Trauma and Injuries

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.

Chiropractic, posture and risk of falling

https://www.researchgate.net/publication/378090792_Risk_of_Fall_Cognition_and_Static_Posture_in_Aging

I came across this very interesting article while listening to one of my chiropractic research podcasts. It reminded me of a conversation I had with a patient and her adult daughter who drove her to her appointment last year. The mother, in her early 80s, had moved closer to her daughter’s family and was trying to reestablish chiropractic care on a more consistent basis. She was a lifelong chiropractic patient, for episodic neck injuries and later on decided to stay on a preventive checkup schedule because she felt overall better and more balanced when she did so. During the history, her daughter chimed in on her mother’s comment that “ she has a tendency to be more clumsy and trip “ when she has not had a chiropractic check and adjustment in a while. The daughter was unfamiliar with chiropractic and simply curious about the correlation between the two. At the time, I share my 30 years of clinical experience in observing that correlation and the biological mechanisms connecting the chiropractic treatment on the neurological adjustment of proprioception and reflex time. I wish I had had that piece of research to add to the conversation.

The research led by a lesser known Brazilian colleague showed a correlation between two key measures of sagittal posture and the risk of fall: the degree of anterior neck shifting in relationship to the trunk, and the anterior angle of the ankle. Both indicating that the body is off its center of gravity and thus has less time to respond to stay upright before hitting the ground. Both posture indicators are exam findings that we observe and report, and both are factors that we aim to improve/correct with manual therapy and guidance on home activities and corrective exercises. One little golden nugget for me to take away from this research is that I can use it in conversation with patients when they question why I work on their lower extremities, especially their ankles and feet, when their primary problem seems to lie elsewhere. I almost often look at the lower extremity alignment when doing my initial evaluation and I will adjust them if needed, something that makes some folks a little testy when I ask them to take off their shoes and poke at one more body area. Now I can remind them that when I take on that additional endeavor at 5 pm, when their footsies are a little more “ aromatic”, it is indeed solely for their own benefit and backed by solid scientific research

(photo courtesy Freepik)

Can I have a pinched blood vessel ?

Patients will often precede a question with the disclaimer “ this may be a dumb question, but I am wondering if….”. This disclaimer almost always guarantees that they are usually pretty astute in their observation and closing in on some matter of importance.

The latest “dumb question” that came up this week was interesting: could my symptoms be caused by a pinched blood vessel ?  The patient had some pins and needles sensations in the front of the shoulder, they had noticed that the skin on the front of the arm was a little darker and a little colder than on the other side. Good logic led them to wonder if there was decreased blood flow in the affected area.

The surprising answer to that question is not only: yes !, but the fact that most instances of pinched nerves probably have some degree of pinched vascular structures that go along with the pinched nerve. And there is a very simple reason for that: if you go back to basic anatomy, nerves, arteries and veins very often travel as a trio before splitting off prior to their final destination. Anyone who has done college level anatomy will recall the acronym NAV, standing for  nerve, artery and vein, describing the bundles of the three structures lumped together. And anyone who has done anatomy cadaver dissection recalls how difficult it was to separate the three structures from each other and tell them apart.

From a practical and clinical standpoint, there is a lot of overlap in the symptoms of nerve and vascular compression. Both can cause pain, and both can cause abnormal sensation like numbness and tingling, making it difficult to differentiate them based on symptoms alone. Physical examination can be helpful, but also somewhat limited. Mild vascular compression can cause subtle swelling, changes in color and temperature, but those can be difficult to differentiate from inflammation related edema, and most body areas have collateral circulation that can take over when there is mild vascular compression from one source. 

In day to day chiropractic practice, we tend not to aim our treatment to relieve mild vascular compression independent from relieving nerve compression, which is probably why we talk about this topic infrequently. Relieving nerve compression is the main goal, and vascular structures will basically benefit from that approach. Nerve tissue and vascular tissues have distinct features that makes nerves more vulnerable in NAV bundles: they lack collateral back up, and they are not as adaptable to move out of the way of compressive forces. But that is not to say that some patients will show up with unusually strong vascular compression symptoms that need to be taken into account when setting up a treatment plan, for example limiting the use cold pack therapy and compression

Caregiver injuries and transfer belts

https://www.youtube.com/watch?v=5GC_OETvnRc

This video is geared for a wide audience, not just for the professionals in the personal care industry. Many of us are finding ourselves in a season of life involving caring for loved ones at home with progressive leg weakness and balance issues. I have treated enough injuries sustained in that context to spur this brief video on how you can prevent many injuries using this simple tool and technique. If you are not sure on how to use a transfer belt, please bring your own to your appointment and I will be glad to give you a short tutorial