EPIDEMIOLOGY OF WHIPLASH ASSOCIATED DISORDERS

EPIDEMIOLOGY OF WHIPLASH ASSOCIATED DISORDERS

The term whiplash injury has been used since the late 1920s, when H.E. Crowe coined the term at a medical meeting in San Francisco. It was originally described as an injury mechanism to the neck, but was later also used to define the actual symptoms after such an event. The first known case report was published in the Journal of the American Medical Association in 1953, when Gay and Abbot described 50 patients who had been exposed to whiplash mechanism in car collisions. It was reported that the majority had been exposed to rear-end collisions and that the majority were also examined between one and 24 months after the collision, thus representing a mix of patients with acute or persistent symptoms. Cervical pain with radiation into the occipital region of the skull, shoulder girdle or upper extremities were reported as common symptoms, but irritability, poor concentration and subjective vertigo were also described.

People who are exposed to energy transfer to the neck, in sports, falls or other mishaps, may also experience cervical pain. After such events, however, it is less common that the injury is labeled “whiplash”, but instead other terms, such as neck strain, neck sprain or simply neck injury, are used. The term whiplash associateddisorder (WAD) was introduced in 1995 by the Quebec Task Force (QTF), who published the first systematic review on whiplash injuries. The term was intended to reflect that whiplash is an injury mechanism, and the consequences of the mechanism were the spectrum of symptoms (disorders). The QTF formulated the following conceptual definition:

               Whiplash is an acceleration-deceleration mechanism of energy transfer to the neck. It may result from rear-end or side-impact motor vehicle collisions, but can also occur during diving or other mishaps. The impact may result in bony or soft-tissue injuries (whiplash injury) which in turn may lead to a variety of clinical manifestations (whiplash-associated disorders).

The reason for excluding frontal collisions from the definition is not discussed in the report and is likely to be an error, since it is known that 25-30% of whiplash injury occurs in such impact direction.

The QTF also suggested a classification of WAD into five categories based on clinical signs and symptoms. This classification is mostly used to classify WAD in the acute phase.

Since the publication of the QTF findings, the term WAD has been increasingly used in the medical literature, and it is also a frequently used term in insurance medicine.

CLASSIFICATION OF SOFT TISSUE INJURY

CLASSIFICATION OF SOFT TISSUE INJURY

Ligament Trauma

Ligament injury is classically divided into first (mild), second (moderate), and third (severe) degree tears. In a few locations, e.g., the acromioclavicular joint, there is further classification of the degree of displacement and the amount of associated muscle trauma, but these joints are the exception.

First degree injuries entail microscopic stretching or minimal tearing of a few fibers of a ligament. It is a painful injury, but there is little loss of structural integrity. The treatment progress is guided mainly by the athlete’s pain, with anticipated return to full physical activity within 10 days to 2 weeks. Indeed, controlled training may be carried out even before this point. Early protection of the joint with taping or orthoses may be desirable, and frequently little or no interruption of training is necessary.

It is the second degree injury, with moderate tearing of the ligament’s collagenous fibers and some loss of structural integrity, that usually presents the most difficulty for accurate classification. In part it is because the second degree category encompasses a broad spectrum of injury. At the one extreme there is an injury similar to a first degree sprain and at the other a badly torn ligament that is bordering on complete disruption. Underestimating this second degree injury and thus allowing premature resumption of activity may lead to re-injury or possibly conversion to a third-degree situation. Conversely, overestimation of the severity gives rise to unnecessary loss of time from training. These clinical decisions are always difficult, and there is no substitution for the physician’s experience.

In general, second degree tears require 2 to 3 weeks of modified rest and rehabilitation, followed by 2 to 3 weeks of controlled introduction of increasing stress before full training is resumed. It may be as long as 2 to 3 months before full training and competition are allowed, depending on the joint involved, the magnitude of the disruption, and the requirements and stresses of the sport. The more severe second degree tears, along with the third degree injuries, may have a tendency for the healed ligaments to stretch out with time, leading to increasing functional instability, despite excellent rehabilitation and satisfactory early stability.

A third degree injury signifies complete tearing of the ligament with loss of structural integrity. In many situations, it requires complete or modified immobilization of the involved joint for a period of 3 to 6 weeks and frequently surgical intervention. Failure to treat these third degree disruptions adequately lead to recurrent instability and possibly degenerative changes of the involved joint. This long-term implication of degenerative articular surface pathology in inadequately treated or incompletely healed major weight-bearing joints cannot be overemphasized.

It has already been stressed that each structure has an anticipated healing time, and that one cannot accelerate the normal recuperative abilities of the tissues. Therefore, therapy is aimed at optimizing healing conditions. With extra articular collagenous structures, ligamentous strength after tearing is in the region of 60 to 70 percent of normal after 6 weeks of healing. More specifically, there is often a revascularization phase during healing that is usually accompanied by a dramatic reduction of tensile strength. Because this phase usually coincides with the period during which most external supports have been removed, it is mandatory that the physician be aware of the dangers of unduly stretching healing structures at this point. It requires considerable knowledge and skill to balance exercise progression with protection of the vulnerable tissue. It may take up to 3 months before 80 percent of the original strength is acquired. Intra-articular ligaments usually gain tensile strength more slowly. Healing times for intra-articular collagen are such that it may take up to 3 months to achieve 50 percent of the normal strength and 6 months before a functional strength of 70 percent is reached. The reintroduction of stress to the unprotected joints must be planned with these figures in mind. Furthermore, although little is known of the effects of ligament tears on the neural protective mechanism of joints, it is likely that after significant tears there is a distorted or decreased biofeedback. Particularly for the major weight bearing joints, such as the knee and ankle, some specific exercises are needed to either retrain or compensate for this potential loss of sensory information. 

Definitions of Pain

Pain is a universal human experience and the most common reason people seek medical care. In many cases, pain tells us something is wrong, that tissue in our body has been damaged, and we need to do something to change the situation.

Pain – Some definitions you should know:

Algesia: Your sensitivity to pain.

Analgesia: Absence of pain in response to stimulation which would normally be painful.

Hypoalgesia: Diminished pain in response to a normally painful stimulus.

Hyperalgesia: Increased response to a stimulus which is normally painful.

Allodynia: Pain due to a stimulus which does not normally provoke pain.

Pain Threshold: The least experience of pain which a subject can recognize.

Pain Tolerance Level: The greatest level of pain which a subject is prepared to tolerate. 

Shoulder Pain

SHOULDER PAIN 

Shoulder pain is an extremely common complaint, and there are many common causes of this problem. It is important to make an accurate diagnosis of the cause of your symptoms so that appropriate treatment can be directed at the cause. If you are unsure of the cause of your shoulder pain, or if you do not know the specific treatment recommendations for your condition, you should seek medical attention. Treatment of these conditions must be directed at the specific cause of your problem.

You should see a doctor if you experience the following:

1. Inability to carry objects or use the arm

2. Injury that causes deformity of the joint

3. Shoulder pain that occurs at night or while resting

4. Shoulder pain that persists beyond a few days

5. Inability to raise the arm

6. Swelling or significant bruising around the joint or arm

7. Signs of an infection, including fever, redness, warmth

8. Any other unusual symptoms

MRI

MRI

MRI stands for Magnetic Resonance Imaging and it is a test that uses a magnetic field and pulses of radio wave energy to make pictures of organs and structures inside the body.

There are several types of MRIs. There are head MRIs, chest MRIs, blood vessel MRIs, abdomen and pelvis MRIs, bones and joints MRIs, and Spine MRIs.

Bone and joint MRIs check for problems such as arthritis, bone marrow problems, bone tumors, cartilage problems, torn ligaments, torn tendons, or infections. It can also check for broken bones.

Spine MRIs check the discs and nerves of the spine for conditions such as spinal stenosis, disc bulges, and spinal tumors.

Shoulder Pain and Chiropractic

Shoulder Pain and Chiropractic

The shoulder is the most mobile joint in the human body. The joint includes four tendons that hold muscle to bone. Together, these four "rotator cuff" tendons stabilize the upper arm bone to the shoulder socket and allow a wide range of motion in the shoulder.

Shoulder pain is an extremely common complaint, and there are many common causes of this problem. It is important to make an accurate diagnosis of the cause of your symptoms so that appropriate treatment can be directed at the cause. If you are unsure of the cause of your shoulder pain, or if you do not know the specific treatment recommendations for your condition, you should seek medical attention. Treatment of these conditions must be directed at the specific cause of your problem.

Types of shoulder pains are bursitis, rotator cuff tendonitis, arthritis, rotator cuff tear, frozen shoulder, calcific tendonitis, labral tear, shoulder instability, shoulder dislocation, shoulder separation, SLAP lesion, and biceps tendon rupture.

The treatment of shoulder pain depends entirely on the cause of the problem. Therefore, it is of utmost importance that you understand the cause of your symptoms before embarking on a treatment program. If you are unsure of your diagnosis, or the severity of your condition, you should seek medical advice before beginning any treatment. 

Your chiropractor may recommend other types of treatment for relieving your shoulder pain. These may include moist heat, ice packs, massage, traction, or stretching and strengthening exercises. Your chiropractor can discuss these with you.

Apportionment

5. Apportionment

Once causation is determined and there is probable cause related to the event, then apportionment is evaluated. If there is no causal relationship then apportionment is not necessary.

American Medical Association: Guides to the Evaluation of Permanent Impairment, fifth edition. Chicago, AMA 2001

The extent to which each of 2 or more probable causes are found responsible for an effect (injury, disease, impairment, etc..)

American Medical Association: Disability Evaluation, second edition. Chicago, AMA 2003.

A distribution of causation among multiple factors that caused or significantly contributed to the injury and resulting impairment.

American Medical Association: Guides to the Evaluation of Permanent Impairment, sixth edition. Chicago, AMA, 2008

Precipitation - Injury or exposure causes a “latent” or potential disease process to become manifested.

Acceleration - Injury or exposure hastens the clinical appearance of an underlying disease process.

Aggravation - A permanent worsening of a prior condition by a particular event or exposure.

Exacerbation - A temporary worsening of a prior condition by an exposure / injury.

Recurrence - Signs and symptoms attributable to a prior illness or injury occur in the absence of a new provocative event.

American Medical Association: Disability Evaluation, second edition. Chicago, AMA 2003, page 99 -100.

The phrase "pre-existing condition" often causes confusion.

There are only two types of pre-existing conditions. The first is known as an "inactive" or "dormant" pre-existing condition. The second is known as an "active" or "symptomatic" pre-existing condition.

The difference between an active vs. inactive pre-existing conditions is "like night and day."

This may require a detailed review of past and present medical records.

Inactive pre-existing condition is if there is no evidence that a pre-existing condition is causing pain or disability before trauma is sustained.

The "proximate cause" of the present symptoms is the recent trauma, even though the symptoms may be worse or healing may take longer because of a pre-existing condition.

Besides classifying the apportionment it may also be necessary and beneficial to relate the percentage that the present condition or impairment is attributable to the new injury or event. To do this there must be:

1.   Documentation of a prior factor.
2.   Current impairment is greater than the prior factor (prior impairment, prior injury or illness).
3.   There is evidence that the prior factor caused or contributed to the impairment, based on      reasonable probability.

Chiropractic & Lifting Atlanta Georgia

Lifting doesn't have to be a dangerous proposition, even when it's done regularly at work or at home. As long as you know the facts about correct lifting and bending techniques, you can protect your back from unnecessary added stress and possible injury.

Everyone puts a lot of stress on their backs every day from the process of bending and lifting, even those people who don't have a job that requires frequent heavy lifting. Think of how many times a day you bend down to pick something up: laundry, your pet, a piece of paper, etc. Continued bad form when lifting, even something small, can cause unneeded stress on your back and make it more prone to injury.

There are two common mistakes made in lifting. The first is using the wrong muscles, the back muscles, instead of the leg and buttock muscles. You should always bend your knees when lifting heavy objects so you have a solid foundation for your spine. You should keep your trunk vertical when bending down and lifting something. A horizontal trunk can put pressure on the lower back amounting to hundreds of extra pounds. This pressure can eventually compromise a disc or sprain or strain a back muscle.

Lifting Techniques
The second common error is lifting an object too far from the body. Get close to what you are lifting. It decreases the pressure on your spine. Try to start with the center of the weight no more than 8 inches from your body, then lift the object with a straight back using your leg and buttock muscles. These are simple principles that will help you minimize injury to your back when lifting.

Just to illustrate, if you lift a 10-pound weight at arms length, it will put 150 pounds of pressure on your back. Lifting an object that weighs 86 pounds puts over 700 pounds of force on the discs in the lower back. An object that weighs over 86 pounds should not be lifted more than a distance of 12 to 13 inches and should not be lifted more than once every five minutes if possible. The heavier the object, the shorter distance it should be lifted. If the object must be lifted higher, assistance or a machine should be utilized. In the case of mandatory occupational lifting, positions or loading platforms should be adjustable to the height of different people. Try not to reach when lifting items higher than chest level. Lifting objects higher than chest level puts considerably more stress on your lower back. When lifting items above your head, make sure to use a stool or a ladder.

Another important guideline to follow is to limit twisting when lifting. This adds more force to your back. If you must turn when lifting, pivot your feet instead of twisting your back. In addition, always be sure of your footing. A sudden change in footing or a trip can cause enormous amounts of added stress on the back.

Another problem with lifting is fatigue. The more you bend and lift, the more fatigued your muscles become. When muscles are fatigued they are more prone to injury. Frequent breaks when lifting are preferable to help rejuvenate strength.

Always use both hands when lifting and lift slowly and deliberately. The ideal situation is to have someone or something to help you when lifting, but if that's not possible, follow all the above listed guidelines to minimize your risk of injury.

Following is a review list of dos and don'ts when bending and lifting:

Don'ts

* Don't lift things when your feet are too close together. If your feet are closer than shoulder width you'll have poor leverage, you'll be unstable, and you'll have a tendency to round your back.
* Don't lift with your knees and hips straight and your lower back rounded. This is the most common and stressful bad lifting move. Twisting the trunk during this bad move compounds the problem.
* Don't tense and arch the neck when lifting. This crams your neck joints together and causes pain especially if maintained for a long period of time.
* Don't lift and/or carry an unbalanced load.
* Don't lift and bend too much in a short period of time.
* Don't lift objects that are too heavy for you.
* Don't lift heavy objects directly following a sustained period of sitting, especially if you have been slouching.
* Don't lift things overhead with your neck and back arched, if possible.

Dos

* Do place your feet and knees at least shoulder width apart or front to back in a wide-step position. This will help you bend at the hips, keeping your back relatively straight and stress free.
* Do lean over or squat with the chest and buttocks sticking out. If you do this correctly, your back will be flat and your neck will balance in a relaxed neutral position.
* Do take weight off one or both arms if possible. When you squat down or push back up, use your hand or elbow as support on your thigh or any available structure. This takes some of the compression and strain off of the lower back.
* Do balance your load on either side if possible, or switch sides so that both sides are equally stressed.
* Do level the pelvis or tuck in your buttocks and suck in your abdomen, when reaching or lifting overhead. Keep your chest up and use a step stool to keep the low back and neck in neutral alignment.
* Do walk around and use backward-bending and/or stomach-lying positions before or after bending or heavy lifting, especially if you've been sitting for a while.

The materials on this Web site are for your general educational information only. Information you read on this Web site cannot replace the relationship that you have with your health care professional. We do not practice medicine or provide medical services or advice as a part of this Web site. You should always talk to your health care professional for diagnosis and treatment.