Ruotures of the Achilles Tendon

RUPTURES OF THE ACHILLES TENDON Version III Rupture of the Achilles tendon is one of the most devastating injuries which the competitive and recreational athlete can suffer.   Overall it is not as common an injury as, for example, tendonitis of the elbow, but it is much more difficult to treat in the higher levels of competitive sports.   Although it is not entirely avoidable, there is much that can be done to reduce your chances of suffering such an injury. First it is necessary to understand the anatomy of the area.  The tendocalcaneus (Achilles tendon) is the thickest and strongest tendon in the human body.  It is approximately 15 cm long and begins in the mid-aspect of the calf and extends distally (towards the foot) to its insertion on the heel bone (calcaneus).  It actually originates from three separate muscles which join together to form the strong muscular group which is responsible for pushing the foot downward to provide the push-off for propelling the body forward.  This is especially accentuated in sports such as squash where a rapid push-off is required.  It is obvious, therefore, that when this tendon ruptures it is a major injury. The classic history of the injury is that it usually occurs in males, although it certainly occurs in females as well.  It most commonly affects people aged 30-50 but can cross all age groups.  Unfortunately, it can particularly affect athletes and will simply occur as they are pushing off to reach forward, although it has been known to occur when the athlete is simply in the ready position anticipating forward movement.  The classic story is that the athlete feels a sudden pain in or just below the calf and, due to the sudden nature of the pain and the sensation of a direct blow, turns around to see who hit him with the tennis ball.   The sudden pain stops play immediately and medical attention should be sought without delay. The medical and surgical treatment is controversial at times.  This is mostly related to the fact that treatment is difficult and there is no one simple answer to the problem.  The leg can either be operated on or casted for a prolonged period of time, and there are proponents of both types of treatment.  However, with either treatment there is a long period of casting and immobilization of up to ten weeks with a long and arduous course of physiotherapy after the casting is over.  Surgical repair is most commonly advocated for the more distal (lower) injuries which are closer to the insertion on the calcaneus (heel bone).   Often at higher levels of competition it is a career-ending injury in spite of vigorous surgical or casting treatment.  Although the athlete is able to recover, they rarely attain the high level of sport which they were at prior to the injury. It is obvious that the best thing to do with the injury is to avoid it in the first place.  This can be done very simply with stretching exercises prior to the workout.  All stretching exercises, whether they are done for the Achilles tendon or for any other muscle group in the body, should be done with the speed of a glacier; that is to say that they should not be rapid twisting motions or pumping motions up and down.  The affected area should be put on a stretch and then held for 15 seconds just below the feeling of discomfort.  The best way to determine exactly how much of a stretch should be put on a limb is strained but still comfortable.  The stretch should be held for 15 seconds and repeated several times prior to workout if the best results are to be obtained.  This also promotes flexibility as well as protecting the tendon from injury. By far the best treatment of this injury is prevention itself and although the stretching exercises do take a few minutes of time, they are well worth the effort and should be part of every athletes warm-up to avoid this devastating injury.

Information on Bunions

BUNIONS What is it? A bunion is a very common foot deformity that develops over the first metatarsal phalageal joint of the big toe of the foot. The joint that joins the big toe to the foot is called the first MTP joint. When it becomes prominent and the big toe starts to become crooked this is known as a bunion. The term referring to deformity of the big toe as it becomes crooked is called Hallux Valgus. It is the bump itself that is known as the bunion. When it gets red and swollen over the bunion because it gets sore this is usually due to an inflamed soft tissue over the underlying bone. Causes The commonest cause of bunions is prolonged wearing of poorly designed shoes such as the narrow high heels that women wear. This is one of the reasons why bunions are much more common in women than in men. There is also a hereditary component to bunions in that many times we will see a grandmother, mother and daughter all with various stages of bunions. 38% of women in the United States wear shoes that are too small and 55% of women have some degree of bunion formation. Bunions are 9 times more common in women than they are in men. History Left untreated bunions will gradually become worse especially if women continue to wear the narrow pointed shoes. Not all bunions progress because if the patient starts wearing good shoewear and they are caught early enough they may not get any worse. In general however, they will certainly not get any better no matter how they are treated. We generally reserve surgical treatment for bunions that are painful. If they are not painful they should simply be observed and shoewear modified. Occasionally the patient will want the bunion corrected for cosmetic reasons.

Treatment for "Sprained Ankle"

Treatment In the more mild forms of sprains the best treatment is known as R.I.C.E.  This is an acronym which stands for Rest, Ice, Compression, and Elevation.  The rest is quite self-explanatory and consists of non-weight bearing with crutches.  The ice should be applied as ice packs, and these should be applied for the first 72 hours as much as can be conveniently performed in order to keep the swelling down.  Compression consists of a tensor bandage which will help to limit the swelling, although occasionally a cast is required.  Elevation must be performed to help keep the swelling down.  This period of compression and elevation can often take up to 2-3 weeks if the sprain is bad enough.  As the pain subsides an exercise program with physiotherapy can be started to increase the strength of the ankle and foot muscles.  The advice of physiotherapists or similar knowledgeable individuals should be sought for proper teaching of these exercises. Although somewhat controversial it is rare to operate on even severely sprained ankle injuries.  In the U.S.A., immobilization involving bracing and non-weight bearing with crutches is usually employed. Depending upon the situation, the surgical repair for instability, whether acute or chronic, is a viable alternative and can be very gratifying. Prevention Perform stretching exercises. Use proper footwear.  Your shoe should have good lateral support, a relatively low heel (different from jogging shoes which have a built up heel and poor lateral stability) and rounded contours to avoid "going over."  Shoes with a higher boot top ("high cuts") may be indicated for those with chronic instability.  Lace-up ankle supports may be very helpful. Avoid uneven surfaces which might include anything from your opponents foot to poor court flooring to uneven training ground. Deciding on Surgery If you get repeated ankle spraining easily, you may need to have your ligaments reconstructed.  This will re-stabilize your ankle and allow you to return to sport without constantly worrying about re-spraining your ankle.  It is a very satisfying procedure, but like all surgeries, does carry some elements of risk to it.  Discuss these risks/advantages with your doctor.

The Lingering Effects of Whiplash

The Lingering Effects of Whiplash

Soft-tissue Injuries of the Cervical Spine 15-year Follow-up

Key Points from Dan Murphy

1)      At a mean of 15.5 years post whiplash trauma, 70% of whiplash-injured patients continued to complain of symptoms referable to the original accident.

2)      Long-term symptoms from whiplash injury include neck pain, arm paresthesia, back pain, headache, dizziness, and tinnitus.

3)      Women and older patients have a worse outcome from whiplash injuries.

4)      Radiating arm pain is more common in those with severe symptoms.

5)      Between 10 and 15 years after the accident, 18% of the patients had improved, whereas 28% had deteriorated.

6)      Soft-tissue injuries to the cervical spine may give persisting symptoms.

7)      Most whiplash-injured patients reach their final state by two years after being injured, but this study shows ongoing symptom fluctuation between years 10 to 15.

8)      At the 15-year follow-up, neck pain was present in 65% and low-back pain was present in 48%.

9)      80% of women and 50% of men continued to have symptoms at 15 years.

10)   Back pain and tinnitus increased between years 10 and 15.

11)   Symptoms remained static in 54%, improved in 18% and worsened in 28%.

12)   Degenerative changes are associated with a worse prognosis for recovery.

13)   60% of symptomatic patients had not seen a doctor in the previous five years because the doctors were unable to help them.

14)   18% had taken early retirement due to health problems, which they related to the whiplash injury.

15)   Whiplash symptoms do not improve after settlement of litigation.

16)   Most radiating pain is referral from the facets, and not radicular.

17)   Chronic whiplash symptoms will cause an abnormal psychological assessment after 3 months.

18)   In this study, 100% of patients with severe ongoing problems had cervical spine degeneration.

MIGRAINE HEADACHE PREVENTION

MIGRAINE HEADACHE PREVENTION

A very well researched naturopathy site, www.healthy-alternative-solutions.com, covers this well.

80% of adult migraine sufferers have food intolerance. This is immune based reactions, to foods most commonly eaten. Amine containing foods can also precipitate attacks.

A hypoallergenic, stone age diet, may help now.

If someone has a recent increase in the frequency of their migraines, I generally expect to find they have put their neck out.

A little known cause of headaches is sensitivity to alternating electromagnetic fields^1.
It is worth shifting bedside clock-radios and unplugging electric blankets at the wall socket rather than just turning the blanket off with its switch, etc, just as an experiment.

Copper deficiency may contribute to this last problem.

The Lingering Effects of Whiplash

The Lingering Effects of Whiplash

Soft-tissue Injuries of the Cervical Spine 15-year Follow-up

Key Points from Dan Murphy

1)      At a mean of 15.5 years post whiplash trauma, 70% of whiplash-injured patients continued to complain of symptoms referable to the original accident.

2)      Long-term symptoms from whiplash injury include neck pain, arm paresthesia, back pain, headache, dizziness, and tinnitus.

3)      Women and older patients have a worse outcome from whiplash injuries.

4)      Radiating arm pain is more common in those with severe symptoms.

5)      Between 10 and 15 years after the accident, 18% of the patients had improved, whereas 28% had deteriorated.

6)      Soft-tissue injuries to the cervical spine may give persisting symptoms.

7)      Most whiplash-injured patients reach their final state by two years after being injured, but this study shows ongoing symptom fluctuation between years 10 to 15.

8)      At the 15-year follow-up, neck pain was present in 65% and low-back pain was present in 48%.

9)      80% of women and 50% of men continued to have symptoms at 15 years.

10)   Back pain and tinnitus increased between years 10 and 15.

11)   Symptoms remained static in 54%, improved in 18% and worsened in 28%.

12)   Degenerative changes are associated with a worse prognosis for recovery.

13)   60% of symptomatic patients had not seen a doctor in the previous five years because the doctors were unable to help them.

14)   18% had taken early retirement due to health problems, which they related to the whiplash injury.

15)   Whiplash symptoms do not improve after settlement of litigation.

16)   Most radiating pain is referral from the facets, and not radicular.

17)   Chronic whiplash symptoms will cause an abnormal psychological assessment after 3 months.

18)   In this study, 100% of patients with severe ongoing problems had cervical spine degeneration.

7 bad foods that are actually good for you

           7 bad foods that are actually good for you

Are you shying away from bad foods that are actually good for you? With all the hoopla about healthful eating, it’s hard to separate fact from fiction. As a nutrition consultant, I’ve come to realize there is no shortage of surprises and superstitions in the world of nutrition. Here are reasons to enjoy some of your favorites.

Gluten and wheat
They are “the most demonized ingredients beyond high fructose corn syrup and hydrogenated oil,” said Melissa Abbott, culinary director at the Hartman Group, a company specializing in consumer research.
Yet decades of studies have found that gluten-containing foods, such as whole wheat, rye and barley, are vital for good health, and are associated with a reduced risk of diabetes, heart disease, cancer and excess weight.
“Wheat is a good source of fiber, vitamins and minerals,” said Joanne Slavin, nutrition professor at the University of Minnesota. She added that the confusion about gluten, a protein, has caused some people to avoid eating wheat and other grains.
Only about 1 percent of the population, or less, cannot tolerate gluten and must eradicate it from their diet to ease abdominal pain and other symptoms, including the ability to fully absorb vitamins.
One reason wheat-free or gluten-free diets are popular is that people who don’t eat wheat often end up bypassing excess calories in sweets and snack foods. Then they start feeling better, lose weight, and mistakenly attribute their success to gluten or wheat avoidance.

Eggs
Eggs also don’t deserve their bad reputation. In recent decades, their high cholesterol content has been thought to play a role in increasing LDL (“bad”) cholesterol and heart disease risk.
But cholesterol in food is a minor factor contributing to high blood cholesterol for most people, and studies have not confirmed a correlation between eggs and increased heart disease risk. The major determinant of LDL (bad) cholesterol is saturated fat, and while eggs are high in cholesterol — 184 milligrams in the yolk — they’re relatively low in saturated fat — about 1.6 grams in the yolk.
Interestingly, some of the biggest egg eaters in the world, the Japanese, have low cholesterol and heart disease rates, in part because they eat a diet low in saturated fat. In contrast, Americans eat eggs alongside sausage, bacon, and buttered toast.
“The amount that one egg a day raises cholesterol in the blood is extremely small,” says Walter Willett, professor of epidemiology and nutrition at Harvard’s School of Public Health. “Elevations in LDL (bad) cholesterol of this small magnitude could easily be countered by other healthy aspects of eggs.”

Potatoes
Potatoes have been blamed for increasing blood glucose levels, insulin resistance, excess weight and Type 2 diabetes. A recent Harvard study that followed large populations and their disease rates linked potato eating with being overweight, blaming it on the blood glucose rise.
But many foods, including whole-wheat bread and whole-grain cereals, cause similar spikes in blood glucose, and are correlated with superior health and lower body weights. How could the higher body weight in the Harvard study be explained?
The study lumped all potato products together, including potato chips and french fries, very fattening versions of potatoes usually eaten in large portions alongside hamburgers, hot dogs, and sodas.
“It’s an easy food to attack; but the meal pattern may be the culprit,” said David Baer, a research leader at the Agricultural Research Service of the Department of Agriculture. “Other epidemiological studies have not verified a connection between potatoes and weight gain or any diseases, and no clinical studies have shown a connection.”
Potatoes are a great source of potassium, Vitamin C and fiber that many cultures — Scandinavians, Russians, Irish, and Peruvians — relied on as a nutritious staple for centuries. And they were not fat.

 Fruits
People often ask me if fruit is too high in sugar, especially for diabetics. This fear of fruit, I believe, is left over from the Atkins craze, which discouraged eating some fruits on the grounds that they are high in carbohydrates.
Avoiding fruit could actually damage your health. Study after study over many decades shows that eating fruit can reduce the risk of some cancers, heart disease, blood pressure and diabetes.
Fruit is high in water and fiber, which help you feel full with fewer calories, one reason why eating it is correlated with lower body weight. Even though they contain simple sugars, most fruits have a relatively low glycemic index. That is, when you eat fruit, your blood sugar raises only moderately, especially when compared with refined sugar or flour products.
Several health organizations, including the U.S. Dietary Guidelines, the National Cancer Institute, and the American Heart Association, recommend Americans eat at least five cups of fruits and vegetables a day because of their superior health benefits.

Soy
Though popular for centuries in many Asian cuisines, soy is sometimes seen as dangerous after studies found elevated rates of breast cancer among rats when they were fed a concentrated soy derivative.
But studies looking at whole soy foods in humans have not found a connection. In fact, the reverse may be true.
Soy, “when consumed in childhood or adolescence may make breast tissue less vulnerable to cancer development later in life and probably has no effect on breast cancer risk when consumption begins in adulthood,” said Karen Collins, registered dietitian and nutrition adviser with the American Institute for Cancer Research.
Actually, Collins said, the evidence is so strong for protection against heart disease that the FDA allowed a health claim for labels on soy food products.

Alcohol
Alcohol is feared because of the potential for abuse and alcoholism and complications such as liver disease, which are valid concerns.
But decades’ worth of research shows that moderate alcohol consumption “can reduce deaths from most causes, particularly heart disease, and it raises HDL (good) cholesterol,” the USDA’s David Baer said.
Wine may have additional benefits because its grapes are filled with nutrients called polyphenols, which reduce blood-clotting, inflammation and oxidation.
The key is to drink alcohol moderately and with meals. What’s moderation? One serving daily for women and two servings for men, with a serving being 5 ounces of wine, 12 ounces of beer or 1.5 ounces of spirits.

Fried Foods
While it’s true that frying food usually increases its caloric content, that doesn’t necessarily make it unhealthful.
As long as food is fried in healthful oil instead of butter, shortening, or trans fat, and it’s eaten in moderation, it isn’t less healthy. In fact, fat-soluble vitamins A, D, E, and K, and heart-healthy, cancer-preventive carotenoids such as beta-carotene (e.g., carrots, sweet potatoes), lycopene (e.g., tomatoes) and lutein/zeaxanthin (deep-green leafy vegetables such as spinach and kale), need fat in order to be absorbed by the body.
“The consumption of certain fats, such as saturated fatty acids and trans fatty acids [fats that are solid at room temperature], is associated with an . . . increased risk of cardiovascular disease. On the other hand, the unsaturated fats, monounsaturated fatty acids and polyunsaturated fatty acids [canola, safflower and olive oils] have significant metabolic benefits and are health promoting,” said the 2010 U.S. Dietary Guidelines Advisory Committee.

The Economic Burden of WAD

THE ECONOMIC BURDEN OF WAD

Little is known about the individual and societal economic burden of WAD. For instance, little is known about the prevalence of long-lasting work disability due to WAD, which probably the most costly part. This burden is probably largely dependent on the legislation in different countries. In 2002, an independent and temporary Commission on whiplash-related injuries was informed in Sweden, initiated by the four largest motor vehicle insurers. The mandate of the 3-year commission was an examination of the problems of WAD from road safety, medical care, insurance and societal aspects. One of the conclusions of the final report was that the yearly cost for society and for the insurance industry was approximately SEK 1.5 billion (US$201million), while projected costs (i.e. what new cases of WAD arising in a particular year will cost society and insurers by the time the person reaches retirement age) amounted to SEK 4.6 billion (US$648 million). These calculations were based on an annual incidence of 30,000 WAD cases (324 per 100,000 inhabitants) in the year 2002. Since the report’s publication, the number of WAD cases have decreased dramatically to about 16,000 claims in 2008 (173 per 100,000 inhabitants), which, of course, has an impact on the overall costs.

Comparable data has not been found, but there is some evidence from a study that addressed the incidence of WAD in 10 European countries. The administrative data suggests that the total claims cost in Switzerland was 500 million Swiss francs (US$467 million). Switzerland’s population is 80% that of Sweden. Expenditures in addition to the claims cost was not reported in that study. 

WAD and Widespread Pain

WAD and Widespread Pain

One important aspect about the course of recovery from WAD is whether the neck injury is a trigger for subsequent widespread body pain. This has been suggested from cross-sectional studies, but knowing whether widespread pain came before the neck injury remains unclear from this type of study design. A potential aetiological explanation is a neurophysiological disturbance in the peripheral and central nervous system, which, in some stances, leads to an increased sensitivity to pain in other ‘uninjured’ areas. Another possible explanation for widespread pain is that new tissue damage may result from an altered pattern of movement in the body due to the neck pain. The exact aetiology of widespread pain is that new tissue damage may result from an altered pattern of movement in the body due to the neck pain. The exact aetiology of widespread pain is probably complex and multifactorial, but there are no indications that it would be specific to WAD. It can also occur after surgical intervention or any tissue damage. In addition, large prospective studies on pain of other aetiology have demonstrated that psychosocial factors at work, repetitive strains or other physical strains at work, awareness of symptoms and illness behavior may increase the risk of development of widespread pain. Thus, it seems that biological as well as psychological and social factors contribute to the development of widespread pain.

Prospective studies on WAD and its association with widespread pain are sparse and the evidence is not clear. The results from one study suggest a relationship between the onset of neck pain or other associated symptoms as well as self-perceived injury severity, after an MVC, and subsequent widespread pain. However, age, gender, health behavior and somatic symptoms prior to collision were at least as important. Another study investigated the incidence of onset of more extensive pain during 12 months of follow- up of WAD claimants, and associated factors with such an outcome. In that study, a less conservative definition of widespread pain was used and probably have resulted in higher incidences. The main conclusions were that widespread pain was common over a 12-month period (21%), but most improved over the follow- up period. Female gender, poor prior health, greater initial symptomatology (including pain intensity) and more depressive symptoms were associated with the development of extensive pain. The authors also found that local neck/ back pain, raising the question of the potential cause of widespread pain in other studies.

THE ECONOMIC BURDEN OF WAD

THE ECONOMIC BURDEN OF WAD

Little is known about the individual and societal economic burden of WAD. For instance, little is known about the prevalence of long-lasting work disability due to WAD, which probably the most costly part. This burden is probably largely dependent on the legislation in different countries. In 2002, an independent and temporary Commission on whiplash-related injuries was informed in Sweden, initiated by the four largest motor vehicle insurers. The mandate of the 3-year commission was an examination of the problems of WAD from road safety, medical care, insurance and societal aspects. One of the conclusions of the final report was that the yearly cost for society and for the insurance industry was approximately SEK 1.5 billion (US$201 million), while projected costs (i.e. what new cases of WAD arising in a particular year will cost society and insurers by the time the person reaches retirement age) amounted to SEK 4.6 billion (US$648 million). These calculations were based on an annual incidence of 30,000 WAD cases (324 per 100,000 inhabitants) in the year 2002. Since the report’s publication, the number of WAD cases have decreased dramatically to about 16,000 claims in 2008 (173 per 100,000 inhabitants), which, of course, has an impact on the overall costs.

Comparable data has not been found, but there is some evidence from a study that addressed the incidence of WAD in 10 European countries. The administrative data suggests that the total claims cost in Switzerland was 500 million Swiss francs (US$467 million). Switzerland’s population is 80% that of Sweden. Expenditures in addition to the claims cost was not reported in that study.

SUMMARY

In summary, as in almost all other diseases and injuries, factors that are involved in the risk or prognosis of WAD are multifactorial and constitute a web of biological, psychological and social components.

REFERENCES

1.      Crowe H. A new diagnostic sign in neck injuries. Calif Med 1964; 100:12-13.

2.      Gay J. Abbott K. Common whiplash injuries of the neck. JAMA 1953; 152:1698-704.

3.      Benson BW, Mohtadi NG, Rose MS, Meeuwisse WH. Head and neck injuries among ice hockey players wearing full face shields vs half face shields. JAMA 1999; 282(24):2328-32.

4.      Versteegen GJ, Kingma J, Meijler WJ, ten Duis HJ. Neck sprain not arising from car accidents: a retrospective study covering 25 years. Eur Spine J 1998;7(3):201-5.

5.      Lorish TR, Rizzo TD, Jr., Ilstrup DM, Scott SG. Injuries in adolescent and preadolescent boys at two larger wrestling tournaments. Am J Sports Med 1992;20(2):199-202.

6.      Spitzer WO, Skovron ML, Salmi LR, et al. Scientific Monograph of the Quebec Task Force on whiplash-associated disorders: redefining “whiplash” and its management. Spine 1995;20(8 Suppl):1S-73S.

7.      Holm LW, Carroll LJ, Cassidy JD, Ahlbom A. Factors influencing neck pain intensity in whiplash-associated disorders in Sweden. Clin J Pain 2007;23(7):591-7.

8.      Ferrari R, Russell AS, Carroll LJ, Cassidy JD. A re-examination of the whiplash-associated disorders (WAD) as a systematic illness. Ann Rheum Dis 2005:1337-42.

9.      Berglund A, Alfredsson L, Jensen I, et al. Occupant- and crash-related factors associated with the risk of whiplash injury. Ann Epidemiol 2003;13(1):66-72.

10.   Bylund P-O, Bjornstig U. Sick leave and disability pension among passenger car occupants injured in urban traffic. Spine 1998;23(9):1023-8.

11.   Versteegen GJ,Kingma J, Meijler WJ, ten Duis HJ. Neck sprain in patients injured in car accidents: a retrospective study covering the period 1970-1994. Eur Spine J 1998;7(3):195-200.

COURSE AND PROGNOSIS OF WAD AFTER A MOTOR VEHICLE CRASH

COURSE AND PROGNOSIS OF WAD AFTER A MOTOR VEHICLE CRASH

Course of Recovery

Understanding the course and prognosis in WAS is critical. Will people recover from this common injury? Is so, when? If the injury is transient and self-limiting, there would be no need for major prevention and intervention strategies. The natural course and prognosis of WAD has been a controversial matter. Some claim that the prognosis is solely determined by the physical injury and its severity, and that pre- and post-psychosocial factors are not relevant in recovery. Others claim that persistent WAD is mainly a ‘psycho-cultural’ illness, and refer to studies from Lithuania and Greece where there is no or little awareness or reporting of WAD resulting from a whiplash mechanism. Studies from these countries report that 2% or less of study participants report long-lasting symptoms after car collisions. However, drawing firm conclusions based on the findings of these studies is inappropriate, since ‘psychocultural’ factors were not studied per se. Nevertheless, when persons who do not experience neck pain following a car collision have been asked to report on which symptoms they would expect after neck injury or minor head injury, those from Lithuania and Greece do not expect to have as many symptoms or do not have as long-lasting symptoms compared to persons in Canada.

In the majority of studies, the recovery rate is substantially lower than recovery rates reported in Greece and Lithuania. Some report a 66-68% recovery rate at one year after the injury, whereas others report a less than 40% recovery rate at a similar time point. Differences in recovery rates are at least partially due to selection bias. For instance, in the study by Miettinen et al., only 58% of the invited study population was followed up 12 months post injury, so it was unknown what the recovery rate was for the 42% of participants who could not be contacted at follow-up.

Prognostic Factors

A prognostic factor is a factor that is independently associated with the prognosis, and which can contribute to or work against recovery from a condition. Some factors known to contribute to a poor prognosis in WAD are similar to those for other forms of persistent neck pain. These factors include, among others, passive coping strategies, poor mental health, high level of stress, high pain intensity and more ‘associated’ symptoms, such as arm pain, headache and nausea. Similar to the literature on neck pain in the general population, gender does not seem to be a clear prognostic factor in WAD, after adjustments have been made for psychosocial factors. This suggests that the observed poor prognosis in females in some studies might be explained in terms of the psychosocial factors rather than the biological factors of gender. Furthermore, societal factors, such as insurance systems with possibilities to claim for pain and suffering, and extensive healthcare utilization in the early stage of the injury, have been suggested to be associated with delayed recovery in WAD.

Surprisingly, the bulk of evidence suggests that crash-related factors (e.g. impact direction, awareness of collision, head position) are not associated with the prognosis.

There is evidence that people’s lowered expectations of recovery and return to work, assessed early in the process of recovery, are an important predictor for long-lasting WAD, even after controlling for other factors, such as prior health, pain areas and acute post-traumatic stress symptoms. An expectation is defined as a degree of belief that some as being tied to an outcome, such as a recovery state or return to work, rather than the individual behaviors required to achieve that outcome (self-efficacy expectations). It is believed to be influenced by personal and psychological features, such as anxiety, self-efficacy, coping abilities and fear, and recent studies have demonstrated that in those with WAD, initial pain, depressive symptomatology, and some crash and demographic factors were associated with recovery and return-to-work expectation.

Health expectations are postulated to be primarily learned from the cultural environment, and based on ‘prior knowledge’. The mechanism by which expectations influence emotional and physical reactions may also actually affect the autonomic nervous system, involving biochemical processes, which may explain some of the power observed in studies of the placebo and nocebo effect. These mechanisms help to explain why persons who strongly anticipate they will recover really do, and why strong expectations about bad health actually lead to bad health. A concept that is closely related to expectations is a person’s belief—the lens through which a person views the world—which is shaped by the environment. In a study where injured persons were asked about their belief of the origin of their neck pain (casual belief), those who believed that something serious had happened to their neck had greater perceived disability during follow-up compared to those who did not have such beliefs.

WAD and Widespread Pain

One important aspect about the course of recovery from WAD is whether the neck injury is a trigger for subsequent widespread body pain. This has been suggested from cross-sectional studies, but knowing whether widespread pain came before the neck injury remains unclear from this type of study design. A potential aetiological explanation is a neurophysiological disturbance in the peripheral and central nervous system, which, in some stances, leads to an increased sensitivity to pain in other ‘uninjured’ areas. Another possible explanation for widespread pain is that new tissue damage may result from an altered pattern of movement in the body due to the neck pain. The exact aetiology of widespread pain is that new tissue damage may result from an altered pattern of movement in the body due to the neck pain. The exact aetiology of widespread pain is probably complex and multifactorial, but there are no indications that it would be specific to WAD. It can also occur after surgical intervention or any tissue damage. In addition, large prospective studies on pain of other aetiology have demonstrated that psychosocial factors at work, repetitive strains or other physical strains at work, awareness of symptoms and illness behavior may increase the risk of development of widespread pain. Thus, it seems that biological as well as psychological and social factors contribute to the development of widespread pain.

Prospective studies on WAD and its association with widespread pain are sparse and the evidence is not clear. The results from one study suggest a relationship between the onset of neck pain or other associated symptoms as well as self-perceived injury severity, after an MVC, and subsequent widespread pain. However, age, gender, health behavior and somatic symptoms prior to collision were at least as important. Another study investigated the incidence of onset of more extensive pain during 12 months of follow- up of WAD claimants, and associated factors with such an outcome. In that study, a less conservative definition of widespread pain was used and probably have resulted in higher incidences. The main conclusions were that widespread pain was common over a 12-month period (21%), but most improved over the follow- up period. Female gender, poor prior health, greater initial symptomatology (including pain intensity) and more depressive symptoms were associated with the development of extensive pain. The authors also found that local neck/ back pain, raising the question of the potential cause of widespread pain in other studies.

Work absenteeism and work disability

Many persons with acute WAD also have some absence from work, and no clear difference occurs between ‘blue’ and ‘white’ collar workers. In one population- based study, 46% persons had been off work due to the injury. A similar figure (49%) was seen in a Dutch study. The majority of people returned to work within a few days and only 4-9% were reported to be off work at six months past injury. In a study form the Netherlands, factors associated with not returning to work were older age and concentration problems. There was no association between degrees of manual labor, (‘blue’ or ‘white’ collar work). 

RISK FACTORS FOR ONSET OF WAD

RISK FACTORS FOR ONSET OF WAD

A risk factor for an outcome (i.e. disease/injury) is a factor that is independently associated with the outcome or condition in question. Knowledge of the etiology (cause) of WAD is limited. One reason for this is the difficulty in obtaining accurate and appropriate denominators to calculate risks. Rather than using persons exposed to collisions as the denominator, researchers have used proxies, such as registered licensed drivers, population censuses, or persons involved in collisions where at least one person was injured. Some studies have adjusted for possible confounding factors, while others have not. A confounding factor is an independent risk factor for the outcome and is also associated with the exposure/risk factor of interest. Examples of possible confounding factors include gender, age, pre-collision physical and mental health, and severity and direction of crash impact.

Risk factors for WAD reported in published studies include presence of neck pain prior to the collision, being the driver or the front-seat passenger (compared to the rear-seat passenger), and being exposed to a rear-end collision or frontal collision rather than a side collision. Female gender has been suggested to be associated with a slightly higher incidence of WAD in some studies, but other studies have found no gender differences. All these studies have weaknesses, primarily, the lack of ‘true’ denominators and/or the limited possibility to control for potential confounding factors.

One possible risk factor for WAD is the severity of the crash (impact). The biomechanical research on WAD is mainly based on experimental studies using cadavers, volunteers and simulation experiments. So far, the injury mechanism has not been established as a known risk factor. Reasons for this may be that there are different injury mechanisms occurring with different crash types. Car occupant acceleration, velocity and rebound are all factors that should be considered. In much of the research, a major focus is on rear-end injury mechanisms despite consistent findings that rear-end collisions are only responsible for 40-55% of all cases of WAD in MVCs. However, there are some promising results from actual rear-end collisions in that the redesign of headrests and seats so that head/neck extension is limited in rear-end collisions has reduced the incidence of WAD. Before firm conclusions about the magnitude of such preventive interventions can be drawn, larger studies with well-defined outcome measures and controls for potential confounding factors are needed.

Risk Factors for WAD

RISK FACTORS FOR ONSET OF WAD

A risk factor for an outcome (i.e. disease/injury) is a factor that is independently associated with the outcome or condition in question. Knowledge of the etiology (cause) of WAD is limited. One reason for this is the difficulty in obtaining accurate and appropriate denominators to calculate risks. Rather than using persons exposed to collisions as the denominator, researchers have used proxies, such as registered licensed drivers, population censuses, or persons involved in collisions where at least one person was injured. Some studies have adjusted for possible confounding factors, while others have not. A confounding factor is an independent risk factor for the outcome and is also associated with the exposure/risk factor of interest. Examples of possible confounding factors include gender, age, pre-collision physical and mental health, and severity and direction of crash impact.

Risk factors for WAD reported in published studies include presence of neck pain prior to the collision, being the driver or the front-seat passenger (compared to the rear-seat passenger), and being exposed to a rear-end collision or frontal collision rather than a side collision. Female gender has been suggested to be associated with a slightly higher incidence of WAD in some studies, but other studies have found no gender differences. All these studies have weaknesses, primarily, the lack of ‘true’ denominators and/or the limited possibility to control for potential confounding factors.

One possible risk factor for WAD is the severity of the crash (impact). The biomechanical research on WAD is mainly based on experimental studies using cadavers, volunteers and simulation experiments. So far, the injury mechanism has not been established as a known risk factor. Reasons for this may be that there are different injury mechanisms occurring with different crash types. Car occupant acceleration, velocity and rebound are all factors that should be considered. In much of the research, a major focus is on rear-end injury mechanisms despite consistent findings that rear-end collisions are only responsible for 40-55% of all cases of WAD in MVCs. However, there are some promising results from actual rear-end collisions in that the redesign of headrests and seats so that head/neck extension is limited in rear-end collisions has reduced the incidence of WAD. Before firm conclusions about the magnitude of such preventive interventions can be drawn, larger studies with well-defined outcome measures and controls for potential confounding factors are needed.

EPIDEMIOLOGY OF WHIPLASH ASSOCIATED DISORDERS

EPIDEMIOLOGY OF WHIPLASH ASSOCIATED DISORDERS

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

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

               

      Whiplash is an acceleration-deceleration mechanism of energy transfer to the neck. It may result from rear-end or side-impact motor vehicle collisions, but can also occur during diving or other mishaps. The impact may result in bony or soft-tissue injuries (whiplash injury) which in turn may lead to a variety of clinical manifestations (whiplash-associated disorders). The reason for excluding frontal collisions from the definition is not discussed in the report and is likely to be an error, since it is known that 25-30% of whiplash injury occurs in such impact direction. The QTF also suggested a classification of WAD into five categories based on clinical signs and symptoms. This classification is mostly used to classify WAD in the acute phase.

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

Is it safe to go to a chiropractor while pregnant?

Is it safe to go to a chiropractor while pregnant?

Not only is it safe to visit a chiropractor during your pregnancy, it’s also highly beneficial. All chiropractors are specially trained to treat pregnant women, but you may want to do a little research and find one who specializes in prenatal or perinatal care. Getting regularly adjusted while pregnant is a great way to relieve the added stress on your spine that comes along with the weight gain. It can also prevent sciatica, the inflammation of the sciatic nerve that runs from your lower back down through your legs and to your feet. It’s also important to maintain pelvic balance, which is oftentimes thrown off as your belly grows and your posture changes.

Besides making you feel better during pregnancy, getting regular chiropractic adjustments can also help control nausea, prevent a potential C-section, and has even been linked to reducing the amount of time some women spend in labor.  www.thebump.com

Chiropractic care through pregnancy is not only safe, it is essential. We can look at the implications of subluxation from a bio mechanical, hormonal and neurological standpoint. It is easy for all of us to see postural changes through pregnancy-the centre of gravity changes, the weight of the baby places increased pressure on the spine and pelvis, and towards the end of the pregnancy, changes are seen in gait pattern-the "waddle." What we can't see, are the millions of different hormonal changes and chemical reactions occurring both in the mother and the developing baby--all of which are controlled and coordinated through the nervous system.

Adjustments result in easier pregnancy, significantly decreased mean labor time, and assists new mothers back to prepartum health. In one study, women receiving Chiropractic care through their first pregnancy had 24% shorter labor times than the group not receiving Chiropractic, and multiparous subjects reported 39% shorter labor times. Thirty-nine percent-that's a massive difference. In addition, 84% of women report relief of back pain during pregnancy with Chiropractic care. Because the sacroiliac joints of the pelvis function better, there is significant less likelihood of back labor when receiving Chiropractic care through pregnancy.

Body position during delivery is also critical. Any late second stage labor position that denies postural sacral rotation denies the mother and the baby critical pelvic outlet diameter and jams the tip of the sacrum up to 4cm into the pelvic outlet. In other words, the popular semi-recumbent position places the laboring woman on her back onto the apex of the sacrum, which closes off the vital space needed for the baby to get through the pelvic outlet.

Workers' Compensation

Workers’ Compensation

There is increased use of the Guides to translate objective clinical findings into a percentage of the whole person. Typically this number is used to measure the residual deficit, a loss--a number that is then converted to a monetary award to the injured party. The scheme is most commonly used in various workers’ compensation systems in the United States and abroad.

In the United States, 44 states, 2 commonwealths, and federal employee compensation systems (in about 90+% of US jurisdictions) either mandate or recommend using the Guides to measure impairment in workers’ compensation cases, the Guides is often used to assess damages in personal injury claims under federal statutes and state common law.

Whiplash Stone Mountain Doctor

Whiplash?

Whiplash is an injury caused by the neck and head being thrown suddenly backward then forward upon impact. The impact forces the neck and head beyond their normal range of movement, causing tissue damage and pain.

But what is Whiplash?

Causes of Whiplash:

Car accidents
A sports injury
Shaken baby syndrome (which is child abuse)

Symptoms of Whiplash

Whiplash is a term used most often to describe the symptoms resulting from a car accident. A victim of whiplash may experience any or all of these symptoms:

• Headaches
• Pain in the shoulders
• Pain between the shoulder blades
• Pain in one or both arms
• Fatigue
• Dizziness
• Vision problems
• Ringing in the ears (tinnitus)
• Poor concentration or memory
• Neck pain/stiffness
• Tight muscles
  
• Tenderness in the muscles
• Low back pain
• Sleep disturbance
• Loss of motion in the neck

It's Best to See a Doctor
Even without symptoms, it is a very good idea to see a doctor in the case of a car accident. There can be damage without symptoms, or there can be delayed symptoms. Your doctor can help to determine the location and extent of the damage and develop an appropriate treatment plan.

According to a study done in 2006 at the Medical College of Wisconsin, whiplash due to a rear end collision can be prevented with positioning of the head close to the headrest

.

Sources:
1. Whiplash. (2005). In MedlinePlus [Web]. National Institute of Health. Retrieved 12 22 2006, from http://www.nlm.nih.gov/medlineplus/ency/article/000025.htm

2. Stemper, Brian, Ph.D., Yoganandan, Narayan, Pintar, Frank, (2006).Effect of head restraint backset on head-neck kinematics in whiplash.. Accident Analysis and Prevention. 38, 317-323.

Whiplash Symptoms

Whiplash is a nonmedical term used to describe neck pain following an injury to the soft tissues of your neck (specifically ligaments, tendons, and muscles). It is caused by an abnormal motion or force applied to your neck that causes movement beyond the neck's normal range of motion.

* Whiplash happens in motor vehicle accidents, sporting activities, accidental falls, and assault.

* The term whiplash was first used in 1928, and despite its replacement by synonyms (such as acceleration flexion-extension neck injury and soft tissue cervical hyperextension injury), it continues to be used to describe this common soft tissue neck injury. Your doctor may use the more specific terms of cervical sprain, cervical strain, or hyperextension injury.

The most frequent cause of whiplash is a car accident. The speed of the cars involved in the accident or the amount of physical damage to the car may not relate to the intensity of neck injury; speeds as low as 15 miles per hour can produce enough energy to cause whiplash in occupants, whether or not they wear seat belts.

* Other common causes of whiplash include contact sport injuries and blows to the head from a falling object or being assaulted.

*Repetitive stress injuries or chronic strain involving the neck (such as using your neck to hold the phone) are a common, non-acute causes.

These signs and symptoms may occur immediately or minutes to hours after the initial injury; the sooner after the injury that symptoms develop, the greater the chance of serious damage.

* Neck pain

* Neck swelling

* Tenderness along the back of your neck

* Muscle spasms (in the side or back of your neck)

* Difficulty moving your neck around

* Headache

* Pain shooting from your neck into either shoulder or arm

Who's at Risk of Developing Chronic Whiplash?

Auto injuries are a common problem seen in clinical practice. Most of the time, a patient will have some temporary discomfort that will resolve within a few weeks. A significant percentage of patients – around 20 to 30% – will develop some kind of chronic pain or disability from their injury. Four recent studies have looked at the issue of chronic pain to see if there are any predictive factors that can help us determine who is at risk of developing long-term problems.

The following is a list of documented risk factors found in these studies:

Gender. One of the four studies4 found that women were more likely than men to be injured in general, which confirms previous studies. Researchers speculate that the lower muscle mass in female necks may increase the risk of injury.

Turned head. Two recent studies have been done on this issue, and they both have found that when the occupant’s head is turned at the moment of impact, the spine is exposed to motion that exceeds the normal physiological range. This can result in ligament tears or damage to the spinal nerve roots.2

Direction of impact. It has been known for years that a rear-end collision is more likely to result in injury than is a frontal collision. Pape et al.1 found in their study that rear-end collisions were a greater risk factor than frontal impacts.

Previous injuries. It’s not surprising that a pre-existing injury to the neck or shoulder could be worsened after an auto collision, and that’s what Pape et al.1 found. In fact, patients with a history of neck and/or shoulder pain were more than twice as likely to have chronic problems three years after the collision.

Muscular tension immediately after the crash. Pape et al.1 found that patients with increased muscular tension soon after the crash were 3.43 times as likely to develop long-term symptoms.

Reduced range of motion. Sterling et al.3 found, as have other studies, that reduced ROM predicts symptoms two to three years after the injury.

Immediate pain and/or numbness. Both Sterling3 and Berglund4 found that patients who reported symptoms immediately after the crash were more likely to develop chronic pain. Immediate numbness indicates that the patient suffered some kind of nerve injury in the collision, and unless these types of injuries are diagnosed and treated quickly, they could easily develop into chronic pain. Berglund4 found that these patients were 6.5 times as likely to develop long-term problems.

The issues of reduced ROM and increased muscular tension are related, and understanding this issue is critical in treating auto injury patients. Upon injury to the disk or ligaments of the spine, an immediate reflex reaction is instigated – causing surrounding muscles to contract. This muscular guarding can be palpated as tension or inflammation. The increased muscular activity has the result of restricting ROM. How do these symptoms predict chronic pain? If the underlying tissue damage – ligament or disk – does not heal properly, long-term pain and restricted motion can result.

These studies help us treat auto injury cases in two ways: first, they demonstrate the need to take a careful and thorough history of the collision. For instance, asking the patient if his or her head was turned at the moment of impact can help us diagnose the injury. Second, by being aware of risk factors, we can focus our attention on those patients more likely to suffer long-term consequences of their injury.

1. Pape E, Brox JI, Hagen KB, et al. Prognostic factors for chronic neck pain in persons with minor or moderate injuries in traffic accidents. Accident Analysis and Prevention 2007 Jan;39(1):135-46.
2. Panjabi MM, Ivancic PC, Maak TG, et al. Multiplanar cervical spine injury due to head-turned rear impact. Spine 2006;31(4):420-429.
3. Sterling M, Jull G, Kenardy J. Physical and psychological factors maintain long-term predictive capacity post-whiplash injury. Pain 2006;122:102-108.
4. Berglund A, Bodin L, Jensen I, et al. The influence of prognostic factors on neck pain intensity, disability, anxiety and depression over a 2-year period in subjects with acute whiplash injury. Pain 2006;125(3):244-56.