“Whiplash Injuries, The Cervical Acceleration/Deceleration Syndrome, third edition”

They say that the term whiplash has evolved now into a vague, non-descriptive diagnosis of the problem described by patients about their major symptoms of neck pain after motion trauma. 

Croft says that there have been calls for the diagnosis name to be updated to be more descriptive and injury relevant, such as acceleration/deceleration trauma or hyperextension/hyperflexion trauma.  However, the latter diagnosis would hint that the injury was caused by an initial hyperextension, followed by hyperflexion of the neck but, if the injuries occurred in reverse, the diagnosis may need to reflect the reverse and become hyperflexion/hyperextension.

Additionally, in high acceleration, the sudden head and neck rotation backwards may cause significant hard (bone and cartilidge) and soft (tendon, ligament and muscle) tissue damage, as seen in cervical ‘whiplash’, which is unique to this type of injury.  So, hyperextension and/or hyperflexion of the neck is not pre-requisite to such an injury and, as many patients cannot accurately remember the exact direction of force after an accident, this terminology would be obsolete.

Interestingly, there has been some research done that suggests, and I think with ‘authority’, that the main mechanism of injury is not the flexion and extension bit but the lateral translation.  Bearing in mind that 40 mph is the same as 58.6 feet per second and, if you are hit from behind, your body, pushed by your seat, will accelerate to over 50 feet per second in less than a second.  At the same time your head remains relatively stationary.  So, there is a huge difference in speed between these two parts of your body, the main body mass travelling at about 50 feet per second and the head at about 0 feet per second.  The damage this will cause is pretty significant and stretches and snaps ligaments and tendons, crushes soft tissue and can fracture bones. 

 The term has become most associated with rear-impact collision but it has also been used by various practitioners for any generally harmful motion or impact to the cervical spine, unrelated to the direction of force or size of force.

Croft calls for the use of the more descriptive diagnostic term “cervical acceleration/deceleration injury”. The term does not give an estimation of direction of the force and, if the accident was a frontal impact, the term could be reduced to cervical deceleration injury but a side on impact injury would be expanded to lateral cervical acceleration/deceleration or lateral CAD injury.

This is what their web site looks like:

We already offer a discount to service personnel but I think this has formalised the arrangement for us a bit further and we hope we can add something to support this lot who have given in many cases more than we can imagine.

We are looking forward to seeing how the campaign develops, I suspect it’ll be a popular one.

There is a fair old pile of misconception out there about what happens in whiplash and even the term is misleading with it now described far more accurately as cervical acceleration/deceleration, or CAD injuries.

The best study about the correct treatment for CAD injuries was put together by a study group called ‘The Quebec Taskforce’ who produced a report called Redefining Whiplash and its Management. One of the first things you’ll notice in the report is that they acknowledge that there’s a lack of evidence about what goes on in a whiplash and they were critical of the traditional treatment approaches. They set out a new approach to management of patients with whiplash induced cervical spine soft-tissue injuries and neck pain. These are:

1. Avoid rest, passive treatments and the use of a soft collar support – these approaches prolong pain and disability and lead to chronic or long-term problems.

2. Patients should keep as active as possible. Treatments that promote activity – such as manual treatments (joint manipulation and mobilization, soft-tissue techniques) and exercises should be used in combination with time-limited use of mild NSAIDs and or analgesics.

3. Avoid unproven therapies, including acupuncture, spray and stretch, transcutaneous electrical stimulation, ultrasound, laser, shortwave diathermy, heat, ice, massage, epidural or intrathecal injections, corticosteroid injections of the facet joints, muscle relaxants and psychosocial interventions.

Spritzer WO, Skovoron ML et al (1995) Scientific Monograph of the Quebec Task Force on Whiplash- associated Disorders: Redefining Whiplash and its Management, Spine 20:88.

And there was this approach to caring for whiplash which appeared in two leading multidisciplinary text books:

Rehabilitation of the Spine: a Practitioner’s Manual by Craig Liebenson and Conservative Management of Cervical Spine Disorders by Donald Murphy.

Liebenson, who is no slouch, says that there must be:

‘an integration of rehabilitation and manipulative therapy’ which involves ‘a comprehensive analysis of the locomotor system’ to understand the true causes of the problem and then a ‘specific prescription of manipulation and rehabilitation’.

But what’s going wrong?

Well, 90% of patients with chronic pain following whiplash have limited cervical ranges of motion and in about 60% of these the pain arises directly from facet dysfunction.

- Lord SM, Barnsley L et al. (1996) Chronic Cervical Zygapophysial Joint Pain after Whiplash. A Placebo-Controlled Prevalence Study, Spine 21(15):1737-1745.

Interestingly, this lot add that the diagnosis ‘cervical facet pain’, unrecognized by most family physicians/GPs is ‘extraordinarily common’ and ‘cannot be ignored any longer’.

The Quebec Taskforce thrashed through whiplash and they came up with a classification for whiplash that is still recognised as the best way to classify the condition. It is called the WAD (whiplash-associated disorders) grading system (a.k.a. Quebec Grading System) is now de rigueur in the scientific community. Though it has to be said that it looks scarily similar to an earlier bit of work (1993) which produced the Gargan and Bannister grading system in which grade A was an absence of symptoms; grade B symptoms were described as a “nuisance”; grade C symptoms were “intrusive”; and grade D symptoms were classified as “disabling”. Here it is:

Grade Clinical presentation

0 No complaint or physical sign

1 Neck complain of pain stiffness or tenderness No physical sign

2 Neck complaint and musculoskeletal signs (range of motion loss or tenderness)

3 Neck complaint and neurological signs

4 Neck complaint and fracture or dislocation

Scarily, up to 71% of patients who have chronic pain following whiplash have undetected vertebral end plate fractures at the spinal levels associated with the pain that were overlooked on standard medical imaging.

- Michael Freedman Dec 2001.

And Uhrenholt, Grunnet-Nilsson et al. carried out a systematic review of the literature on cervical injuries following traffic accidents leading to fatalities and found that 93.5% of minor lesions were missed by conventional radiographic examination, MRI and CT scanning.

- Uhrenholt, Grunnet-Nilsson et al. (2002) Cervical Spine Lesions after Road Traffic Accidents: A systematic Review: Spine 27(17):1934-1941

“Models Direct have put together our top ten tips on beating back pain.
Approximately nine out of ten adults suffer with back pain at some point in their lives, so its important to take care of your back. Models Direct have put together our top ten tips on beating back pain.

1.Don’t be a martyr: If you experience a sudden back pain, stop whatever you’re doing and look after yourself. Do not feel obliged to continue working – even if you are helping someone out.

2.Other symptoms: If you experience any of the following symptoms alongside your back pain, seek immediate medical attention; fever: progressive leg weakness and/or loss of bowel or bladder control, severe stomach pain, neurological impairment.

3.Don’t panic: When back pain comes on, and if it does not include any of the additional symptoms mentioned above, try resting and taking painkillers before rushing to casualty. The chances are that it will rectify itself if you take it easy for a day or so. If you feel that there is no improvement after 24 hours, arrange to see your doctor.

4.Be careful when lifting or carrying. When lifting always bend with your knees rather than your spine. When carrying hold the object as close to your body as you can, and ask for help if it is too heavy!

5.Posture: Think about your posture. When using a computer, try to keep your back straight rather than hunching.

6.Exercise: Work on core strength in order to maintain a healthy back and try exercises like yoga for flexibility.

7.Cold and hot packs: Cold packs can be as helpful as hot packs, give both a try and see what works best for you. A warm bath can also be soothing.

8.Mattress: Opt for a firm mattress or add a mattress topper if you feel this could be the reason behind your back problem.

9.Car seat: Spend time positioning your car seat properly. This can be a forgotten cause of back pain.

10.Alternative therapies: If you find that conventional therapies are not working it may be worth giving alternatives a try. Some back pain sufferers find that acupuncture or homeopathy based around treating inflammation can help.

www.modelsdirect.com

And they do have a point.

Dwight Freeney’s ankle injury was a major story in the run-up to the Superbowl. The Colts kept their cards close to the chest on the whole matter though some details have leaked as to what they did to treat the issue.

They are very active with their treatments and Freeney is using some methods that have helped him in the past. The main one is Dr. Leon Mellman, Freeney’s Chiropractor, who was making sure not only his ankle is getting the proper care, but is also monitoring how his newly guarded walk is effecting the rest of his body. Most notably how his lower back could be adversely affected due to his newly acquired limp.

Freeney’s injury was being treated as any other low ankle sprain would be in the NFL with some minor tweaks. Although he was seen in a supporting boot very recently, he spoke openly about keeping the motion in the ankle joint to promote healing. This became common place in joint surgeries; where immediately following the surgery, the joint are put into passive motion to prevent adhesion build-up and promote a quicker recovery. Freeney was spotted walking the beach without his boot on, most likely advised by team doctors for the same reason: a quicker recovery.

F8.

In our view, the constellation of the evidence of:
1. the effectiveness and cost-effectiveness of chiropractic management of low-back pain.

2. the untested, questionable or harmful nature of many current medical therapies .

3. the economic efficiency of chiropractic care for low-back pain compared with medical care.

4. the safety of chiropractic care.

5. the higher satisfaction levels expressed by patients of chiropractors, together

offers an overwhelming case in favor of much greater use of chiropractic services in the management of low-back pain.

And isn’t this really what it is all about – are patients satisfied with the treatment we offer – the answer is an overwhelming yes.

We have loads of patients asking about the right number and size of pillow to use, and rightly so.  If you spend 8 hours every day with your head at a strange angle then you’re going to know about it – how many of you have woken up with a ‘cricked neck’ as a result of this? 

Now, your neck can bend forward and backwards further that it can bend side to side and it is this side bending that compresses the delicate joints at the back of the neck and can cause them to really hurt.  So, the key thing is to make sure that your spine is not bent sideways when you are sleeping.  To prevent this you need to adequately fill the gap between the side of your head and the mattress.  The best way to work this out how large a pillow you’ll need is to lean against a wall with your shoulder rolled forward, as you do whilst sleeping in your bed, and feel how large the gap between your head and the wall you need to fill – usually about a hand’s width.  Or, better yet, get someone else to check whilst you are lying in bed.

So, the answer is we don’t know how many pillows you should have as it all depends on you but we know how to find that number out.

Finally, if you are a front sleeper you are in a world of hurt.  If you get a decent pillow then front sleeping does become difficult and you may break the habit – give it a go and good luck.

http://www.news-medical.net/news/20091021/Addition-of-chiropractic-care-increases-value-for-dollar-in-US-employer-sponsored-health-benefit-plans.aspx

The study is a complex one comparing care and the cost of care but the conclusions are spot on:

The results of the researchers’ analysis are as follows:

•Effectiveness: Chiropractic care is more effective than other modalities for treating low back and neck pain.

and:

Gerard Clum, DC, spokesperson for the Foundation for Chiropractic Progress and president of Life Chiropractic College West, says, “While some studies reflect cost efficiencies and others clinical efficiencies, these findings strongly support both for chiropractic care of neck pain and low back pain.”

I think it sets another stone in the path if you know what I mean.

Leg length inequality is common, with a staggering 90% of us having some inequality and 23% of the general population having a discrepancy of 1 cm or more – which is a fair discrepancy. Treatment aims for LLI must include obtaining leg length equality, producing a level pelvis, and improving function.

Guidelines set out by James J. McCarthy, MD, and G. Dean MacEwen, MD for treatment of leg length inequality are: <2 cm — no treatment or a lift in the shoe; 2 to 6 cm — an epiphysiodesis or shortening procedure is considered; 6 to 15 cm — a lengthening procedure is considered. A leg length inequality of 15 to 20 cm — may require a staged lengthening, lengthening combined with epiphysiodesis, or amputation. Numerous complications of limb lengthening procedures occur frequently, even in experienced hands.

Management of Leg Length Inequality
from Journal of the Southern Orthopaedic Association
James J. McCarthy, MD, and G. Dean MacEwen, MD

Now, few and far between, are those who have a LLI of 2 – 6 cm and rare as hen’s teeth are those who have greater but the less than 2 cm are pretty common.

What causes LLI – well it is is uncommon for your limbs just to grow to different lenghts so an anatomical LLI is usually something to do with trauma – breaking a leg or ankle being the most likely cause. If this hasn’t happened that we’d look at the arch of the foot and see if they are symetrical as a collapsed arch can lower a hip height. However, the most common cause of LLI we have seen at the clinic is caused by pelvic rotation at the sacroiliac joint. This is usually treatable depending just on how much movement you can back into the joint and they have a tendency to resolve well if they can be moved.

I’d resist a heel lift as they are a real pain, since they have to be moved between shoes and, on philisophical grounds, as they treat a sign and not a cause in many cases.