North Dallas Chiropractic Blog – All Injury Rehab

Dynamic Chiropractic – January 15, 2010, Vol. 28, Issue 02

Study Confirms Flaws in Standard MVC Defense Strategy
By Arthur Croft, DC, MS, MPH, FACO

The seemingly complex, or perhaps even inscrutable, calculus of what practitioners term personal injury is, in truth, deceptively simple. However, while it keeps getting simpler, many practitioners and lawyers feel hopelessly wrapped around the axle of this puzzling system. The net result is abandonment of needful patients and clients, with a corresponding loss of revenue stream. Consider just a few facts. Motor vehicle collisions are a leading cause of injury in the U.S. and constitute one of our most burdensome public health dilemmas. With 3 million such injuries each year, a total recovery proportion of only about 50 percent, a permanent disability proportion of 10-12 percent, coupled with the fact that many of the injured are young and have many quality life years to lose, the $43 billion annual price tag is hardly surprising.1

Auto insurers make every reasonable effort to insulate themselves from their liability. Some would argue that they engage in efforts most of us would consider unreasonable, if not downright unsavory or unethical. Regardless of your personal judgment, most would agree that over the past two decades, the insurers’ concerted and very expensive campaign to limit claims has been fairly successful.

With Allstate taking the vanguard position with their now-famous three Ds – delay, deny, and defend – most major auto insurers have since instituted similar policies, and the plaintiff persona-injury bar has more often withered than weathered. With a loss of potential legal representation, plaintiffs have had fewer alternatives for compensation. This often has meant that needed health care resources are simply not available to them, which contributes further to the doleful outcome statistics mentioned above. Since inaugurating its get-tough policy in the mid-1990s, which was described by its consulting firm as a transition “from good hands to boxing gloves,” Allstate has reportedly posted surprising high profits.2 Other insurers have not failed to notice.

The Standard Defense and the Importance of Delta V

How could any of this possibly be simple? One need look no further than the essential game plan of most defense lawyers: deception, dissimilation and obfuscation. It requires a team of experts from the fields of medicine (including chiropractic), accident reconstruction and biomechanics who have collectively developed what I consider to be the standard defense strategy. It continues to be the most successful and widely used strategy today, having become the world standard.

This has fostered a small research industry dedicated to the production of pro-defense literature to aid in the cause. Most is junk science. Make no mistake, insurers have the best researchers money can buy and they know how to get published. As a result, even many clinicians remain split on critical issues depending on which brand of literature they rely upon. I note, with all due respect to the Insurance Institute for Highways Safety (IIHS) and members of the International Insurance Whiplash Protection Group (IIWPG), that their research activities are quite laudatory and most welcome. However, there is just a bit of schizophrenia in this industry when it comes to research. While the valid research of the IIHS and the IIWPG is squarely aimed at reducing the industry payout problem by reducing the number of actual injuries, the “other” research seems to be aimed at providing verisimilitude for company experts to wield in courtrooms to sway jurors toward defense theories.

The standard defense has three parts and is based on the ultimate playing field: a court of law, and, in particular, the biases and naivete (i.e., the normal lack of specific factual information in the field of crash traumatology) of jurors. Polls suggest that Americans are also divided on the question of whiplash injuries. As many as 60-70 percent consider it either definitively or very likely a non-injury, but merely an opportunity to bilk insurers at the expense of the rest of us policy-holders who subsidize the system through the increasing premiums we must pay. Thus, jurors are easily misled by the standard defense strategy because it merely reinforces that which they already believe.

The first and most fundamental part of this strategy is to demonstrate that the forces of the collision would not have been of a sufficient magnitude to cause injury. The common currency for this discussion is the plaintiff vehicle’s delta V or change in velocity. For this, an accident reconstructionist is usually employed. Because reconstructionists are rarely allowed to provide opinions as to injury risk, they are often followed by a biomechanist, who is granted more latitude to venture into the discussion of injury risk. In some cases, they are allowed to consider medical records, MRIs, etc., in forming their opinions. Finally, the defense physician (DC, DO or MD) adds the icing to the cake, testifying that either there was no injury or that there was a minor straining-type injury that has long since resolved.

When pre-existing conditions are present, the plaintiff’s complaints are often attributed to them rather than the injury. Company doctors will typically also be of the opinion that a large portion of the medical expenses claimed by the plaintiff are unnecessary, unreasonable,and represent unwarranted treatment and diagnostics. Note that low back injuries are virtually never admitted to be causally related to low-velocity collisions. I have written a paper on this subject which is available upon e-mail request at drcroft@san.rr.com .3

As I have so many times implored readers – and this fact is never contested even by my small army of industry-affiliated detractors – the entire defense mechanism just described is nothing more than a series of interlocking nonsequiturs. The accident reconstructions and biomechanists provide a very polished and seemingly airtight argument based on what appear to be sound mathematical principles and classical Newtonian physics. This is all very interesting, and would be even more so if it had the additional virtue of being true.

Delta V Not a Valid Gauge of Injury Risk?

But figures don’t always add up, which brings me back to the headline of this article. A new study that provides further compelling evidence that delta V, the keystone in the standard defense strategy, is not a valid gauge of injury risk.4 The authors recruited a total of 57 people within 48 hours of their MVCs. The subjects were recruited either from an engineer’s office for vehicle damage assessment or an ER. The whiplash grades ranged from 0-4 (0 indicating no claimed injury and 4 indicating fracture). The collision types included 13 frontal, 21 rear, 19 side, three multiple crashes and one rollover. There were 25 males and 32 females with a median age of 33.

In all cases a trained engineer determined the delta V by examining both crash vehicles. The VAS and Neck Disability Indexes (NDI) scores were tabulated. The authors found no significant correlation between NDI and delta V, no correlation between whiplash grade and delta V, and only a moderate correlation between VAS reported pain and delta V. However, the R2 value (coefficient of determination) for that correlation was only 0.30, which means that 70 percent of the proportion of the variability of pain severity was not explained by differences in delta V.

There was no lower threshold below which a large proportion would predictably not be injured, nor was there an upper threshold above which most would predictably be injured. This was because some people were injured in very low velocity crashes while others were not injured despite fairly high velocity crashes. The authors commented, “It can be concluded that delta V is an irrelevant predictive value for cervical spine injury after MVA [motor vehicle accident].”

Some specific findings include the following: Cervical spine fractures in frontal crashes occurred in delta Vs of 9.3, 19.9 and 31.1 mph. Fractures in side impacts occurred in delta Vs of 6.2 (z-joint fracture of C4), 9.9 (C7 with dislocation of C6-7), 19.9 (z-joint fracture of C2), 31.1 (C5 fracture with C5-6 dislocation and paraplegia), 32.3 (rupture of alar ligaments), 36.0 (atlantoaxial dislocation) and 36.6 mph (rupture of alar ligaments). There was a dens fracture in the one rollover with the delta V reported as 9.3 mph. This article is available for free download at www.ncbi.nlm.nih.gov/pmc/articles/PMC2657117.

A related component of the standard defense strategy is the property damage issue. Specifically, the argument goes, when the property damage is minor, an injury is very unlikely. We addressed this issue earlier in a meta-analysis of medical and engineering literature dating back as far as 1970 that failed to provide a clear link between property damage and any of three outcomes: risk for acute injury, degree of injury severity and risk for long-term symptoms.5 As I always caution readers, this lack of correlation considers the genre of collisions producing property damage that would be described as minor or non-severe. Clearly, when crash severity increases beyond this, there is an increased risk for injury or death.

A related interesting paper by Viano and Parenteau demonstrated that more than 60 percent of the National Automotive Sampling System case database for rear impacts are for crashes with delta Vs of under 15 mph. They noted, “In very low speed crashes, advanced age, stenosis and degeneration of the cervical spinal canal can lead to spinal cord injury and paralysis in crashes otherwise not causing injury in normal adults.”6 I would also note that it has been demonstrated rather conclusively that human variables (i.e., risk factors) are more determinative vis-a-vis injury risk than crash metrics in the lower crash-severity range.

In the end, when essential parts of the foundation of the defense strategy are tested, they repeatedly fail to hold up to the scrutiny of hard science. In a court of law, however, if the plaintiff and their experts cannot effectively present the real facts and rebut the junk science, 12 impressionable jurors will decide the outcome of the case based on their perception of the soundness of the arguments they heard. The simple fact is that more often than not, the plaintiff and their witnesses are simply not adequately prepared. Knowledge is power and information is the currency of success.

References

Zaloshnja E, Miller T, Council F, Persaud B. Comprehensive and human capital crash costs by maximum police-reported injury severity within selected crash types. Annu Proc Assoc Adv Automot Med, 2004;48:251-63.
Berardinelli DJ. From Good Hands to Boxing Gloves: The Dark Side of Insurance. Portland: Trial Guides, LLC, 2008.
Croft AC. Low back injuries in low velocity rear impact collisions. Forum, 2009;39(4):33-7.
Elbel M, Kramer M, Huber-Lang M, et al. Deceleration during “real life” motor vehicle collisions: a sensitive predictor for the risk of sustaining a cervical spine injury? Patient Saf Surg, 2009;3(1):5.
Croft AC, Freeman MD. Correlating crash severity with injury risk, injury severity, and long-term symptoms in low velocity motor vehicle collisions. Medical Science Monitor, 2005;11(10):RA316-21.
Viano DC, Parenteau CS. Serious injury in very low and very high speed rear impacts. SAE, 2008;2008-01-1485.

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Dynamic Chiropractic – March 26, 2010, Vol. 28, Issue 07

Medicare Patients Give Chiropractic High Marks
Results from demonstration project suggest feasibility of expanding chiropractic services in the Medicare program.
By Peter W. Crownfield, Executive Editor

The long-awaited final report on the Centers for Medicare & Medicaid Services (CMS) chiropractic demonstration project, conducted from April 2005 through March 2007, is good news for chiropractic, with 87 percent of patients surveyed giving their doctor of chiropractic a score of 8 or higher when asked to rate their satisfaction with care (1-10 scale), and 56 percent rating their chiropractor a perfect 10. Moreover, in all but one of the demonstration sites (metropolitan Chicago), health care costs did not increase significantly with the addition of chiropractic services.

The demonstration project, “Demonstration of Coverage for Chiropractic Services Under Medicare,” was mandated under section 651 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003. The project evaluated the effects of expanding coverage of chiropractic services in four different regions of the country: Maine, New Mexico, 26 counties in northern Illinois and one county (Scott) in Iowa, and 17 counties in rural Virginia. Approximately 40 percent of eligible DCs in the four regions participated in the project at some point or another.

Key findings from the summary report, relative to patient experiences with chiropractic care and analysis of chiropractic-specific Medicare costs during the project, include the following. To review the report in its entirety, visit www.acatoday.org/pdf/demo_report.pdf.

“Medicare beneficiaries reported good relief of symptoms and high degrees of satisfaction with the chiropractic care they received.”

“The most frequent reasons given for seeking care from chiropractors were favorable earlier experiences (59 percent) and insufficient relief of symptoms by prior treatments of other health professionals (39 percent).”

“Clinical problems involved the back in 78 percent, neck in 50 percent, hip in 38 percent, and shoulder in 32 percent. Pain was the most frequent symptom, followed by difficulty walking. … Sixty percent of [survey] respondents indicated that they received ‘complete’ or ‘a lot of’ relief of symptoms from their chiropractic treatments.”

“Chiropractic care was felt to be easily accessible, and nearly 95 percent of respondents indicated that they had to wait no more than one week for appointments. Similarly high proportions reported that chiropractors listened carefully and spent sufficient time with them.”

“Among users of expanded chiropractic services, visits increased by 60 percent overall and related Medicare expenditures increased by $34.8 million. … Essentially, all of the increased costs occurred in urban non-HPSA [Health Professional Shortage Areas] and in Illinois, and especially in Chicago and its suburbs.”

“Illinois accounted for 80 percent of the total increase in costs and also had the highest per-person increases in costs of $485 per person compared with increases of $136 per person in Virginia and $35 per person in Maine, and decreases in the other two states.” [Per-person costs decreased by $178 in Iowa and $59 in New Mexico.]

“The types of prior treatments received from other health care professionals differed strikingly from those received by chiropractors, including pain pills in 58 percent, pain injections in 30 percent, both pain pills and injections in 22 percent, and surgery in 12 percent. … The high reported use of pain medications and surgery in treatments received from other types of health care professionals suggests the potential for achieving cost offsets [by using chiropractic care].”
The stated purpose of the demonstration project was “for evaluating the feasibility and advisability of covering chiropractic services under the Medicare program (in addition to the coverage provided for services consisting of treatment by means of manual manipulation to the spine to correct a subluxation described in section 1861(r)(5) of the Social Security Act.” Chiropractic was defined as “care for neuromusculoskeletal conditions typical among eligible beneficiaries and diagnostic and other services that a chiropractor is legally authorized to perform by the State or jurisdiction in which such treatment is provided.” Chiropractic care needed to conform with CMS’s policy for reimbursement of chiropractic services, meaning treatment was for active conditions with reasonable expectation of improvement or resolution. Maintenance and prevention services were excluded per the CMS policy.

For additional background information on the Demonstration of Coverage for Chiropractic Services Under Medicare project, read “Details of CMS Demonstration Project Revealed” in the April 9, 2005 issue.

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Dynamic Chiropractic – February 12, 2010, Vol. 28, Issue 04

Chiropractic at the Winter Olympics

Three SCU alumni among five DCs on U.S. medical team.

By Editorial Staff

The 2010 U.S. Olympic Medical Team, 47 members strong, features five doctors of chiropractic including three alumni of Southern California University of Health Sciences (SCU), including Michael Reed, DC, who is serving as medical director. Eric St. Pierre, DC, and Tesuya Hasegawa, DC, are also serving on the team, which is supporting U.S. athletes in Vancouver and Whistler, British Columbia, at the 2010 Winter Olympic Games now underway. “I would like to express my congratulations to Dr. Reed, Dr. St. Pierre, and Dr. Hasegawa,” said SCU Interim President Dr. John Scaringe. “It is certainly an honor and privilege for these exceptional practitioners to serve the members of the U.S. Olympic Team.” Dr. Reed, medical director of the U.S. Olympic Committee’s Sports Performance Division in Colorado Springs, Colo., is coordinating care for the entire U.S. delegation in conjunction with the chief medical officer, James Moeller, MD. A 1981 graduate of SCU’s Los Angeles College of Chiropractic, Dr. Reed has served as a faculty member in the postgraduate division of the college since 1984 and developed the sports medicine residency program at SCU, serving as its first director. Dr. St. Pierre’s responsibilities on the U.S. medical team include caring for members of the short-track speedskating team and athletes in the Olympic Village in Vancouver. Dr. St. Pierre is currently head trainer for the short-track team. Dr. Hasegawa is attending to members of the bobsled and skeleton teams, as well as providing care to U.S. athletes at the Olympic Village in Whistler. Beginning in 2007, Dr. Hasegawa joined the U.S. Bobsled and Skeleton Sports Medicine Team, serving as a chiropractor and certified athletic trainer for team members. Drs. Reed, St. Pierre and Hasegawa are three of five doctors of chiropractic selected to serve as members of the 2010 U.S. Medical Team for the Winter Olympics. Joining the three SCU grads are Dr. Josh Sandell, a chiropractor and certified athletic trainer from Maple Grove, Minn.; and Dr. Blase Soto, a chiropractor from East Brunswick, N.J.

The U.S. Olympic Medical Team serving in Canada consists of medical doctors, chiropractors, physical therapists, massage therapists and athletic trainers. While these five DCs are not the first to be selected to a U.S. medical team, it is always an honor to recognize the profession when it is included in the most prestigious international athletic competition in the world.

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For years Chiropractors have fought for thier right to properly diagnose, treat and help patients, effectively, safely, and without the use of medication.  More and more, people are seeking alternatives to dangerous drugs, and innefective surgies, to releive thier pain.  This has put a strain on physicians that prescribe medication and/or perform surgery, and many of them are having to sell thier yacht to continue raking in the dough.  So what does one do when one doesn’t get thier way, change the rules right?  And so it is that organized medicine is trying to use big money, politicians, and judges to force healthcare to play by THIER rules, by taking away the rights of all healthcare professionals to properly diagnose pastients, which is absolutely necessary in the plan of care for each individual.  If they have thier way, you would HAVE to go to a ”physician”  AKA medical doctor, to be assesed and diagnosed.  This would have huge ramifications for all, including those that have health insurance.  For example, if you have a sore neck, you would have to go to your MD and get assesed initially.  What would have been a safe and much cheaper fix by a Chiropractor, would now not be covered because an MD says that your diagnosis requires a regimine of expensive medication or worst yet surgery.  We work with medical doctors on a daily basis, and have a great relationship with them.  It is a fringe group that wants to push this down the throats of unexpected Americans for monetary gain and control of healthcare.  Control of healthcare you ask?  Sounds familiar doesn’t it?  At least the socialized healthcare that is trying to be pushed in washington is in public view and you can voice your opinion, ie MA Senator election, but this is behind the public’s back and isn’t getting the exposure as it should.  Voice your opinion, protect your healthcare, and have it the way you want it, not the way one group makes you have it.  Here is an addendum article for further reading:

Organized Medicine Pushes Back

Chris G. Dalrymple D.C., F.I.C.C.

Published 01/18/2010 – 6:56 a.m. CST

ABOUT THE AUTHOR Chris G. Dalrymple D.C., F.I.C.C.   Website: http://www.fixback.com   Email: cdal@fixback.com   In the full article found here the American Medical Association claims that “in 2009, physicians fought a blitz of scope-of-practice expansions by other health professionals on legislative, legal and regulatory fronts.  Organized medicine defeated attempts by naturopaths to seek licensure, prevented chiropractors from being able to perform invasive procedures and achieved further regulation of lay midwives. The efforts were among more than 300 scope-related bills the American Medical Association tracked last year. Physicians don’t expect the battles to let up, and with patient safety on the line, they are countering such efforts with some fresh tactics.” “In anticipation of another onslaught in 2010, physicians, with the help of AMA model legislation, plan to push lawmakers to establish state scope-of-practice review panels to evaluate plans by nonphysician health professionals who wish to expand their practice realm.” “The AMA also is helping states with model legislation requiring nonphysicians to identify their credentials clearly — for instance by wearing badges or limiting use of the term doctor.” “When legislative avenues fail, nonphysicians are turning to regulatory boards to expand their realm of expertise — a tactic that increasingly is landing scope debates in the courts, said Rocky Wilcox, vice president and general counsel at the Texas Medical Assn.” “In a recent win, a Travis County District Court judge, on Nov. 24, 2009, struck down a 2005 state chiropractic board regulation allowing chiropractors to perform manipulation under anesthesia and needle electromyography. The court said state law forbade nonphysicians from performing such surgical procedures. The TMA and Texas Medical Board sued the Texas Board of Chiropractic Examiners and the Texas Chiropractic Assn. over the regulation. An appeal is under way.” “The court also found, however, that state law may not preclude a portion of the board regulation allowing chiropractors to use the term “diagnose.” A trial on that issue is expected to begin in March.” If you want to understand WHY your state professional association is “political”, the AMA states it very clearly: “This is a problem that all states are having, and our view is the Legislature has the policy power to decide who can safely do certain things,” Wilcox said. “If these [regulatory] decisions are not challenged, then it allows agencies to go way outside of what the statute says, and allied professionals will be practicing medicine and diagnosing medical conditions when they are not qualified to do it. So it’s a safety issue….Pending a lack of resolution, we are looking at legislative remedies and would not foreclose the possibility of landing in a court of law.”  “Nonphysician health professionals and their boards say their scope and authority are being restricted unfairly, risking access to care.” “Texas Board of Chiropractic Examiners Executive Director Glenn Parker said chiropractors performing manipulation under anesthesia and needle EMG undergo extensive training and are well-qualified to do what he said were nonsurgical procedures. Moreover, they must be able to diagnose patients to determine if chiropractic or medical care is appropriate.” “The Texas case ‘brings up legal questions about the state of Texas allowing medical associations to determine what is and is not within the scope of chiropractors,’ Parker said. State chiropractors also are expected to push for legislative remedies, he added.” The AMA claims “team-based collaboration among physicians and other health care professionals is key to resolving access issues. “Do you want patients to have access to just anything or have access to a quality standard of care?”   This author eagerly awaits the day when the AMA decides to be a “team-player”.  So far it seems that they are merely attempting to “take away” the “turf” of other duly licensed and regulated healing arts professionals. For ways to voice your opinion, visit the Texas Chiropractic Association’s website. Visit us at All Injury Rehab for more information and to set up an appointment.

Often I’m asked what an adjustment is.  I explain to them that it is joint mobilization for your spine and or extremity.  If you have a few restricted segments of your spine or extremity, wether it be from recent trauma, a chronic condition, or just something from activities of daily living,  joint mobilization is for you.  Remember when you popped your knuckles the last time, we all do it and on a daily basis,  you get pain relief in your hand right?  You gain motion right?  Chiropractors are well trained in moving those joints where they are supposed to be.  Here’s a little article:

What is an adjustment?
A Chiropractic adjustment is the use of a specific force in a precise direction that helps normalize spinal function. The adjustment is applied to a joint that is fixated, “locked up”, or not moving properly. Adjustments help return the bones to a more normal position or motion, restoring body’s natural healing.

What does it do?
Adjustments help normalize spinal function and avoid bone and soft tissue degeneration. When nervous system function improves in this way, the body can begin the natural healing process.

What do adjustments feel like?
After the adjustment, many patients report a sense of well-being or a feeling of calmness. Others feel improved mobility. Inflammation or muscle spasms may delay these positive effects. Chiropractors excel at making adjustments comfortable and effective.

Is it safe?
YES! Chiropractic adjustments are so safe, even newborns and children receive adjustments to repair the damage caused from the birth process, learning to walk, or other childhood trauma. Each adjustment is tailored to each patient’s age, size, and unique spinal problem. After years of training, each Chiropractor has selected a variety of methods and become skilled in their delivery.

In fact, adverse effects of medical treatment is the principal cause of death in people under 45 years of age, as well as being the leading cause of morbidity and permanent disability. Costing Australians $401 million dollars per year and consumed 16% of Australia’s total annual health system expenditure for injury. 17% of hospital admission results in adverse events, 5% results in death, and 50,000 people per year are permanently disabled as a result of their medical treatment (from The report, Health System Costs of Injury, Poisoning and Musculoskeletal Disorders in Australia 1993-1994).

Yes! A New Zealand government study concluded that Chiropractic adjustments are “remarkably safe.” Taking an over-the-counter pain reliever is about 100 times more risky.

Why an adjustment?
A Chiropractic adjustment corrects Vertebral Misalignments. An adjustment helps your body to restore itself to optimum health! When the 24 bones that protect the spinal cord lose their normal position or motion, delicate nerve tissue can become choked or irritated. If a thorough examination reveals malfunctioning areas of the spine, Chiropractic adjustments are recommended to help correct this malfunction.

Each day millions of delighted people choose Chiropractic over drugs or surgery, as a common sense approach to better health.

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Happy New Year!!!  Many resolutions include increasing activity, and for those that are not conditioned, injuries often occur.  Shoulder injuries are a very common thing that we see at our clinics.  Here’s an article explaining one of the causes:

By Todd Turnbull, DC, CCSP

The subscapularis muscle is an internal rotator and therefore is overused by almost every patient, especially those involved in throwing sports such as baseball. When a patient complains of shoulder pain, this is usually one of the factors that causes shoulder dysfunction.

Symptoms

The most common area of complaint is along the anterior humeral head or just a generalized region of pain in the shoulder joint. The onset of pain can be either acute, due to a specific mechanism of injury, or a gradual chronic condition that slowly develops. Strain can occur due to sleeping on the involved side, excessive throwing or a fall that traumatizes the shoulder.

Diagnosis

Evaluate shoulder range of motion bilaterally by having the patient elevate both elbows to horizontal. Have the patient internally rotate both forearms and look for a loss of end-range motion and/or an internal rotation of the whole scapula. Next, muscle test bilaterally and note the deficiency of the involved subscapularis.

Treatment

The subscapularis originates along the medial border of the anterior surface of the scapula and inserts into the lesser tubercle of the humerus. There are several approaches to correcting the subscapularis. Cross-fiber massage, instrument-based adjusting and/or contract, relax and stretch principles can all be utilized to obtain good results.

Cross-fiber massage of the belly can be accomplished by the doctor sliding their fingers into the axilla until the subscapularis muscle is found (usually an uncomfortable procedure for the patient). Adjusting instruments can target the origin while the patient’s arm is externally rotated. Contract, relax and stretch protocols tend to be less uncomfortable, but more time-consuming. Post-treatment evaluation should note increased strength and range-of-motion function and decreased pain.

Rehabilitation

Resistance-band strengthening exercises (multiple sets of 15 to 20 repetitions) should be incorporated a minimum of three times per week. I prefer that my patients first work their good side and then train the injured side.

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The other day I was asked by an insurance company to give my reasoning for ordering an MRI within the first 3 days.  OK, in that case, why order or take an X-ray, why do an exam, why do any orthopedic tests?  Before I go off too much, here was my response, and by the way, if you want more reasoning, just let me know.

Dear Sir or Madam,

 When ordering an MRI within the first 3 visits, here are just a few of many reasons for doing so: 

 ·X-rays only show a portion of the patient’s potential injuries, it will not show a soft tissue injury; an injury which could possibly be adversely effected by certain types of treatment.

 ·When coming up with a treatment plan, a physician needs to know what he or she is treating and what the proper course of care would be, such as needing to be referred out for a surgical consult or any other specialist.

 ·It is imperative that conditions be diagnosed as soon as possible in order to treat the problem before further injury occurs.

 ·An MRI could find a soft tissue injury which could be dangerous to continue to work at their job, an injury that could have been missed on an x-ray.

 If you need further reasoning or have questions, please feel free to call me at the number above.

 Sincerely,

 Brian Starry, D.C.

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From the moment we get out of bed everyday, to the moment we get back into bed, and maybe even while sleeping improperly in the the bed itself, or sleeping in a bad bed, we are causing trauma to our spine.  Here is a great article on ways to reduce this trauma:

Wanted: An End to Back Pain
4 Ways to Prevent an All-Too-Common Condition
By Kevin Wong, DC

    When was the last time you or someone you know suffered an episode of back pain? Chances are it wasn’t that long ago. It might have forced you to miss work, take painkillers, anti inflammatories or other medication, or just deal with the pain longer than you wanted to. Wouldn’t it be wonderful to do some simple things to try and prevent back pain from happening in the first place? Here are a few easy ones to get you started.
   

    In the new millennium, the health care pendulum has swung from treating symptoms toward prevention. It is a way of thinking that is analogous to going to the dentist for your six-month check-up or taking your car in for regularly scheduled maintenance – you avoid problems before they start, rather than waiting for something to happen and then “dealing with it.” By that time, your car may be in the junk yard and you may be relegated to long-term medication or even surgery.

    Back pain is the perfect example of a symptom too many people treat instead of preventing, and the consequences are staggering. It is the most frequent cause of activity limitation in people younger than 45 years old. Approximately one quarter of U.S. adults reported having low back pain lasting at least one whole day in the past three months and 7.6 percent reported at least one episode of severe acute low back pain within a one-year period. Low back pain is also very costly: Approximately 5 percent of people with back pain disability account for 75 percent of the costs associated with low back pain.

    Americans spend at least $50 billion per year on back pain – and that’s just what gets reported. With all that said, how are you going to prevent back pain? Here are four things you can start doing today to reduce your risk of suffering back pain and its costly (physically, emotionally and financially) consequences:

1. Get Adjusted by Your Chiropractor
Your muscles, bones and ligaments are stressed continuously by normal daily activities: driving, sitting at the computer, lifting your kids, doing exercise and countless other things. These little stresses add up over time and misalign the joints of your spine, arms and legs. The misalignments can then lead to muscle tightness, spasms, joint stiffness and pain. Although chiropractors commonly see patients who are in pain, getting spinal tune-ups when you are feeling “fine” will keep you feeling fine. Adjustments will put the
bones and joints into healthier positions, which will also help muscle tone.

    Generally, if you get adjusted while you’re in pain, it will take longer to heal, whereas if you get regular or maintenance adjustments, you can avoid terrible episodes of pain before they even start. That’s because keeping the spinal and extremity joints in good alignment will help your nervous system and immune systems function at their best. Even when you think you are feeling good, chiropractors can make sure you stay that way.

2. Practice Proper Ergonomics
Think safety: When you make your everyday activities safe to perform, it will help reduce the undue stress on your body. This includes having your computer work stations at home and at your office set up properly for your body. Generally speaking, the keyboard height should be the same height as when your arms are
comfortably at your side with the elbows bent. The mouse should also be close to your dominant wrist while your arms are at your sides.

Avoid poor posture: Whenever you sit, it is safest to sit on a full-back chair with plenty of support. Crossing the ankles is fine, but do not cross your legs. This puts tremendous pressure on the lower back, contributing to back pain. Also, if you are experiencing low back pain, it’s a good idea not to sit on the couch or sofa, since they are typically too soft and unsupportive for the low back.

Low Back Pain:
One Symptom, Many Potential Causes (Including the Following)
· Strenuous activity, overuse or improper use (repetitive or heavy lifting, vibration, pressure, etc.)
· Physical trauma, injury or fracture
· Obesity (often caused by increased weight on the spine and pressure on the discs)
· Poor muscle tone in the core or stabilizing muscles of the back
· Tightness, spasm, injury and strain of back muscles
· Joint problems (e.g., spinal stenosis – narrowing of the spinal canal, which compresses the spinal cord and nerve roots)
· Protruding or herniated (slipped) disk
· Arthritis or degeneration of vertebrae due to stress and the effects of aging – osteoarthritis, spondylitis (inflammation of the spinal vertebrae), compression fractures, etc.

Lift properly: When lifting items, use the legs and the trunk of the body rather than the arms. Always bring objects closer to your abdomen or chest, as that is the center of gravity and support for most people. Try to avoid bending the back while you lift.

Sleep well: The most supportive position for the body during sleep is on your back with a pillow under your knees. The next best position is on your side with a pillow between your knees and your head on a pillow that is thick enough to span the distance of your neck to the shoulders. A neck pillow that is too thin will kink the neck and could lead to neck and upper back pain down the road.

3. Exercise Regularly
We all know how important it is to participate in some type of regular exercise. Some of you already do that. Whether it be walking, playing sports or going to the gym, make sure you set up a program that keeps you consistent. Exercise helps the human body in so many ways, but one of the most important aspects involves stretching and strengthening of your back muscles. Often these muscles are referred to as core muscles of the body because they are located very close to the spine. The core muscles help move and protect your spine when it is stressed or strained. By keeping them flexible and toned, you prevent pain and injuries from happening. When you are developing an exercise plan, talk to your doctor for ideas on what areas of the body you should specifically focus on to get maximum results, both in terms of overall fitness and protecting the back from injury.

4. Avoid Unhealthy Lifestyle Habits
Stress. Emotional stress can cause muscle tension, which can lead to back pain (it also can lead to heart problems, chemical imbalances, an inability to sleep and a host of other bad things). It’s always hard to maintain balance in your life between work, family and play, but it goes a long way toward helping your
emotional stress.

    Reducing stress can be as simple as scheduling some quiet time to be alone, doing yoga or meditation, taking a bath or just sitting and doing breathing exercises. Whatever activity you find relaxing or energizing, take time to do it. Down time allows you to unplug from the world and get grounded. It also allows your body to reset itself so you can deal with the next crisis or problem that’s sure to arise. Poor nutrition. Watching what you eat is another important factor to consider, because excess weight literally “weighs you down,” which can contribute to back pain. Quite simply, losing excess weight in a healthy manner will take pressure off your lower back and reduce stress on the vertebrae. It is truly amazing that our society is now making an active transition from listening to symptoms or pain to preventative health care. Now is the time for you to be able to take a more active role in deciding how your future health will play out. Armed with the tips discussed above, you can make changes now that will help your back and your overall well-being for years to come. The power of health is in your hands.

The Back Pain Epidemic
Back pain has become an epidemic in our modern society – up to 85 percent of all people will experience back pain at some time in their life, and it is the fifth most common reason for all physician visits in the United States. According to the statistics, if you’re in a room with three other people, one of you has suffered low back pain for an entire day or more in the previous three months and only one of you (if they’re lucky) will avoid suffering back pain at some point in their lifetime.

Kevin M. Wong, DC, a 1996 graduate of Palmer College of Chiropractic West in San Jose, Calif., practices full-time in Orinda, Calif. He is also an instructor for Foot Levelers, Inc.

Visit us at All Injury Rehab for more information and to set up an appointment.

EMG, or electromyogram is a test used to record the electrical activity of muscles. Active muscles produce an electrical current that is usually proportional to the level of muscle activity. Another name for an EMG is a myogram.

There are two types of EMG — the intramuscular EMG and the surface EMG. The intramuscular EMG is the test most commonly ordered and involves inserting a needle electrode through the skin into the muscle in question. Surface EMG (SEMG) involves placing the electrodes on top of the skin overlying the muscle to detect the electrical activity of the muscle.

EMGs can detect abnormal muscle electrical activity in many diseases and conditions, including inflammation of muscles, pinched nerves, damage to nerves in the arms and legs, disc herniation, and degenerative diseases such as muscular dystrophy, Lou Gehrig’s disease, Myesthenia gravis, among others. The EMG helps to distinguish between muscle conditions in which the problem begins in the muscle and muscle weakness due to nerve disorders.

We typically order EMGs when we want to find out if a patient’s pain is related to a pinched nerve or disc herniation most commonly. Most pain conditions that we see  are related to soft tissue injuries such as injuries to the ligaments, tendons, or muscles which do not require EMG testing. These injuries may refer pain down the arm or leg or to other sites. Almost all pain, in our experience, responds well to therapy (at least 85% of all cases seen here). If a patient has a pinched nerve, this person can be experiencing 10/10 level of pain, 24 hours per day, 7 days per week. The patient may experience true numbness, weakness, and decreased grip strength, for example. An EMG in this case helps determine cases of radiculopathy or pinched nerves.

In the nerve conduction velocity (NCV) test, the nerve is electrically stimulated by one electrode while other electrodes detect the electrical impulse “down stream” from the first electrode. The distance between electrodes and the time it takes for electrical impulses to travel between electrodes are used to calculate the speed of impulse transmission (the nerve conduction velocity, or NCV). A decreased speed of nerve conduction indicates nerve disease.

The NCV test is often done at the same time as the EMG in order to exclude or detect both nerve and muscle conditions. The interpretation of an abnormal NCV test depends on why the test was done in the first place. It may indicate damage to a nerve from trauma, diabetic or peripheral neuropathy, herniated discs, polyneuropathy, or myasthenia gravis or Guillain-Barre Syndrome, among other things.

We take a very thorough history on each and every patient, as this is the key to determining the root cause of a patient’s pain. EMG/NCV tests are not something that we frequently order considering the number of pain patients who come through our doors, because we find that most conditions respond very well to therapy. Degenerative disc disease, arthritis, bulging discs, spondylolisthesis, and many other conditions are most typically due to an underlying soft tissue weakness/injury – to the ligaments, tendons, or muscles. These types of conditions respond very well to therapy. The history from the patient is one of the key factors to determining the need for these types of studies. The experience of the physician and clinical team at asking the right questions, can be the difference between getting an expensive test that you may or may not need. If a nerve injury is suspected as being the cause of the patient’s pain, then an EMG/NCV study may be ordered.

Visit us at All Injury Rehab for more information and to set up an appointment.

We’ve often heard that “you are what you eat”.  Well, what you eat can pain you, in more ways than one.

References
1. Cordain L, Eaton SB, Sebastian A et al. Origins and evolution of the western diet: health implications for the 21st century. Am J Clin Nutr. 2005;81:341-54.
2.Franco OH, Bonneux L, de Laet C, Peeters A, Steyerberg EW, Mackenbach JP. The Polymeal: a more natural, safer, and probably tastier (than the Polypill) strategy to reduce cardiovascular disease by more than 75%. Brit Med J 2004; 329:1447-50.
3.O’Keefe JH, Gheewala NM, O’Keefe JO. Dietary strategies for improving post-prandial glucose, lipids, inflammation, and cardiovascular health. J Am Coll Cardiol. 2008;51(3):249-55.
4. Aggarwal B.B., Shishodia S. Suppression of the Nuclear Factor-{kappa}B activation pathway by spice-derived phytochemicals: reasoning for seasoning. Ann N Y Acad Sci. 2004;1030:434-41.
5.Srivastava KC, Mustafa T. Ginger (Zingiber officinale) in rheumatism and musculoskeletal disorders. Med Hypotheses. 1992;39:342-8.
6. Chou R et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.
7.Bucci L. Nutrition Applied to Injury Rehabilitation and Sports Medicine. Boca Raton: CRC Press; 1995: p.167-76.

Getting A Handle On Pain And Inflammation
Anyone with chronic pain has typically tried non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin or ibuprofen (Advil), or anti-pain medications like acetaminophen (Tylenol). Each medication is associated with side-effects, such as liver toxicity for acetaminophen and ulcers for NSAIDs. Interestingly, the second most common cause of ulcers is the regular use of aspirin and other NSAIDs.

In an effort to avoid the side effects associated with NSAIDs, many individuals seek out nutritional supplements that can be used as an alternative. There is a secret that must be understood before one searches out nutritional supplements to reduce pain and inflammation. Our diets substantially determine the inflammation levels in the body, which can directly impact upon the
development of pain.

The foods that cause inflammation and lead to pain include refined sugar, refined grains and related flour products (bread, pasta, bagels, etc.), refined oils, and obese meat. These inflammatory foods make up
approximately 80% of the average American’s calorie intake (1), and yet even 30-40% of calories from these foods is too much. Eating a diet comprised of the inflammatory foods creates a tsunami of inflammation within the body that will hit joint and muscle sooner or later causing pain and suffering. At this point, people start taking NSAIDs and Tylenol, and all the while continue to eat the same inflammatory foods that caused the problem.

In short, most people cannot turn off diet-driven inflammation and pain by taking medications or nutritional supplements. So it is important to make dietary changes to calm the inflammatory state. To expect that drugs and supplements will be curative is not reasonable.
Consider the term “nutritional supplement” it is supposed to supplement a healthy anti-inflammatory diet rather than one that is filled with the various inflammatory foods. The anti-inflammatory diet consists mostly of vegetables, fruit, raw nuts and potatoes in moderate amounts, and healthy proteins (lean meat, skinless chicken, fresh fish, omega-3 eggs or egg whites) (1-3). A little bit of dark chocolate, red wine, and stout beer are also anti-inflammatory. The best oils/fats include olive oil, coconut oil, and butter; and these should be used in moderation. A very popular oil supplement is fish oil that contains omega-3 fatty acids, which is famous for its anti-inflammatory properties.

Not well appreciated in America is that spicing our meals adds a substantial anti-inflammatory boost. Ginger, turmeric, rosemary, oregano, garlic, coriander, and nearly all spices tested thus far have proven to be anti-inflammatory (4).
Because NSAIDs cause ulcers and other dangerous side effects, researchers began to look for alternative substances that can reduce pain and
inflammation in a safer fashion. It was discovered that, when supplementing with ginger, certain individuals can substantially reduce chronic muscle and joint pain(5). For more acute pain, such as flair ups of back pain, research has shown that white willow bark can reduce pain as effectively as Celebrex over a 4-week period(6). Such studies led the American Pain Society and the American College of Physicians to view supplemental white willow bark as a recommended option for treating low back pain (6). There are also natural options for more acute injuries such as muscle strains and sprained joints. A unique enzyme called bromelain is found in pineapple and is known to have protein-digesting actions. It turns out that the inflammatory response associated with acute injuries involves the production of special proteins that are degraded by bromelain. Studies with bromelain and other enzymes demonstrate a reduction in recovery time after injury. In one study with ankle sprains, there was a 50% faster return to work and a 30% faster return to exercise (7).

In summary, if you desire dietary approaches towards a pain-free state, natural options are available. Basic dietary changes and certain key supplements can be very helpful. The most common symptom that brings a patient into a doctor’s office is pain that does not go away adequately, which is called chronic pain. Back pain, neck pain and headaches are some of the most common types of chronic pain.
David R. Seaman
DC, MS, DABCN

Visit us at All Injury Rehab for more information and to set up an appointment.