WHIPLASH AS A PUBLIC HEALTH EPIDEMIC: A HARD LOOK AT REAL DATA TO CALL IT WHAT IT IS

Whiplash as a public health epidemic: a hard look at real data to call it what it is.

https://pubmed.ncbi.nlm.nih.gov/32413544/https://pubmed.ncbi.nlm.nih.gov/32413544/

More recently I have been back on a nerd Safari listening to research podcasts. The most recent series focuses on the career research work of highlighted individuals who happen to have a chiropractic background but later expanded into other health disciplinary approaches. One of the most fascinating individuals in that series is Michael Freeman, third-generation chiropractor who spent the first 12 years of his worklife is a small town chiropractor on the West Coast, later to get a medical degree, public health degree, and multiple specialty additional degrees and certifications in forensics and epidemiology. His initial focus was to better understand the morbidity and mortality of crashes and accidents, especially motor vehicle accidents. I could certainly relate to his dilemma, facing the reality of these low-speed collision injuries in practice, while being told by the "official" date at that such injuries did not really exist.

The space of motor vehicle accident injuries is fraught with conflicting interest. There is certainly a lot of press given to the idea that patients are financially motivated when reporting persistent residuals from injuries, including injuries that happen at relatively low speed and with relatively little vehicle damage (which will be the topic of a subsequent blog). There is also the official statistics from national crash data reporting systems, suggesting that certain types of injuries such as cervical disc prolapses, happen extremely really at low speed collisions. Then again something that conflicts with my observation in 32 years of practice.

The other side of the story is that there is an equal if not higher level of financial motivation on behalf of the payers in the insurance industry. Profit depends upon paying out less in claims than you taken in premiums obviously. And to be fair, I I have seen my share of poor and questionable business practices in some of my colleagues over the last 32 years, who were willing to amplify the treatment needs of people in motor vehicle accidents because you could bill the car insurance company at a higher rate and for more visits than you could a commercial policy. And yet, overwhelmingly, I saw more people with real nasty persistent, difficult to treat and stabilize injuries, that had their benefits cut off long before they had reached the maximum recovery, by insurance claims adjuster hiding themselves behind certain statistics. Some of the statistics never made any sense to clinical providers like myself and my colleagues, and it has taken the hard work of people with strong data background and unquestionable research methodology to counter the narrative put forth by the insurance payers.

Enters Michael Freeman and his work. This particular study focuses on the actual incidence of cervical spine injuries from motor vehicle accidents in the US, using more accurate data from hospital reporting ER visits for motor vehicle injuries to the cervical spine. His research paper also highlights the extreme limitations of the crash reporting data reported by insurance companies, which only look at the first 48 hours of reported injuries following a motor vehicle accident. Unless you're dealing with a fracture, internal bleeding or severe head injury, the majority of people in low to medium speed collision haven't even made it to urgent care 48 hours after the crash: their adrenaline is so high and blocking pain they did not fully capture the level of the injuries, they are overwhelmed trying to figure out their damaged vehicle situation and get replacement wheels to get to work, they're trying to figure out what sort of injury coverage they may have before incurring a huge medical bill etc. Of most interest to me in the study was the discussion about cervical disc injuries. I see those remarkably frequently in collision speeds of 10 miles an hour or less, depending upon other factors associated with the crash such as speed of impact, position of the passenger etc. The official crash statistics tell you they almost never happen, however almost nobody in the low-speed crash will have a cervical MRI in the first 48 hours after an accident, which is the only way to truly diagnose those types of injuries. This is confirmed by Michael Freeman study, which shows that based on hospital statistics alone (and that's even an underestimate of cervical disc injuries since many of them will not have their MRI until they walk into our office three months later with persistent pain from the original accident), 92% of cervical disc injuries are missed by the official crash statistics.

I had the pleasure of listening to an interview by Dr. Freeman recently. In his own words, cervical injuries from motor vehicle accidents are so prevalent, estimated at 1.2 million injuries per year in the US, that we really should think of them as a public health epidemic, considering the morbidity and disability associated with the immediate injury, much less the potential percentage of people who will continue on with chronic persistent symptoms. This certainly resonates with me as a practitioner with a large practice in chronic care management, where people will often show up with a constellation of symptoms that they clearly date back to an original rear end collision 30 years prior.

The moral of the story: whether your patient or doctor, you need to sometimes block off the so-called official statistics, and really look at what your individual situation tells you. If you were in a crash, and within a couple weeks do not develop any symptoms, you're probably not injured. But if you're in an accident, and you start developing pain that is new or unusual for you, regardless of how little scratches you see on the bumper, you need to consider the possibility of an injury and not delay treatment.

Vertigo from the neck or inner ear ? The swivel test

Dizziness and vertigo is one of those problems like fatigue that can make you cringe when it shows up in the office because there are so many possibilities as to what's causing it. Anything from cardiovascular to inner ear to medication to blood pressure to mild head injury etc. However when it comes to positional vertigo that is often triggered by change in position of the head and neck, the two main culprits are going to be the cervical spine in the inner ear and sometimes a combination of both. Most of the time the testing can be a little bit elusive because the testing itself will activate both the cervical spine and the inner ear at the same time. (For example Dixie Hall Pike test). The swivel test can be a useful add-on to other testing because it will hold the head stationary while deeply activating cervical rotation, thus eliminating stimulus to the inner year and vestibular system while deeply stimulating the cervical spine. All you need is a good old-fashioned swivel stool or chair and a good pair of steady hands to hold the head.

ADOLESCENT ATHLETIC MIGRAINES AND FERRITIN

july seems to be the time when of our teens tackle some ruthless sports training camp. I've seen a fair amount of those beat up bodies, full of new muscle bundles and a few injuries, show up for treatment at the office. This flood of athletic teens has reminded me of an important topic I've meant to blog about for a while.

Adolescence seems to be a time when migraine patterns can emerge. Hormones get a lot of the blame, and there is some partial truth to that, although I feel that it's often an easy copout without looking at other causes. (Much less trying to understand hormone imbalance and correct them). Injuries to the cervical thoracic spine, athletic head injuries, and some nutritional deficiencies can also be a huge trigger in genetically predisposed individuals. The good news is that there is some recovery path available. Today I want to talk about one particular subset that affects especially young athletic females. The pattern and distribution of the migraine is similar to other migraine headaches, but the timing seems to often coincide at the end of physical activity, indicating a metabolic trigger to the headaches, as at the end of the menstrual cycle rather than before or during menstruation. Over time however, the temporal correlation to exercise and menstruation becomes less clear as the migraine pattern becomes more frequent.

Migraines can have multiple triggers. One common mechanism among many migraine patients is the drop in available energy production in the central nervous system, since neurons hold a negative charge that requires a lot of continuous energy production in the brain in order to be maintained. If the energy production drops very suddenly, or persistently, the neurons lose their charge and can fire in large patterns, causing a random wave of what's called depolarization that can lead to a migraine.

Energy production in the brain requires several things: stable blood sugar (some people can metabolically adapt to ketone fats as an energy substitute for non-high-intensity activities), adequate blood flow, adequate oxygen concentration, adequate electrolytes balance. So episodes of hypoglycemia and low electrolytes can definitely be a ripe terrain for migraine to spike. I think most teenagers and their parents have already figure that out with pre-exercise electrolyte as well as making sure they've had some sort of preexercise snack.

The contribution of low oxygen concentration however does not seem to be on many people's radar. This happens mostly when a teenager is borderline anemic, or has low iron/low iron reserves. Oxygen concentration in the brain is dependent upon not only the blood flow to the brain but also the amount of oxygen carried by hemoglobin in the red blood cells.

Young athletic females are especially vulnerable to iron deficiency anemia or low iron reserves because of three main factors:

– adolescent females menstruate, often at the time that they pick up the intensity of the athletic activities. They do not necessarily make up the iron loss of menstruation at the time that the need increases. Some of the early periods can be irregular and very heavy too compounding the problem.

– Athletic female teens are increasingly engaging in strength training as part of their sports practice, which is excellent news for the overall health, bone health, and injury resilience. The main protein founded muscle is called myoglobin, which requires a lot of heme iron to manufacture. This is the same heme iron that incorporated into the red blood cell hemoglobin. Practically this means that strength training diverts some of the heme iron resources into muscles and away from red blood cell production, increasing the risk of anemia. This phenomenon has sometimes been referred to as the myoglobin shunt.

– The complex landscape of teenage eating habits, tied into body image, food preferences, and some desire to pursue more vegetarian diets, can often lead to very low content and bioavailability of iron and supporting minerals in the diet.

Assessing an athletic female teenager for the potential of suboptimal iron reserves as a migraine trigger is not as straightforward as you would think. The body is very good at compensating for low iron and maintaining apparently normal routine lab values for a very long time. In order to really assess the iron status, a patient will need a CBC, iron panel including ferritin, which is often the first value to drop before seeing any changes in the red blood cell count. My rule of thumb with our young athletic females is to see a ferritin in the 50 range, to give the margin for fluctuations during the menstrual cycle. Be aware that technically the range of what's considered "normal" ferritin on many of our labs is as low as 10, which is clearly not sufficient for most people much less someone involved in high-intensity athletics.

Restoring normal iron and hemoglobin reserves is also not a straightforward as you would think. Common iron supplements tend to be very irritating to the G.I., resulting in constipation, poor compliance, and not necessarily improving iron levels. My recommendation is to combine more easily absorbable forms of iron with cofactors of copper and zinc, and take them and minimum of twice a day, in smaller doses, and ideally three times a day for the first 30 days until the patient starts feeling better. This obviously should be in addition to changing dietary pattern to have more bioavailable forms of iron for a couple meals a day. In addition, I want to make sure that the athletes is having a pre-workout electrolyte and creatine bolus, and that they have had adequate caloric intake including some healthy form of carbohydrate no more than two hours before an intense exercise session. This will help support sustain energy production for their body and their brain during exercise. Ferritin should also be monitored at six weeks, and 12 weeks, to make sure you adjust the supplement dose into a healthy non-toxic range over time.

VITAMIN D STACKING OVERLOAD

For most of the last 20 years we have been talking to patients about maintaining healthy levels of vitamin D and avoiding deficiencies because of the widespread health ramifications. However more recently we've had a bit of a turnaround in that I have run into several cases of elevated vitamin D levels on blood samples that were in a concerning range. And based on the review of the most recent literature I'm not the only one raising a bit of an alarm.

First it's important to briefly remember your metrics: vitamin D levels below 30 are generally considered insufficient, and vitamin D levels above 80 considered unhealthy high. There is some debate in the medical and integrative space about the upper range, with some groups advocating healthy levels closer to 8 fo certain at-risk populations (autoimmune, active oncology), and the purpose of this blog is not to enter that debate (although my careful review of the issue seems to indicate that something more physiological that humans have experienced over the last 10,000 years based on sun exposure and skin manufacturing of vitamin D would be closer to 60 – 70 as an upper healthy range). But I would like to point out that there is a real risk of overdosing on vitamin D3 if you're taking several supplements at the same time, and not factoring the total vitamin D that may be found in all of them.

Many nutritional supplements sold both professionally and over-the-counter do contain some background level of vitamin D as a synergist, somewhere around 400 IUs on average. The original idea behind the supplementation was that the average person was not getting enough vitamin D and they would roll in a minimum level within a supplement to ensure results. This well-intentioned idea resulted in an unexpected problem over time, as more patients started self administering a variety of supplements for general health and stacking these 400 IU doses of vitamin D. For some of our patients, who are taking a regimen of prescribed supplements for specific goals, such as G.I. restoration, inflammation control etc., That amount could easily get above 10,000. More recently we had a patient whose routine blood level was above 200 (I didn't even think it was possible and had the patient get a second test to rule out or lab error). Looking at the supplementation that I was recommending the total amount she was taking was 6000 IUs, a dose that would never get her anywhere higher than 70 on her vitamin D serum levels. It was really her head scratching mystery for a while, until the patient started looking in her kitchen cabinet at some of the supplements she was taking most days, only to realize that a winter immune support and a hair and skin support she was taking on the side were both stacking over 10,000 IUs combined between those two alone.

The moral of the story: vitamin D supplementation is beneficial for most patients especially in our northern climates, but you have to remember to calculate your total intake. And it's also a great idea to get it measured once a year as part of your annual physical to make sure you're in the ballpark.

Car seat, neck and head pain, irritability

It's one of those overdue blogs about a somewhat seasonal topic, which slips my mind before I have a chance to dictate my thoughts.

Many families are about to hit the road for longer car trips with young children, including some of babes in car seats. Car seats were designed with safety in mind first and foremost, and in the quest to prevent any sort of airway obstruction, were meant to be remarkably safe and remarkably uncomfortable for many children at the same time. As a result, car trips can turn into screaming matches of unhappy little humans balking at the pressure on the back of the head and neck from a rigid cart seats with no support. If you look at it from an adult perspective, none of us would want to be resting her head in that manner for very long either. The problem is compounded by the fact that many children with post birth related upper cervical extension misalignment will really be digging the back of the occiput into the rather inflexible material of the car seat, or aggravating any sort of upper cervical rotational misalignment when they fall asleep.

A relatively happy middle-of-the-road solution that doesn't compromise airway and provides much-needed comfort is one of these cervical support pillows that are designed for car seats. The earlier model were called the butterfly pillows, and only addressed cervical support, but some of the newer versions have a posterior occipital credible as well. I find is more beneficial especially for the children that are still trying to recover from occipital plates protrusion, a common birth related cranium miss shaping.

101 SELF CUPPING BASISC

I find a lot of my patients decide to be proactive to try to treat some of the soft tissue problems between treatments, often acquiring popular tools, but with little knowledge on how to operate them effectively much less safely. At some point we really should be offering a one hour class small group format to take people through the proper use and self customization of the home therapy, but in the meantime, I decided to at least have a quick reference video of the very basics of application and safety.

https://www.youtube.com/shorts/vCveLlXyj9Q

Some light on the dark subject of eating disorders

https://www.rupahealth.com/the-root-cause-medicine-podcast/eating-disorder-treatment-a-functional-medicine-approach

This is a topic that is little bit or a lot outside of my wheelhouse so to speak, but I worked with enough families dealing with this issues which often feels like there is little hope on the horizon, to feel compelled to at least post this as a resource. This podcast came up on my series of integrative health podcasts that I listen to on a daily basis. While I do a fair amount of work with people working out some of their nutritional plan and customize supplementation, the other whole dimension of how people relate to food sometimes in a very pathologically disordered way, is not something that I have really felt comfortable tackling, instead referring to other healthcare professionals. I was aware of Dr. Greenblatt's work in other areas of nutritional psychiatry (especially his work on ADHD and weaning off psychiatric medications), but his no-nonsense practical approach to eating disorders using the concept of nutritional replenishing was brand-new to me. Feel free to use that for resource for yourself and your loved ones, as well as passing it along to people in your life.

INFANT CERVICAL COSTAL SYNDROME ( NECK-RIB-ARM)

I have had more recently the pleasure of working in close collaboration with craniosacral therapists that specialize in pediatric and infant care. It's a highly symbiotic clinical relationship, that allows to get the best outcome if both parties can properly assess and address the problems in our little humans. More recently, I've had a few referrals for evaluation of infants with persistent delayed milestones, general positional discomfort and irritability on very young children, where the therapist indicated to me that the shoulder was the source of continued relapses.

Neuromusculoskeletal pediatric providers normally do a pretty good job at assessing cervical related birth insults, such as torticollis, however there is a particular type of birth related injury that often goes unrecognized, much less untreated, even in our profession and beyond. There is not a classic clinical textbook term to describe the finding below, but in my own notetaking system, I have dubbed it "cervical costal clavicular injury".

The anatomy of the anterior neck and shoulder girdle in infant is ultimately not all that different from adults, with the exception that the bony structures are not fully ossified, and that the clavicle in particular is very malleable, allowing for distortion and occasional green stick fractures so that a child can survive birth if they have large shoulders. The purpose of this blog is not to review the rather complicated anatomical path that an infant has to traversed during birthing, through the maternal pelvis, but rather to pinpoint this particular problem, its presentation and its corrective intervention.

Once the infant's head has cleared the maternal pelvic floor, the shoulders are next, and the shoulders are typically going to be broader. So there could be a delay of multiple pushes between the head and shoulder delivery. This is a particularly vulnerable time for torsional extension and traction injuries in the area of the junction of the neck and the shoulder girdle. Depending upon the position of the head in relationship to the torso, the cervical spine could already be in pretty significant lateral flexion and rotation. The point of failure so to speak, could be in the cervical spine, but in many cases it's going to be in the shoulder girdle, and especially in the anterior part of the shoulder girdle, where the anterior neck meets the sterno-clavicular joint (the joint between the clavicle and the breastbone), as well as the area of the first rib, just posterior to the clavicle, and connected to the neck through anterior cervical muscles called the scalenes. The cervical costal clavicular insults can happen even when there's no overt history of shoulder dystocia during delivery, it can happen simply with a couple really hard pushes between the head and shoulder delivery, and may not be recalled by the parents or birth attendant at the time when I take a history on the infant.

The result can be a pretty significant misalignment and impingement between the first rib, the clavicle, and sometimes the brachial plexus (the nerve bundle exiting the front of the cervical spine to go into the arm). As a result, the infant will often exhibit the following:

– being very uncomfortable while held against a chest and only being able to face a parent with their head in one direction. The parent may also notice that one arm feels very stiff and pushing back against the chest when they're holding the child facing them

– generally being fussy, uncomfortable especially being held facing the parent, or in the prone position, since it causes pressure on the affected shoulder girdle.

– Having some difficulty comfortably turning their head in both directions equally, not being able to nurse well on both sides (although that's a finding that overlaps significantly with cervical problems)

– being very uncomfortable and crying if their head is moved away from the affected side, usually because it increased the amount of pinching and impingement between the first rib and the clavicle, or increases pressure and traction on the brachial plexus.

– Having some difficulty propping themselves up on their arms in the prone position, crying when put on the stomach, and some delay in normally propping themselves up in the stomach lying position. This may be especially noticed on one side more than the other

– delay in rolling over, especially on one side, since you need to have adequate integrity of the anterior shoulder girdle in order to do so.

– Sometimes difficulty with suckling, with the sensation of a really tight jaw on one side. (Moms will often notice that the jaw tends to go sideways with a harsh latch, since the anterior neck muscles connect to the root of the tongue)

– significant difference between position and use of one arm versus the other. Very often the presentation is that of the "T Rex arm", where the infant will hold their affected arm closer to their breastbone and less likely to extend it or relax it normally

The chiropractic intervention for this problem requires a careful examination of the child’s cervical spine, as well as the entire shoulder girdle, sternoclavicular, first rib, anterior cervical, and mid cervical spine. The corrective adjustments are really quite different than the cervical adjustments, and do require very specifically correcting the relationship between the first rib the clavicle and sometimes the mid cervical spine, in order to achieve normal mobility of the sternoclavicular joint, normal brachial plexus integrity and movement at the outlet from the cervical spine. The good news about the treatment is that it's usually remarkably quick, with changes in arm and neck movement and position, within one or two treatments. There may need to to be a few more treatments to stabilize the situation away from rebound, especially if the problem has been there for more than four weeks, but it's not unusual for a child to suddenly start rolling over for the first time within two days of the first treatment.