnosis, as this will enable the doctor to create an accurate prognosis and treatment plan. Woo et al. (1999) also state that, “Final maturation of the injured ligament in the human is not complete for at least 1 year. Even at this time the tensile strength of the healed tissue remains inferior to normal, uninjured tissue.” (p. 314). Simply stated, damaged soft tissues, such as ligaments and tendons of all joints, never heal, they wound repair with permanent, relatively unstable tissue.

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Litigation Does Not Influence Whiplash Recovery

When representing clients with injuries resulting from an automobile accident, mechanism of injury and causality are the first issues that need to be addressed. We need to look to the medical research for answers. The great thing about research is that each paper builds on previous ones so in situations like whiplash, these papers lay a factual groundwork for the discussion of the actual injuries of the patient/client.

In a recent paper published by Bannister, Amirfeyz, Kelley, & Gargan (2009), in a well respected surgical journal, the authors stated, "In 1928 Crowe presented to the Western Orthopedic Association a series of eight patients who had sustained an indirect neck injury as a result of a rear-end collision in their cars. The mechanism of injury was described as ‘whiplash’” (p. 845). With this information, we realize that the first documented cases of whiplash go as far back as 1928, which was 83 years ago! Let's take the time to review some of the important points of this paper. If you are interested in more information, please contact the person that got you this document.

The authors state, "Of all road-traffic accidents 90% occur at speeds of less than 14 mph and it is in these that whiplash injuries occur…it has been recognized that the disability from whiplash is associated less with tire skid marks or the degree of vehicle damage than the effect of differential velocity on the head and upper torso.” (Bannister et al., 2009, p. 845). It is therefore what happens to the body, NOT what happens to the car.

They also report "Accordingly, women have twice the risk of whiplash injury as men” (Bannister et al., 2009, p. 845).

They indicated “The view that a claimants’ symptoms will improve once litigation has finished has long been suggested by psychiatrists but is unsupported by the literature.” (Bannister et al., 2009, p. 847).

The complex nature of injury as a result of motor vehicle trauma is an issue that must be taken on a case-by-case basis. The research has shown over and over again that these injuries do occur and yet most doctors don't understand that they do. Working with a doctor that is familiar with the history of research on whiplash from 1928 until the present has a unique perspective on how and when these injuries occur and most importantly, how to document and describe them properly.

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Low Speed Rear End Collisions & Neck Injury

A study was conducted at low velocity (8km/hr) to determine whether the forces on the muscles in the front and back of the neck would exceed published thresholds for muscle injury, and contribute to the injury of capsular ligaments. Vasavada et al. (2007) found that the muscle injury rate calculated for the neck muscles during whiplash exposures exceeded those which have been found previously to cause injury. The seat used for the study was equipped with a head restraint that positioned less than 10cm from the back of the head. Therefore, the response of these subjects represents a small segment of the motoring public with proper head restraint protection. As a result of the rates of injury reported in this study, it shows that there may be a gross underestimate of the magnitude of whiplash victims in low velocity accidents.

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Low Velocity Impacts Cause Whiplash

There are many cases in which the trauma victim was injured and there was little or no damage to the vehicle. Low velocity collisions and their resulting injuries have been a topic of intense debate in both clinical and legal practices. Duffy et al. (2004) published a case report in a prominent orthopedic journal outlining whiplash-associated disorder following a low velocity collision in the driver of a bumper car. The paper reported, “Although radiology is not 100% sensitive for skeletal injury, the authors maintain that soft-tissue damage is a more likely cause of Whiplash Associated Disorder (WAD) in patients with negative imaging studies” (Duffy et al., 2004, p.1884). This was a case resulting in debilitating, chronic neck pain after a low-velocity collision with negative MRI, CT scan, and electromyography. Objective evidence of injury and indication for adequate surgical treatment was established using cervical range of motion analysis. In conclusion the authors state, “Considering the complex mechanism of trauma, a common pathophysiology is not likely among all individuals with WAD, and their condition must therefore be assessed individually in light of the clinical syndrome and the objective findings” (Duffy et al., 2004, p.1884).

 

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Minimal Vehicle Damage

Many patients present with significant complaints of pain and functional loss after a traumatic event such as a motor vehicle accident. There have been attempts to correlate little or no damage to the vehicle to bodily injury. Thresholds for property damage had arbitrarily been established for bodily injuries which have been proven to be incorrect, see Bimonthly Fax # 26 MIST Invalid sent June 2008. In a research paper published in a respected orthopedic journal, Hijioka, Narusawa, & Nakamura (2001) studied data related to the duration of treatment of 400 whiplash cases. Damage to the vehicle was correlated to treatment length. Patients in vehicles with no damage and damage that involved ½ of the vehicle were under treatment longer than those in the other groups.

It is a common misunderstanding to classify many whiplash victims as having injuries that are expected to make a full and complete recovery within 4-6 weeks. The authors of this study stated, “Our data show that only 29% of patients recovered by 4 weeks” (Hijioka et al., 2001, p. 492).
The authors also established pre-existing injury predisposed trauma victims to increased injury and prolonged treatment time by stating, “Degenerative changes occur more frequently with increasing age, and these changes disrupt early tissue repair” (Hijioka et al., 2001, p. 492). Establishing causality, bodily injury and significant functional loss takes detailed examination by a practitioner that understands these principles.

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Missed Disc Herniation at the Emergency Room

Properly documenting CAUSALITY is critical in the initial management of a personal injury case. Was there an injury sustained or not? From a medical-legal perspective, at the beginning, nothing is more important.

Many trauma patients are first examined in the emergency room. When they are released are you, as an attorney, confident they received a thorough evaluation and that when indicated, CAUSALITY was properly documented? The consensus on the national level is a resounding NO.

In a recent study by Schoenfeld, Bono, McGuire, Warholic, & Harris (2010), the authors inquire, “Thus, the question remains: does adding an MRI provide useful information that alters treatment when a CT scan reveals no evidence of injury” (p. 109)?

They go on to state “In light of its ability to detect ligamentous, soft tissue, and osseous edema, many clinicians contend that the sensitivity of MRI for detecting injuries exceeds that of CT” (Schoenfeld et al, 2010, p. 111).

When a traumatically induced injury is examined, it is imperative that a complete and thorough examination be obtained by the doctor. This includes MRI which will show clinically significant injuries that are NOT diagnosed on a CT scan.

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Long Term Symptoms in Low Velocity Crashes (MIST)

The MIST Protocol Does Not Appear to be Valid

Property damage is neither a valid predictor of acute injury risk nor of symptom duration. After an extensive review of the literature, Croft & Freeman (2005) found only four papers that compared property damage resulting from low velocity motor vehicle crashes to any of the three injury categories (1) injury risk, (2) injury severity, (3) duration of symptoms, which were conducted using acceptable scientific rigor and statistical assessment of the results. One paper followed a group of 32, another only 26 subjects. In the largest dataset (n=5083 claims), the authors did not interview or examine the subjects. According to Croft & Freeman (2005), a substantial number of injuries are reported in crashes of severities that are unlikely to result in significant property damage. They concluded that “…property damage is neither a valid predictor of acute injury risk nor of symptom duration” (p. 320). This educational fax correlates with the findings of Trauma Series #14, “Bumpers.”

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MRI Documented Muscle Injury in Whiplash Disorder

Muscle pain and injury is a common finding after whiplash trauma. Elliott, Jull, Noteboom, & Galloway (2008) produced the first MRI study demonstrating that female patients (18-45 years) with persistent Whiplash Associated Disorder (3 months-3 years) show quantifiable alterations in the cervical paraspinal muscles that differ significantly from subjects with no history of neck pain. They also determined that injury to the muscles surrounding the cervical spine would show changes of increased cross sectional areas specific to whiplash trauma at 3 months post injury. This is the first study of its kind to show muscle injury/pathology as a result of whiplash. The types of muscles examined in this study were deep cervical muscles and influence many factors, including spinal stability and joint position sense. This now explains and objectively quantifies injury when an accident victim complains of neck pain in the absence of herniated discs.

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MRI Parameters

In Medical-Legal Flier Bi-monthly #69, we presented a study in which the specific morphology of the herniation was not reported by the radiologist in 42.2% of cases.

In Medical-Legal Flier Bi-monthly #34, it was outlined how on physical examination, 30% of patients with a suspected intervertebral disc herniation, were not confirmed by traditional MRI.

Objectively documenting the causes of a client’s injuries is critical in today’s medical legal environment. There are many reasons why this may not happen as effectively as it should, and one of the MOST COMMONLY OVERLOOKED is MRI technical parameters. Many in the health and legal professions mistakenly feel that strength of the MRI unit is the key factor. Although it does play a role, the thickness of the slices through the body and the gaps between them are most important.

Working with a doctor that understands MRI and the technical parameters is crucial in insuring that objective injuries are not overlooked. The following chart is a guide to understanding which thicknesses should be used. Please contact the medical legal professional below to learn more on this very important medical legal issue and to truly understand why all MRIs are NOT CREATED EQUAL.

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Myelopathy

In Trauma Series #8 we discussed spinal cord compression, where a herniated disc pushes into the spinal cord and the cord pressed against the back of the spinal canal (see left picture). This “pincer” action on the spinal cord can cause serious neurological consequences as a result of trauma. Should your client have neurological deficits as a result of a disc herniation distal to the level of lesion (see right picture where the outer shaded area in the arm is affected), this is a called a myelopathy. A myelopathic finding is one of the most significant insults to the spinal cord resulting is an immediate surgical consultation and often surgery is the only solution to the injury. Distal to the level of lesion means that if the herniation is in the neck, the problem can be in the arms or legs (below the herniation), however if the herniation is in the mid to lower back, the problem in the arms cannot be from a myelopathy because the symptoms are above the problem area. Remember, this cannot happen in the lumbar spine because there is no spinal cord in the lumbar region.

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Neck Injury Increased with Head Turned

In Bi-Monthly Fax #39, we discussed injury to the joint capsules in the cervical spine (facet joints) being a source of pain and cervical instability in the Whiplash victim. Siegmund et al. (2008), in a very recent UPDATE, not only confirmed whiplash trauma tears the ligaments in the cervical spine, but showed if the head is turned, the injury is actually worse. The authors stated, “Thus a head-turned posture increases facet capsular ligament strain compared to a neutral head posture—a finding consistent with the greater symptom severity and duration observed in whiplash patients who have their head turned at impact” (Siegmund et al. 2008, p. 1643). They actually determined “…the maximum principal strain in the facet capsule doubles on the side toward which the head is turned” (Siegmund et al. 2008, p. 1649). This injury scenario demonstrates why mechanism of injury is of major importance and why some victims of whiplash trauma experience life-long debilitating pain after whiplash injury.

 

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Neck Muscles Injured in Whiplash

There are many structures in the neck that can be injured as a result of a whiplash trauma. The medical research overwhelmingly supports injury to soft tissue, nerves and the intervertebral discs found in the neck.

Injury to soft tissue has been one of the more difficult injuries to objectify until a paper published by Vasavada, A.N, Brault, J.R., and Siegmund, G.P. (2007) demonstrated how neck muscles respond to whiplash trauma. The authors’ purpose of the study was, “To calculate the musculotendon and fascicle strains during whiplash and to compare these strains to published muscle injury thresholds” (p. 756).

The results of the research conducted revealed, “The cervical muscle strains induced during a rear-end impact exceed the previously-reported injury threshold for a single stretch of active muscle” (Vasavada et al., 2007, p. 756). The authors have demonstrated how the forces produced by a rear-end collision can cause injury to the neck muscles and how the pain associated with these injuries can complicate diagnosis, treatment and recovery.

Lastly, the authors reported, “…the larger strains experienced by extensor muscles are consistent with clinical reports of pain primarily in the posterior cervical region following rear-end impacts (Vasavada et al., 2007, p. 756). When working with a clinician that understands whiplash forces, it is important to realize that the medical research supports whiplash injury as a cause of bodily injury and persistent functional loss.

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Neck Pain in "Minor" Traffic Accdients

There seems to be continued discussion regarding the factors that need to be present in order to predict whether an injured victim will develop chronic pain. In a recent study by Pape, Brox, Hagen, Natvig, and Schirmer (2007), certain “factors” were identified that may lead to chronic neck pain in an injured population of 636 people with minor or moderate traffic injuries. The authors stated in the research paper, “Daily severe or very severe neck pain at three years follow up was defined as chronic neck pain” (p. 135).

The authors stated in the introductory portion of the paper, “In the systematic review of the literature on whiplash published by the Quebec Task Force in 1995 (Spitzer et al., 1995) it was concluded that the symptoms are self-limited with favorable prognosis for most patients. However, the authors found that the scientific quality of the prognostic studies was poor and that it was impossible to make evidence-based recommendations on prognostic factors for recovery (Spitzer et al., 1995)” (Page et al., 2007, p. 135).

This is important because is correlates with the mindsets of many clinicians that work with the traumatically injured, in that each person’s symptoms and objective findings are just that, individual. Rendering an individual diagnosis, prognosis and correlating bodily injury to persistent functional loss needs to be done on an individual basis. Researchers’ desires to place people into categories or groups continue to be ineffective. Each person responds to the accident and care differently. In this paper published 12 years after the Quebec Task Force paper, there were factors that were identified that can help to determine who is most likely to have continued pain 3 years post injury. It happens more frequently than many doctors realize.

These authors showed that there are factors that have been able to predict who will develop chronic neck pain following a whiplash injury. They state, “The present study identified eight significant independent prognostic factors for chronic neck pain after traffic accidents. These comprised neck and/or shoulder pain before the accident, the impact of the collision, early post-accident bodily tension and impaired cognitive and physical function, as well as pessimism for the future ability to work” (Page et al., 2007, p. 140). The details of the accident mechanism are critical, as are taking a good past medical and current history. Doctors that understand how to identify these factors and properly report them are crucial for establishing a proper diagnosis and management of functional loss due to whiplash injury.

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Neck Trauma Causes Headaches

When victims of whiplash trauma are examined properly, it is clear that a vast majority complain of headaches following neck injury. Headaches that originate from the neck are called cervicogenic headaches. “The term cervicogenic headache (CEH) was coined by Sjaastad and coworkers in 1983 and its manifestations described…Accidents with whiplash mechanism were among the first-version diagnostic criteria for CEH” (Drottning, Staff & Sjaastad, 2002, p. 165).

“To our knowledge, there has been no previous, prospective study that has brought into focus the putative presence and development of CEH in a whiplash population, based on the CEH criteria” (Drottning et al., 2002, p. 165).

“Reduced neck mobility has been reported to be a common finding in chronic CEH in general” (Drottning et al., 2002, p. 170). “Approximately two-thirds felt that the quality of their working capacity and/ or social and family life were below par because of the accident” (Drottning et al., 2002, p. 169).

There are very specific criteria used to quantify the nature of CEH in the trauma population. It is critical to understand these criteria and how they apply to trauma victims when reviewing medical records and working with clinicians. Determining causality depends on accurate assessment and documentation.

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Normal Range of Motion in the Cervical Spine

Accurately objectifying bodily injury through the use of diagnostic tests is a critical componenet to rendering a proper diagnosis, prognosis and treatment plan. One of the most imporant diagnostic tests available to the clinican is the range of motion study. These studies are an objective measurement of the patient’s ability to use the joints in the injured area. The measurements are then compared to the standard “normals” for that particular body part. The problem is many clincians and examiners misquote the “normal” measurements since many do not know what the current standard for “normal” is, nor do they understand the current technical standard (what tool is appropriate). The current standard reference for range of motion studies and the technical components associated with it is the AMA’s Guides to the Evaluation of Permanent Impairment, 5th Edition.

There are particular areas in the cervial spine that are assocatied with specific ranges of motion. In the traumatically injured, these have to be properly measured and clinically correlated to the level involved especially in the presence of spinal pathology on MRI (disc herniation). Clinicians that are trained and aware of these normal ranges of motion, how to properly measure them and how to accuratly correlate any percentage deficits to MRI findings, are the best qualified to render an opinion on functional losses to the areas involved.

Cerival Spine Normal Ranges of Motion: Flexion – 50, Extension – 60, Right Lateral Flexion – 45, Left Lateral Flexion – 45, Right Rotation – 80, Left Rotation – 80

Measurement Technique – Dual inclinometers with a single warm up range of motion should be utilized. The measurements are obtained with three consecutive measurements in each range with the mean (average) of each being calculated. If the average is less than 50 degrees, the average must fall within 5 % of the average. If the average is greater than 50 degrees, the three consecutive measurements must fall within 10% of the average. Motion testing may be repeated up to six times to obtain three consecutive measurements that meet these criteria. If after six measurements inconsistency persists, the spinal motions are considered invalid.

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Objectifying Ligament Injury in the Cervical Spine

Traumatic injuries to the cervical spine can injure many sensitive structures including the ligaments that hold the vertebrae together. These ligaments connect the bones and allow movement within a certain “normal” limit. When these structures are overstretched by traumatic forces, they are torn, resulting in the formation of scar tissue. The problem is a normal ligament has elastic properties, allowing it to return to “normal” length. The scarred ligament has no elastic properties. Essentially it turns into a “loose” rubber band.

This injury is generally difficult to identify unless the doctor really knows where and how to look. Properly objectifying this has huge implications for causality. In a study on George’s Line by Muggleton and Allen (1998), the authors discussed different measurement protocols and compared them.

The authors state, “The concept of George’s line provides an ideal against which measured positions of vertebrae acquired in vivo [in the body] can be compared” (Muggleton & Allen, 1998, p. 31). If you are unfamiliar with George’s Line and how it can be used to objectify bodily injury, please contact the doctor that provided this information. It is a technical skill that only the best of the best understand.

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Pre-existing Conditions INCREASE Bodily Injury

After a motor vehicle collision, many clients present with underlying degenerative conditions or prior injuries. It is imperative to understand how these conditions increase bodily injury. A recent study by Craig D. Newgard (2008) at the Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, examined age and co-morbid conditions and their relation to bodily injury following a motor vehicle collision. What the research showed was that age had no bearing on the amount of injury, but on the body’s physical intolerance to traumatic forces. The author stated, “However, the assessment of serious injury as the outcome may be less effected by the presence of comorbid conditions and more reflective of the inherent physical intolerance to the biomechanical stress of traumatic events” (p. 1503). In other words, pre-existing conditions do not react to trauma forces the same way as healthy tissue, often resulting in increased bodily injury and prolonged recovery. Evaluation by a doctor that understands this important biomechanical concept is important in the correlation of bodily injury, causation and persistent functional loss.

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Pre-existing Injuries Increase Bodily Injury

Physical intolerance of the body to the traumatic forces in an automobile crash are more likely to result in significant injury and should be considered more significant than other co-morbid factors. Physical intolerance factors listed in this paper were changes in “bone density, lean muscle mass, [and] pliability of tissues” (Newgard, 2008, p. 1503). As occupants age, they become inherently more fragile and less tolerant to the multitude of forces involved in an MVC. Medical fragility, as measured by crash-related mortality rates, has been previously demonstrated (Li et al., 2003, p.1503). This study found there is no real cut off point relating to age. Pre-existing changes (AKA medical fragility) are the key factors. Therefore, the physiological age of the body is a more important prognostic factor than actual chronological age and arthritic degeneration, no matter the age of the occupant, This is a key risk factor (one of many) rendering an increased incidence of bodily injury.

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Rear End Collisions

Neck Injury & Risk Factors Due to Rear End Collisions. A recent study revealed that occupants that have their head turned during a rear end collision suffer greater injury than all other collisions. Manohar et al. (2006) stated that “In a 5-year retrospective study of 11,000 patients with cervical spine injury, 87.4% had soft tissue injuries…more than 25 of the patients. reported symptoms more than 5 years following whiplash” (p. 420). The symptoms commonly encountered included cranial nerve irritation, neck and upper extremity pain, restricted neck motion and paresthesia (numbness). This study concluded that “Head-turned rear impact caused significantly greater injury [to the cervical spine], as compared to head-forward rear and frontal impacts…” (Manohar et al., 2006, p.420) Therefore, when taking a history on your whiplash patients, be sure to ask, “Were you looking straight ahead or was your head turned?” as this is a “significant risk factor (a circumstance that makes a situation worse),” it is vital to determine when eliciting a client’s history.

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Recurrent Meningeal Nerve

A branch of the spinal nerve that passes in a recurrent fashion back through the vertebral foramen, innervates or supplies many areas, one being the outer 1/3 of the annular fibers of the disc. These nerve fibers are sensory and carry pain signals to the brain when the tissue is damaged. The herniated disc (as discussed in Trauma Series #2 and #6) can only be caused by trauma, and in many cases, the client is in pain without the disc compressing the spinal cord or spinal nerve root. Where is the pain coming from? The answer is disco-genic pain. The disc itself has pain fibers, the recurrent meningeal nerve, and if the disc is torn (herniated), then the disc itself is the competent producing cause of the pain. This answers many questions regarding the disc not compressing the spinal cord or spinal nerves, and the cause of the client’s pain.

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Rib Fractures

Rib Fractures-Significant Trauma & Conclusive Diagnosis. The presence of rib fractures in blunt force chest trauma, such as an automobile accident, indicates significant trauma. The greater the number of ribs involved, the greater the risk for complications and even death. Additional injuries, such as punctured lungs, infections, and internal lacerations, are all valid concerns, some of which may be related more to the force of trauma than the rib fractures themselves. Sirmali et al. (2003) state that, “…patients with three or more fractured ribs should be hospitalized…” (p. 136). They also recommended that “elderly patients with six or more [rib] fractures [be treated] in the intensive care units.” (Sirmali et al., 2003, p. 136). This is due to high rates of complications. Many times fractures go undetected, causing chronic pain and disability. Although plain film radiographs are common, nuclear medicine, particularly bone scan technology, has a high sensitivity to fracture detection and can be positive for up to two years post trauma. Most doctors overlook this technology, that has proven successful for decades, in concluding an accurate diagnosis.



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Shmorl's Nodes

Shmorl’s Nodes Can = Fracture. Schmörl's nodes are herniations of intervertebral disk material through areas of weakness in the endplate. The endplate defect may occur during development or from traumatic lesions caused by compressive vertebral loads. The weakened endplate of the vertebra has less resistance to the expansive pressure of the adjacent nucleus pulposus during the herniation and causes a defect in the vertebrate itself. According to Grivé, et al. (1999), traumatic lesions are common in many individuals. Often, the shmorl node can be considered a fracture of the vertebra and that is best diagnosed in cooperation between the clinician and the radiologist. The shmorl node is a fairly common finding upon radiological evaluation, and MRI would be required to determine if it is traumatic.

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Shoulder Injury Commonly Missed in Whiplash Victim

Triaging victims of a traumatic event takes very specific clinical skills. Many times, victims are categorized into loose groups oriented towards diagnosis based on “syndrome” rather than anatomical lesions. These groups include whiplash, cervicalgia, headache and lumbago, to name a few. The astute clinician will dig deeper to solve the diagnostic dilemma. In many cases, the only common factor between victims can be the mechanism of injury. Everyone reacts to traumatic forces differently. A recent article by Abbassian and Giddins (2008), demonstrated this syndrome-based diagnostic phenomenon in a prominent orthopedic journal, and outlined an often “missed” injury in traffic accident victims. In relation to traumatic shoulder injury, the authors stated, “The diagnosis is, however, frequently overlooked and shoulder pain is often attributed to pain radiating from the neck resulting in long delays before treatment” (Abbassian & Giddins, 2008) The authors found that only 27% of patients had a proper diagnosis. When working with clinicians, it is important to work with the best of the best. Accurate and efficient diagnosis is paramount to documenting causality to bodily injury and persistent functional loss.

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Spinal Cord Injury W/O Radiographic Abnormalities

When assessing the traumatically injured, correlation of findings is paramount. Do the physical, neurological and orthopedic examinations correlate with the radiographic and advanced imaging results? Kasimatis et al. (2008) published a paper on SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) in which they state “SCIWORA is thought to represent mostly a pediatric entity and its incidence in adults is rather underreported” (p. 86). “Differences in radiological and clinical examination findings in patients with spinal cord injury can occur and pose challenges to their management” (p.86). These injuries are also influenced by degenerative changes in the adult spine, such as bone spurs, narrowed spinal canal and degenerative disc disease, where the cord can be stretched over these structures with hyperextension injuries. Cord Concussion Syndrome can also occur, which can result in negative MRI findings at which time. Finally, it was stated “MR imaging has substantially aided in our understanding of the pathomorphology of SCIWORA, revealing the following distinct abnormality: pressure exerted by the intervertebral disc and/or the ligamentum flavum, and epidural hematoma.” (Kasimatis et al., 2008, p. 91). Proper diagnosis of spinal cord trauma can be difficult and correlation of all clinical and imaging findings will allow trauma patients to receive proper specialist referral and appropriate medical interventions.

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Spinal Stenosis Increases Bodily Injury

A research study was published following a group of patients that suffered traumatic cervical spine injury. These patients were compared to a group of healthy individuals. They were specifically looking at the diameter of the spinal canal, specifically spinal stenosis and neurological symptoms. Debois, Herz, Berghmans, Hermans, and Herregodts (1999) stated, “Results from this study strongly suggest that the degree and severity of neurologic symptoms accompanying cervical disc herniation are inversely related to the sagittal diameter and the area of the bony cervical spinal canal”(p. 1996). In other words, spinal stenosis, whether acquired or congenital (present at birth), resulted in further injury as compared to those patients that had spinal canals of normal diameter. When evaluating the traumatically injured, conditions that are present in the spine can cause increased injury with less trauma than would be required to cause injury in a healthy individual. It is important to correlate all findings to the client’s bodily injury and persistent functional losses

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Spondylolysis

This is the medical term used to describe the presence of a "defect" or fracture in the posterior arch of the vertebra (see figure, arrow). It occurs at the lumbo-sacral junction (L5/S1) in about 85% of cases. The remainder occurs at the L4/5 level or above, and in about 20% of cases, the defect is on one side.
Spondylolysis is not a congenital condition and has never been identified in a newborn infant, or a child who has not started to walk. Defects can develop as a stress fracture in individuals predisposed to the condition, due to the shape or orientation of the bones at the base of your spine.

There is an increased incidence in people who take part in certain physical, sporting activities or are post traumatic. To diagnose spodylolysis and ascertain if this is a recent injury, x-rays and a bone scan are indicated to conclusively diagnose your client.

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Sprains are Permanent

Strain/Sprain has 2 parts; The strain is an overstretching of the muscle and tendon. The sprain component is an overstretching and tearing of the ligament, and as explained in Trauma Series #13, has 3 grades. All 3 grades involve overstretching of the ligament and tearing of tissue to some degree from minor in grade 1 to moderate and severe in grades 2 and 3. It is well-documented in medical research that grades 2 and 3 have permanent sequelae, as the tissue will not heal, but wound repair with adhesions (internal scar tissue), leaving the joint unstable for a lifetime. Current research reveals that all 3 grades of strain leave the ligement with permanent bodily damage. Torrez and Dupree (2005) reported “that no treatment currently exists to restore an injured tendon or ligament to its normal condition” (p. 231).

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Steering Wheel Injuries

In automobile accidents, the steering wheel can be considered a “blunt instrument” that can create bodily injury. The one thing in common for virtually every driver is that they are holding onto the steering wheel during an accident, leaving their hands and wrists exposed to injury. Carpal Tunnel Syndrome (CTS) is one of the most common steering wheel injuries. Conservative care is indicated as soon as possible, often with favorable outcomes, yet many victims are left with permanent loss of function, even if treated. In Trauma Series #5, CTS is examined in detail, explaining that the median nerve is entrapped by the overstretched transcarpal ligament. In Carpal Tunnel Syndrome and Motor Vehicle Accidents, by Ames, E.L. (1996), it is concluded that “Symptoms of carpal tunnel syndrome developed in 96 patients within 2 months after an automobile accident. Forty-four (46%) of these 96 patients underwent carpal tunnel release [surgery]” (p. 223).

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Stenosis

Constriction or narrowing of a passageway or opening, such as the spinal canal when a disc herniates and causes the canal to become smaller. Stenosis can also be caused genetically. In the congenital stenosis, see picture, the fact that there is narrowing of the spinal canal, indicates that a disc herniation in that area will have a greater detrimental effect because there is no room in the spinal canal and can cause greater insult on the spinal cord or nerve roots. In this instance, a congenital problem has predisposed the client to greater bodily damage with trauma.

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Strain/Sprain & Permanency

Strain/sprains can be permanent. There are 3 grades of sprain/strain:
Grade 1: Overstretching of the ligament that is a transient condition that resolves.
Grade 2: Partial tearing of the ligament that does not heal, it wound repairs, with internal scar tissue called adhesions. This is a permanent change in tissue structure and leaves the joint unstable.
Grade 3: This is a complete tear of the ligament and can require surgery. This leaves the joint very unstable, that over time will fill in with adhesions. This, too, is a permanent scenario.
Doctors are not given the choice of choosing which type of strain/sprain in their diagnosis, as the coding guidelines only gives the doctor 1 choice. When confronted with a diagnosis from a doctor with strain/sprain, do not assume that it is a grade 1. Ask the doctor to clarify which grade the client has to determine if it is a permanent condition or not. These can happen in any joint of the body including the spine and all extremities.

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Structures Injured Generate Pain & Functional Loss

Traumatic events that cause injury to the structures in the spine can generate painful stimuli that may produce irreversible functional losses. This educational flier is focused on dispelling myths related to the innervations of the intervertebral disc and surrounding structures of the spinal column. It is important to understand that research related to the innervations of the intervertebral disc and the front of the spinal canal has been going on since the early 1930s. With that being said, the nerve supply to these structures was well defined by the 1960s. The facts of how these areas are “wired” have been established for the past 49 years. THESE NERVES ARE DIFFERENT THAN THE SPINAL NERVE ROOTS.

In a recent research review published in 2007 by M. A. Edgar, the author states, “Branches were
traced to the posterior longitudinal ligament, to the outer layers of the annulus fibrosus, and to the anterior dura” (p. 1135). The most interesting fact about the research surrounding the innervation of the intervertebral disc is contained in the following statement by the author, “Most authors concluded that the lumbar sinuvertebral nerves had up to three segmental levels of overlap…” (Edgar, 2007, p. 1135). This shows that there is a redundancy of innervation and demonstrates how injuries to one spinal level can have effects on adjacent levels.

The following structures contain nerve endings that transmit pain:
1. Intervertebral Disc
a. Healthy Disc – outer 1/3 of the annulus fibrosis
b. Degenerated Disc – increased innervation as far inward as the nucleus pulposus
2. Posterior Longitudinal Ligament
3. Anterior Dural Sac
a. This is important in cases where the disc herniation is compressing the sac that surrounds the nerve roots and spinal cord.
4. Outer Layer of the Vertebral Body

Understanding anatomical structures and how they relate to bodily injury and persistent functional loss are extremely important to the diagnosis, management and documentation of the traumatically injured.

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Thoracic Outlet Syndrome

Overlooked & Often Misdiagnosed in Whiplash Victims. Thoracic Outlet Syndrome (TOS) is the result of pressure of a nerve bundle in the neck between the collar bone and a rib caused by a spasm of the scalenus muscle or a congenital misplacement of the muscle into the first rib. Symptoms of TOS are weakness, tingling, numbness of the arm and portion of the hand as well as heaviness of the upper extremities and headaches. In many patients with whiplash who do not respond to conventional therapy, doctors often overlook or misdiagnose the Traumatic Thoracic Outlet Syndrome as a congenital problem. According to Kai et al. (2001), ‘A special type of EMG is essential in diagnosing this syndrome, but there is no effective long term therapy for these patients.’ (p. 492). This gives some answers to why victims of whiplash type injuries suffer chronic, long term pain and symptoms.

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Trauma and Activation of Pain

When a victim of a traumatic event is evaluated for causally related bodily injury, an accurate and factual analysis is imperative. There are many structures that can generate pain in the body and one of the most common is the intervertebral disc. A healthy disc is comprised of two major portions, the outer rings called the annulus fibrosis and the inner fluid center called the nucleus puplosus. Scientific research has shown that the disc has nerve fibers that carry pain sensation imbedded from the edges into the outer 1/3 of the annulus fibrosis.

This is the major reason that injury to the disc causes pain resulting in persistent functional losses. One of the more complex and confusing scenarios in the medical legal world is injury in the presence of pre-existing degenerative changes in the intervertebral disc. If you understand the anatomy of the disc and how this anatomy evolves in the presence of degenerative changes, the resulting bodily injury, if and when present, makes perfect sense. In a paper published in 1997 by Freemont et al., the authors researched the changes in nerve endings that carry pain sensation in degenerated intervertebral discs. The comparison between healthy discs and degenerative discs was VERY interesting. The authors stated, “Therefore, as in previous studies, we measured nerve in-growth in terms of how deep within the annulus fibrosis nerves were seen and whether nerves had penetrated the nucleus pulposus. Deep nerve in-growth was defined as growth into the inner third of the annulus fibrosis, in the nucleus pulposus, or both” (Freemont et al., 1997, p. 179).

The results of this study showed that when degenerative discs at the level of pain were examined, there were a greater number of pain nerves deep into the disc when compared to healthy controls. The authors also discovered that these nerves are not “activated” until there is a pain generating event. That is why a previously asymptomatic degenerative disc can be activated by a single distinct traumatic event. It is absolutely necessary for doctors working with the traumatically injured to understand how traumatic forces contribute to bodily injury, even when there are pre-existing changes in the intervertebral disc.

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Traumatic Brain Injury & Whiplash

In many cases, the head does not have to contact a stationary object to produce Traumatic Brain Injury (TBI). Often times, the shearing forces that occur during whiplash are significant enough to produce separation of nerve endings in the brain. This is also called Axonal Shearing or Diffuse Axonal Injury (DAI) and results in symptoms such as pain, memory loss, seizures and coma. DAI has two components; one is immediate and the second delayed, resulting from nerve damage from chemicals released at the first stage. DAI has no correlation to bleeding of the brain or skull fractures. A recent study published in the Journal of Neurotrauma, stated that victims should be imaged within 2 weeks post trauma, as the damage in the acute phase is most useful for prognostic value. Marquez De La Planta et al. (2007) stated that, “…in DAI CT is usually normal or reveals only small deep (shear) hemorrhages. Magnetic resonance (MR) imaging is recommended in these situations, as MR is significantly more sensitive to axonal shear injuries than CT” (p. 592). When trauma victims are demonstrating symptoms of DAI, it is imperative they receive an accurate diagnosis through MRI of the Brain.

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Undetected Neck Injuries

Occult Ligament Tears are complete tears or ruptures of the ligament (ligaments connect bone to bone). In neck trauma, such as whiplash, the ligaments are severely compromised and often rupture due to overstretching, as a result of the trauma. Often, patients present clinically with severe symptoms, yet are both neurologically and structurally intact. Many times with occult ligament tears, the structure stays in place due to the supportive surrounding tissues and therefore, neurologically, nothing is compressed or damaged. Over time, those supportive tissues will become lax and the joint will first aberrantly position, followed by neurological compromise. Clinical findings demonstrate that ultimately, the joint will prematurely degenerate. According to Robert et al. (2000), negative X-Rays and MRI’s do not exclude cervical injury with significant mechanism of injuries. They conclude that examination under fluoroscopy or digital motion x-ray is an effective tool to diagnose the occult ligament tear. Therefore, it is not responsible to consider that no injuries were sustained in the presence of negative x-rays or MRI’s until all testing has been concluded.

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When Working with Traumatically Induced Clients

When working with traumatically induced clients, it is imperative that the clinical expertise of the doctor is at the highest level possible. This is most important when it comes to understanding the correlation between physical examination and diagnostic imaging. When clinical findings are missed and not properly documented, the result is a convoluted case and can possibly lead to health consequences for the client.

In a very recent article published in the journal Injury, Leucht, Fischer, Muhr, & Ernst (2009) analyzed 562 patients that presented to a level 1 trauma center after an accident. They stated, “The most common cause of accident was a high-energy fall (39%), followed by traffic accidents (26.5%)” (Leucht et al., 2009, p. 166). What they were looking to do was to correlate the findings on physical examination to those on imaging studies.

One important aspect of clinical examination is the testing of neurologic systems to screen for damage. There are simple tests that can give a complex look into the body to ensure the proper tests are ordered. When a trauma victim presents for clinical work up, these tests are performed and are used to help determine a working diagnosis. For years, astute clinicians have argued there are many cases in which clinical examination findings are minimal in the presence of significant underlying injuries.

The authors of this paper showed, “Sixty-three (11.2%) patients exhibited a complete motor and sensory deficit, 76 (13.5%) an incomplete and 423 (75.3%) no neurological deficit” (Leucht et al., 2009, p. 166). The important point in this reference is 75.3%. These trauma patients presented for evaluation and the neurological tests performed on physical examination were NORMAL. However, the patients had sustained spinal fractures.

When working with clinicians in the trauma arena, it is imperative that they understand implications of injury and how to properly use the tools available. Proper diagnosis and prognosis is imperative to establish causality to bodily injury. The absence of findings on portions of the physical examination does not necessarily mean there are no injuries. If you are working with traumatically injured clients, this article is a MUST have for your library.

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Whiplash

Another name for whiplash is cervical acceleration-deceleration injury. In this instance, there is a rear impact and the occupant’s first motion is up. This is called the ramping effect and is due to the spine pushing against the seat, flattening the spinal curve. This upward motion, in many cases, causes the head to rise above safe levels of the head-rest. The neck-head fully extends past its normal limits, tearing ligaments and discs (herniations-see Trauma Series #6.) The head then “whips” forward while the brain is still going backwards, due to the fluid area in the back of the brain, and the brain hits the back of the skull. This can cause bleeding in the brain or hematoma. The neck-head then goes past its normal forward limits, tears ligaments and discs (herniations), then “whips” back once more, with the brain hitting the front of the skull. The damage to the brain is called a “Coup-Contrecoup Injury,” and can cause bleeding in the brain. The whiplash mechanism, which is often taken lightly, usually causes serious pathology, such as herniations, bleeding and tearing of tissue, that are permanent conditions. In many cases, whiplash can be caused from a single vehicle, no damage, accident.

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Whiplash & "Slight" Bumper Damage

We have already established in Trauma Series #15 that bumpers can sustain crash impacts greater than 5 mph and deform, on the average, between 8-12 mph. What is apparent, is in a rear end collision where there is no gross deformity of the bumper, there is usually slight damage in the form of paint chipping or a small dent. This is demonstrative evidence that cars collided and energy was transferred from the striking car to the car in front. Biomechanical engineers have concluded that in rear-end collisions, pent up energy in contracted bumpers and seat backs spring, being released simultaneously, as the driver in the front car reapplies the brakes and causes the occupant to be exposed to more destructive force than the car. This is the cause for whiplash in these “slight” damage crashes. The Insurance Institute for Highway Safety concurred, when Farmer, Wells and Lund researched for them in 1999 and wrote ‘when property damage was slight…neck injuries could occur.’

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Whiplash & Cervical Ligamentous Instability

Medical-legal professionals that care for the traumatically injured are often faced with patients/clients that are injured as a result of a motor vehicle accident. These whiplash presentations are commonly evaluated. However, there is often little discussion as to the exact tissues that are involved in creating the bodily injury. Even less is correlated to persistent functional loss.

A recent study (Stemper, Yoganandan, Pintar, Rao, 2005) took a closer look at the ligaments of the cervical spine after whiplash injury. The authors state, “Present results demonstrated that anterior structures in the lower cervical spine may be susceptible to injury through excess distraction during the retraction phase of whiplash, which likely occurs prior to head restraint contact. Susceptibility of these structures is likely due to non-physiologic loading placed on the cervical spinal column as the head translates posteriorly relative to the thorax” (Stemper, et al., 2005, p. 515). Whiplash injury to anterior spinal structures can result in cervical instability in extension, axial rotation, and lateral bending modes. Diagnostic studies such as MRI, range of motion, digital motion x-rays and/or x-rays can be critical to determining causality, bodily injury and persistent functional loss. In addition, this requires clinical correlation by a doctor expert in caring for the traumatically injured.

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Whiplash & Chronic Headaches

PROOF – Whiplash Causes Chronic Post-Traumatic Headache

2009 - Research conducted at Department of Neurology, University of Duisburg-Essen, Essen, Germany

In a recent study published in Neurology, the authors stated, “Over 50%of patients develop mild to moderate headache after the accident, with 8-15% still complaining about frequent headache after 3 months” (Obermann et al., p. 978). There are many times when a healthy individual is injured as a result of a traumatic event, resulting in chronic pain, including headaches. The authors of this study sought to produce OBJECTIVE evidence of whiplash induced headache.

The authors report, “Mechanisms associated with the development of chronic pain in this patient population are highly debated and range from psychosomatic to unconfirmed diffuse axonal injury (Obermann et al., p. 978). The authors showed objective structural changes (increase) in brain tissue (gray matter) in patients with chronic posttraumatic headache reporting, “Structural changes seem to reflect neuronal adaptation to the development and cessation of chronic pain in affected patients over time” (Obermann et al., p. 982).

Finally, the authors state, “These results suggest that patients’ concerns are real and should be managed accordingly” (Obermann et al., p. 982). It is imperative that clients that are injured as a result of a traumatic event are triaged accordingly and their care is coordinated by a doctor who understands the nuances of these types of injuries. Many people that are injured do not receive the care they deserve, especially when it comes to posttraumatic headache and whiplash.

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Whiplash & Disc Herniation Stats

According to Panjabi et al. (2004):
1. 25% of whiplash victims get herniated discs
2. 20% of whiplash victims have herniated discs with radicular symptoms
3. 39% of whiplash victims have degeneration 5-10 years post trauma
4. 2 times the number of whiplash patients required discectomy and fusion as compared to the control group
5. Whiplash patients require fusion 8 years earlier, on the average, than non-whiplash patients
According to Freeman et al. (2001)
In Acceleration-Deceleration accidents (whiplash), where significant spinal injuries were reported:
1. 72% revealed single or multilevel cervical disc herniations
2. 23% revealed lumbar or thoraco-lumber disc herniations
3. 18% revealed spinal fractures

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Whiplash Causes Instability in the Cervical Spine

Whiplash injuries are caused by shearing forces between the skull, neck and upper back during motor vehicle accidents. They have been associated with both acute and chronic symptoms due to injuries to the intervertebral discs, the soft tissue surrounding the spine and the ligaments that hold the vertebrae together. A recent study by Ivancic et al. (2008) studied the forces distributed through the ligaments holding the joints in the cervical spine together. The results showed whiplash forces are capable of tearing the cervical capsular ligaments, demonstrating a biomechanical basis for prolonged neck pain in whiplash victims. Ligaments have a relatively poor blood supply and wound healing often results in scar tissue formation, Facet Syndrome and clinical instability, accounting for the long-term pain in victims.

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Whiplash Causes Post-Traumatic Stress Disorder (PTSD)

Frequently, when a client presents after a traumatic event, there are signs that they may be reliving the incident. These may include recurrent distressing dreams, anxiety and avoidance of talking about or confronting the event. If these symptoms persist for more than a month and cause clinically significant distress, the trauma victim may be suffering from Post Traumatic Stress Disorder (PTSD). Coronas, Garcia, Viladrich, Santos and Menchon (2008) published a paper examining a sample of trauma survivors who experienced a road traffic accident in 2004 and the subsequent relationship to PTSD. They reported, “It is known that a sizable proportion of motor vehicle collision survivors who seek medical attention (from 5 to 45%) will develop PTSD in the year following the accident, particularly in the first 2 months after the accident” (Coronas et al., 2008, p. 17). In this study, statistics of the PTSD group revealed (1) 76.7% were female, (2) 83.3% had what were considered moderate or minor injuries, (3) 53.3% had a change in employment status after the crash. “Interestingly, no relationship was found between PTSD and previous personal psychiatric morbidity or previous traumatic experiences, a result not consistent with general findings on this subject” (Coronas et al., 2008, p. 21). When evaluating the traumatically injured, long term persistent functional loss is not always due to damage to the musculoskeletal or nervous systems; it can be psychogenic in origin.

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Whiplash Causes Stenosis

Whiplash victims often complain about numbness and tingling in their arms or legs, along with intense burning and shooting pain. A portion have also presented with balance and coordination issues. It has long been discussed that injuries to the spinal nerve roots or the cord itself are involved with these types of symptoms. However, no studies have actually evaluated the mechanism of these injuries.

Panjabi, Maak, Ivancic, MPhil, & Ito (2006) conducted a “biomechanical study of intervertebral foraminal narrowing during simulated automotive rear impacts” (p. E128). This study objectified how nerves are injured and what levels are typically involved. They concluded that “acute ganglia compression may produce a sensitized neural response to repeat compression, leading to chronic radiculopathy following rear impact” (p. E128).

Most importantly, they found that “significant dynamic narrowing…in foraminal width at C5-C6 and foraminal area at C4-C5 occurred, beginning at 3.5g impacts” (p. E133). This simply means that nerves are damaged with considerably less force in rear impacts due to compressive forces of the vertebrae in relation to each other. When evaluating the traumatically injured, a clinician that understands how forces affect spinal biomechanics is paramount.

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Whiplash Causes Working-Disability in 58% of Cases

Clinicians that are working with traumatically injured patients must understand how injuries can relate to working disability and persistent functional losses. In a recent study by Buitenhuis, de Jong, Jan, Jaspers, and Groothoff (2009), the authors state, “Research has shown that up to 40% of neck complaints may become chronic and persist for at least a year” (p. 262).

Medical-legal professionals need to understand the research related to chronic persistent symptoms in injury victims. This current study, published in 2009, focused on work disability after whiplash. The authors reported, “A total of 58.8% of the studied population with neck complaints was work-disabled after the accident” (Buitenhuis et al., 2009, p. 266). The authors of this study also included concentration complaints along with the pain complaint. “In line with previous research, concentration complaints were found to be related to concurrent work disability at 12 months” (Buitenhuis et al., 2009, p. 266).

In working with trauma victims, it is critical that cognitive complaints are included in assessment when appropriate. Omission of these fundamental functional problems leads to much misunderstanding in the medical-legal world.

Lastly the authors reported, “No evidence emerged to indicate that the degree of manual labor (blue or white collar work) or educational level was involved in persistent work disability in postwhiplash syndrome” (Buitenhuis et al., 2009, p. 267). Understanding that it is not just the physical complaints that are causes of disability is a very important aspect of working with trauma victims, especially those with whiplash injuries.

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Whiplash Injures Intervertebral Discs

Much research has targeted facet joints and spinal nerves relative to whiplash injuries. Prior to this study, very little information was produced regarding the exact mechanism of intervertebral disc injury as a result of whiplash trauma. Punjabi et al. (2004) determined that, “Following impact, the lower cervical spine experiences complex loading consisting of an extension moment and posterior shearing and compressive forces” (p. 1217). They hypothesized “that this loading pattern may injure the intervertebral disc” (Punjabi et al., 2004, p. 1217). Clinical studies have also shown that whiplash injuries accelerate degenerative disc disease when compared with age matched controls, most likely due to tearing the annulus fibrosis. In this study, the shearing forces caused by the whiplash trauma were most severe at the C5-6 level, which is the most common level of disc herniation in whiplash trauma.

Punjabi et al. (2004) also state, “The presence of nerve endings in the outer anulus fibrosus makes disc injury a plausible etiology of neck pain...” (p. 1224). This is an important fact to consider, as annular tearing may not necessarily result in an intervertebral disc herniation, but affects the nerves located in the annular fibers of the disc and can cause discogenic, or localized pain in the whiplash victim that can last a lifetime.

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Whiplash Injuries Made Worse By Cervical Stenosis

There are cases when clients present with severe pain following a motor vehicle collision along with pre-existing conditions, such as spinal stenosis. Spinal stenosis is a very important consideration when evaluating the traumatically injured client. In a study presented by Debois, Herz, Berghmans, Hermans, and Herregodts (1999), the authors showed that “A small diameter of the bony cervical spinal canal predisposes to an adverse clinical outcome after whiplash injury” (p. 1999-2000). They went on to discuss, “People with a sagittal diameter and cross sectional area of the bony cervical spinal canal significantly smaller than those of normal healthy individuals seems to be more susceptible to the development of neurologic symptoms in the event of soft cervical disc herniation” (p. 2001). Therefore, when evaluating the traumatically injured client with either acquired or congenital cervical stenosis, it is important to work with professionals that understand how to clinically correlate causality to bodily injury and persistent functional loss in persons with a narrowed spinal canal. This means, a very small problem can be made worse in the presence of a stenotic canal.

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Whiplash Injury is More Than Neck Pain

When representing clients that have been injured as a result of a whiplash type injury, eliciting a proper history is critically important. Looking into every aspect of the patient’s condition and documenting the injuries properly is often overlooked or incomplete. Hincapié, Cassidy, Côté, Carroll and Guzmán (2010) conducted a population based study of the location of pain after a traffic injury. They stated, “Pain after traffic injury is most commonly reported in multiple body areas; isolated neck pain is extremely rare” (Hincapié et al., 2010, p. 434).

As the time from injury progresses, there are many injuries that get overlooked in favor of the more obvious. This fact was highlighted with the authors stating, “Only 0.4% of respondents reported posterior neck pain only” (Hincapié et al., 2010, p. 434). This concept has been visualized by astute clinicians that understand the mechanisms of injury in trauma patients. However, there have not been any studies prior to this one that investigated such occurrences. The authors go on to state, “Our results suggest that conceptualizing pain after traffic injury as primarily neck pain may be misdirected” (Hincapié et al., 2010, p. 437).

When injury victims are being evaluated, it is important that the examining doctor be aware of this very important research. Staying up to date with newly published research related to trauma is an important aspect to properly caring for these clients. Having a detailed conversation and properly documenting injury sites should be norm and not the exception.

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Whiplash Most Common Injury

In a recent paper published by Yadla, Ratliff, & Harrop, (2008), the authors state, “Whiplash is the most common injury associated with motor vehicle accidents, affecting up to 83% of patients involved in collisions, and is a common cause of chronic disability” (p. 65). When evaluating the client that is injured as a result of a motor vehicle accident, the authors state, “The diagnosis of whiplash remains clinical” (Yadla et al., p. 66). They go on to state that injury is most often not identified radiographically in the acute phase” (Yadla et al., p. 66). This simply means that working with qualified clinicians that understand the nuances of clinical symptoms associated with whiplash disorder is imperative. Since whiplash is the most common injury associated with motor vehicle accidents, correlating bodily injury to causality and persistent functional loss requires accurate and in-depth clinical workup and reporting.

 

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Whiplash, Brain Injury and Concussion

Some structures that have the potential of being injured during a motor vehicle collision require specialized testing. Injury to the brain as a result of whiplash can have long term consequences, such as headaches, memory impairment, sleep disturbances, anxiety, etc. Therefore, it is important to recognize on clinical examination. The fact that persistent symptoms have been shown to exist in some victims, requires special attention during clinical examination.

A recent study by Zumsteg, Wennberg, Gütling, & Hess (2006) compared neurological testing of whiplash and concussion syndrome. The results revealed a similar underlying mechanism of rotational brain injury evidenced by altered processing of the middle-latency Somatosensory Evoked Potentials (SEP). Specialized neurological testing in the presence of specific clinical findings using SEP can provide a sensitive measure of cortical function. When victims present with symptoms of brain trauma following whiplash injury, documenting causality along with persistent functional loss using SEP, is an important aspect of caring for the traumatically injured.

 

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CONDITIONING FACTS & REFERENCES

There are pressures today in the insurance industry, particularly in workers’ compensation, to include a system of accountability for the results of the rehabilitation/conditioning program. Peer review is being instituted to evaluate the appropriateness of the use of different methods of rehabilitation ranging from specific modalities to rest and exercise. Demand is high for a series of specific protocols that will define the most effective pathway for the rehabilitation of specific injuries. (Reference: Kibler, Ben, MD Functional Rehabilitation of Sports & Musculoskeletal Injuries 1998)

A large body of literature exists that shows the advantage of aggressive rehabilitation of injuries around the knee, the ankle, the elbow, the shoulder, and the back. In fact, the earlier the rehab, the better the outcome. (Reference: Zarins, B. Soft Tissue Injury & Repair – Biomechanical Aspects Int’l Sports Medicine, 1998)

The benefits of early rehab include:
• earlier restoration of range of motion
• decreased pain
• decreased neural inhibition
• quicker return of muscle function
• more appropriate return of muscle function
• earlier return to performance with decreased injury risk

An injury is viewed as a disability. The injury, whether traumatic (macro-trauma) or chronic and repetitive in nature (micro-trauma), will have the same outcome: strength imbalance and biomechanical changes. (Reference: Trial Magazine, 2000 National Inst. of Occupational Safety & World Health Organization Bureau of Labor Statistics)

Rehabilitation always begins with resolving the clinical symptoms. The absence of symptoms does NOT mean the person has normal function. An injury demands more than relief of symptoms. For proper rehabilitation it is the necessity to restore function. In order to do this the clinician must understand proper rehabilitation:
Muscle can diminish or decrease by 17% within the first 72 hours post-injury
• Losses of muscle strength can be as much as 40% in the 6 weeks
following the injury depending on the amount of immobilization of the injured joint.
• Immobilization or lack of use of an injured joint can cause significant biomechanical alterations and the joint capsule, subchondral bone, bone-ligament complex, and cartilage are markedly affected within 6 to 8 weeks post-injury
In addition to the local effects of the injury, general fitness can be affected as well. Cardiovascular fitness can be decreased very rapidly with inactivity due to injury. Maximum volume decreases by up to 25% after 3 weeks of inactivity due to injury.

A proper rehab and work conditioning program should specifically address restoration of strength, power, flexibility, balance, and proprioception for both local and general deficits that will assure optimal treatment and restoration. The earlier the rehabilitation program begins the better the results.

The principles of early motion following an injury are as follows:
(Reference: Frank et al Am J Sports Medicine 11:379-389, 1983)
Muscle atrophy begins within 6 hours post-injury
• Soft tissue such a muscle if injured will atrophy by about 1.5% each day

• The healing process of ligament and soft tissue such as muscle in general has show that a fibrous (scar tissue) repair occurs first, NOT the regeneration of the damaged tissue
• This fibrous repair process begins between the 5th and 21st day after the injury and during the next 3 weeks thereafter
• Adhesions then form a “contracted” collagen tissue that develops over a 3- to 14-week period
• There are changes in nerve impulses and an alteration of normal motor patterns within the injured joint, as well as the entire kinetic chain
• Muscle imbalance then begins

The cornerstone of therapeutic rehabilitation is Davis’ Law, which states the following concept: “Soft tissue will model according to imposed demand. Collagen fibers in muscle and ligaments will adapt to mechanical demands of exercise and movement. Movement in the form of rehabilitative exercise is responsible for the orderly arrangement of muscle fibers. This results in a small, flexible scar at the injury site to facilitate recovery.”

In each phase of rehabilitation of a musculoskeletal injury are introduced forms of exercise therapy appropriate for the phase of care. Each phase of care, (acute, sub-acute and chronic), demand this type of rehabilitation process. Work conditioning in each phase of care is essential for the work related injury. Work Conditioning is defined as a “work-related intensive, goal oriented treatment program specifically designed to restore the individual’s systemic, neuromusculoskeletal, (i.e., strength, endurance, movement, flexibility, and motor control), and cardio-pulmonary functions.” The clinician must offer work conditioning protocols specific to the injury and appropriate to the stage of healing.

This information represents a model of explanation and justification precisely appropriate to the type of evidence-based treatment planning and protocols advocated by the ACOEM Guidelines. Furthermore, it provides a model for the overriding emphasis placed on the provider by the Guidelines: To restore function, prevent or reduce the chances of further injury or re-injury, and to return the injured worker back to work. Also, do not forget that one of the overriding principles and goals of the AMA Guide to the Evaluation of Permanent Impairment (5th Ed.) is functional restoration of the injured worker. In the majority of cases, whether the insurance carrier agrees or not, that means conditioning.

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