Definition of Pain

Definition of Pain

The International Association Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” Pain is a prominent symptom in many acute injuries and illnesses, and often subsides as the medical condition resolves. Since such acute pain is usually short lived, it is not a problem that is considered in an impairment rating system. However, chronic pain is a problem that potentially could be the cause for an impairment rating. The definition of chronic pain is imprecise but, in a general way, it refers to pain that persists over time. For the purposes of the Guides, chronic pain is defined as pain that persists beyond the expected healing time of the medical disorder thought to have initiated the pain. For many sections in the Guides, chronic pain will be pain that persists beyond 3 months, as most common conditions affecting the musculoskeletal and other organ and systems will substantially heal in this time frame. The nervous system is a notable exception. Although any time point is arbitrary, 3 months should encompass the expected healing time in most situations where there is tissue injury but will allow for situations in which there is no expected healing time. 

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.

Soft Tissue Injuries

Soft Tissue Injuries

Injuries to the soft tissues of the body are probably the most frequent cause of musculoskeletal dysfunction. With the recent development and implementation of MRI, it is now possible to evaluate noninvasively all the soft tissue structures in the body (eg, muscles, tendons, ligaments, and cartilage) that may be responsible for a patient’s symptoms. Ultrasonography is also used to assess soft tissue disorders of the musculoskeletal system. The major advantage of US is its availability, safety, and lower cost compared with MRI. It is waves; thus osseous structures or soft tissues shielded by osseous tissue cannot be evaluated. Compared with the other imaging modalities the efficacy of US is heavily dependent on the operator of the equipment, but this should not preclude its use in appropriate clinical situations. Considering its cost and availability, the role of US may grow as staff in more centers become proficient in its application. This is already true in many European countrieswhere US is heavily used in the evaluation of musculoskeletal disorders. The following sections present the role of radiologic imaging in the assessment of patients with musculoskeletal injuries. 

The Cervical Spine

The Cervical Spine

Axioms of Cervical Spine Assessment

1.      Cervical spine syndromes are extremely common and are probably the fourth most common cause of pain.

2.      At any given time, 9% of men and 12% of women have neck pain with or without arm and hand pain, and 35% of the population can remember having had neck pain at some time.

3.      The cervical spine is the origin of a large proportion of shoulder, elbow, hand, and wrist disorders.

4.      Most people who develop pain in the neck do not seek medical attention because they regard such pain as a part of life, so they simply wait for it to disappear.

Disability and Handicap

Disability and Handicap

Disability is a present when a tissue, organ, or system cannot function adequately. A handicap exists when disability interferes with a patient’s daily activities or social/occupational performance. A marked disability does not necessarily cause a handicap. Conversely, minor disability may produce a major handicap. Both conditions require separate assessment. Patients’ perception of their problems will be molded by their adaptation to the depreciated tissue as well as their aspirations for recovery. 

Assessing Disability

An aid in assessing the more important aspects of disability is the PILS mnemonic, which considers four issues:

1.      P Preventable causes of disability (e.g., falls, direct trauma)

2.      I Independence (e.g., self-care)

3.      L Lifestyle (roles, goals)

4.      S Social factors (e.g., family, friends, shelter)

Functional Assessment

A complete functional assessment includes evaluation of the following:

1.      Self-care: ability to wash, bath, attend to toilet needs, dress, cook, and feed oneself

2.      Mobility: ability to stand, transfer, walk, negotiate stairs, drive, and use public transportation

3.      Lifestyle: nature of occupation, work capacity, and Social Security benefits

Clinical Pearl

Clinical Pearl

A straight-leg-raising test this is positive under 30 degrees reveals a large disc protrusion. The nerve root is stretched long before it would normally be. The straight-leg-raising test is most useful for identifying L5-S1 disc lesions because the pressures on the nerve root are highest at this level. During straight leg raising, L4-L5 is not as apt to give as much pain as L5-S1 because the pressure between the disc and the nerve root at L4-L5 is half that at L5-S1. Therefore the L5-S1 disc lesion gives more pain in the lower back and leg than does the L4-L5 disc lesion. No movement on the nerve root occurs until straight leg raising reaches 30 degrees. No movement on L4 occurs during a straight leg raising test. From this, the presence of Turyn’s sign indicates a large disc protrusion at the level of the L5-S1 nerve root.

Whiplash and Auto Accidents

Whiplash and Auto Accidents

1. A Minor Accident Equals A Big Problem Presented
2. From the State of Florida Department of Highway Safety and Motor Vehicles The following crash information is compiled from traffic crash reports (long form) submitted by Florida Law Enforcement Agencies: *Low-speed crashes are when no vehicles are traveling over 10 mph and does not include bicycles or pedestrians.
3. “ The National Highway Traffic Safety Administration reports that, in 1995, there were 5,500,000 Americans injured in motor vehicle crashes (MVCs).” Freeman, Croft, Rossignol, Weaver, Reiser (1999-01-01). “A Review and Methodologic Critque of the Literature Refuting Whiplash Syndrome.” Spine 24(1), p. 86-98.
4. There were an estimated 6,289,000 car accidents in the U.S. in 1999. There were about 3.4 million injuries and 41,345 people were killed in auto accidents in 1999. Freeman, Croft, Rossignol, Weaver, Reiser (1999-01-01). “A Review and Methodologic Critque of the Literature Refuting Whiplash Syndrome.” Spine 24(1), p. 86-98.
5. 39.6% of those injured in a rear-end motor vehicle crash have chronic neck pain seven years later. This means that there is an approximate three times increased probability for neck pain for those injured in a motor vehicle crash seven years later. J Clin Epidemiol. 2000. Nov;53(11)1089-94
6. • The primary injury is to the soft tissues.
   • The initial injury causes an increased mobility of the injured joints (increased flexibility).
   • The injuries result in substantial percentage of individuals with chronic symptoms.
   • The injuries can not be identified with available imaging methods.
   • With time, symptoms may become chronic because of clinical instability.
   • The most common site of injury is at C5-C6 level, and injury occurs in extension.
   MM Panjabi, K Nibu, J Cholewicki. (1998-06-01). “Whiplash injuries and the potential for mechanical instability.” Eur Spine J . 7(6):484-92.
7. Victims of motor vehicle crashes are likely to develop chronic and multiple symptoms. In North America, motor vehicle crash soft tissue injuries of the neck are increasing, even though fatal motor vehicle crashes are decreasing. These injuries can result in substantial levels of disablement, even following a rear-end collision that seemed innocuous at the time of the crash. Whiplash injuries can create physical and psychological problems for an individual, as well as a financial burden for both the individual and society. Journal of Musculoskeletal Pain. A prospectice study of acceleration-extension injuries following rear-end motor-vehicle crashes . Vol. 8(½), 2000, p. 97-113.
8. Damage begins within 2 weeks of having a car accident. This injury to the spine causes a cycle of degeneration that leads to nerve damage. Research shows that if left uncorrected, permanent scar tissue forms. Wound Healing: Alternatives in Management p 18-19.
9. At 6% strain, the function of the nerve had decreased by 70% in one hour. The nerve returned to normal during the recovery period. At 12% strain, the nerve was completely blocked after one hour. Minimal recovery ocurred. Wall EJ, Massie JB, Kwan MK, Rydevik BL, Myers RR, Garfin SR: Experimented stretch neuropathy. Changes in nerve conduction tension. J Bone Joint Surg Br January 1992; 74(1), pages 126-129.
10. Dr. Sharpless states, “It takes the pressure of a dime on a nerve to take away 60% of its function.” Sharpless, SK: Susceptibility of Spinal Roots to Compression Block, NINCDS Monograph 15, DHEW publication (NIH) 76-998, 1975, p 155-161.
11. A Broken Wrist Is An Event...
    • And it is treated like an event…it is set & put in a cast.
    • BUT THEN it takes time to heal!
    • Healing is a process and all processes take time.
12. 75% of patients with whiplash injuries will heal spontaneously in 2-3 months. These patients sustained minor injuries to their muscles and ligaments, but not to their discs or zygophyseal joints. Bansley, Lord, Bogduk. Whiplash Injury: Clinical Review . Pain 58, 1994, 283-307.
13. One-third of all patients with whiplash injuries were still symptomatic 2 years after the accident. The other two-thirds were symptom-free by the end of 2 years. Of these patients, 88% were symptom-free within 2 months. Barnes & Allen, Whiplash Injutries of the Neck: A Retrospective Study , p. 395.
14. 10% of patients with whiplash injuries develop constant severe indefinite neck pain. 1% of the people in the entire population have chronic neck pain caused by whiplash injury. 0.4% of the people in the entire population have severe chronic neck pain caused by whiplash injury. Bansley, Lord, Bogduk. Whiplash Injury: Clinical Review . Pain 58, 1994, 283-307.
15. 25% of patients with whiplash injuries will progress to chronic symptoms. These patients injured their intervetebral discs, zygapophyseal joints, or alar ligaments. These patients will not resolve spontaneously and they do become chronic. Bansley, Lord, Bogduk. Whiplash Injury: Clinical Review . Pain 58, 1994, 283-307.
16. After 2 years follow-up, 44% of those initially presenting with only symptoms had residual complaints. 81% of those with initial symptoms and physical findings were symptomatic, while those with neurologic involvement were 90% symptomatic. Hohl, The Cervical Spine , Fractures and Dislocations, p. 440.
17. In An Automobile Accident...
    • Women are more vulnerable to injury.
    • Women are more likely to suffer long-term consequences from an injury.
    Accident Analysis & Prevention. How crash severity in reat impacts/influences short and long-term consequences to the neck . Vol. 32, Issue 2; March 2000; p. 187-195.
18. Rear End Collisions Deans, Neck Sprain - A Major Cause of Disability Following Car Accidents , p. 10. Holm, in The Cervical Spine , Lippincott, 1989, p. 440. Rear-end collisions cause extension-acceleration whiplash injuries, which are considered to cause the greatest damage. Follow-up x-rays taken an average of 7 years after injury in one series of patients without prior roentgenographic evidence of disc disease indicated that 39% had developed degenerative disc disease at one or more disc levels since the injury.
19. Head Rotation Cailliet, Neck and Arm Pain , F.A.Davis Company, 1981, p. 85. McCain, Clinical Spectrum and Management of Whiplash Injuries , p. 316. If the head is turned at the moment of impact, there is increased injury on the side to which the head is turned, as: “not only will the already narrowed foramen be compressed more, but the torque effect on the facets, capsules, and ligaments will be far more damaging.”
20. The head being turned at the moment of impact increases injury.
    • When the hyperflexion-hyperextension or hyperextension-hyperflexion occurs with head rotation present, the pattern of tissue injury is different, and the extent of damage produced is always more severe. Rotation increases stress in certain soft tissue structures, which then reach their limit of motion at an earlier point, thus resulting in more severe injury with less application of force.
    Webb, Whiplash: Mechanisms and Patterns of Tissue Injury , Journal of the Australian Chiropractors’ Association, June, 1985. McCain, Clinical Spectrum and Management of Whiplash Injuries , p. 316.
21. Lack of Awareness Ryan, Neck Strain in Car Occupants: Injury Status after 6 Months and Crash-Related Factors , p. 536. McCain, Clinical Spectrum and Management of Whiplash Injuries , p. 316. Sturzenegger, The Effect of Accident Mechanisms and Initial Findings on the Long-Term Course of Whiplash Injury , p. 446-447. Being caught by surprise or being unaware prior to impact worsens the prognosis.
22. A Pre-Existing Degenerative Condition Cailliet, Neck and Arm Pain , F.A. Davis Company, 1981, p. 103. Turek, Orthopaedics Principles and their Applications , Lippincott, 1977, p. 740. The injury may be compounded by the presence of degenerative disc disease of the spine. With advancing age, especially in the presence of degenerative disc disease, the tissues become inelastic and are easily torn.
23. Gray’s Anatomy, page 4, states “The nervous system regulates and coordinates all functions of the body.” (This includes seeing, digesting, breathing, eliminating, etc.) The autonomic nervous system regulates the actions of organs, glands, and blood vessels. Thermography (heat scan) allows the chiropractor to detect interference in your nervous system from the injury.
24. ABNORMAL NORMAL
25. THE COLLAPSE OF THE MEDICAL MODEL
    • 3rd Leading Cause of Death in the U.S. (Heart Disease, Cancer)
    • 1. 180,000 Iatrogenic Injury
    • 3 Jumbo Jet Crashes every 2 days - JAMA 1994
    • (Swissair Jet Flight 111-229 Die)
    • 2. 106,000 Drug Reactions
    • 3. 80,000 Medical Malpractice
    • According to the Dean of the University of Arizona: College of Pharmacy, “We spend $75 billion for drugs annually and $76 billion of the problems caused by drugs.”
26. Pain Pill Research Overuse Linked to Kidney Damage A study, published in a recent issue of the New England Journal of Medicine , found that the risk of kidney failure appeared to be doubled by either heavy average use (more than 365 pills in a year) or moderate cumulative use (more than 1,000 pills in a lifetime). IBUPROFEN Brand Names : Advil, Nuprin Advantages : Relieves pain, fever, and inflammation. Disadvantages : Interferes with clotting. May cause stomach bleeding, ulcers and irritation. Heavy or prolonged use may damage liver and kidneys. ACETAMINOPHEN Brand Names : Tylenol, Datril Advantages : Relieves pain and fever. Does not irritate stomach. Disadvantages : Heavy or prolonged use may damage liver and kidneys. NAPROXEN Brand Names : Aleve Advantages : Relieves pain and fever. One dose lasts 8-12 hours. Disadvantages : May cause stomach bleeding, ulcers and irritation. Prolonged use may harm kidneys. Associated Press. Studies , p. A7
27. Did You Know...
    • People over 60 make up about 17% of the U.S. population, but they take 40% of all prescribed drugs and average 8 different drugs each year?
    • In 1991, the average American was prescribed 6½ drugs, and the average cost of each was $22.50?
    • The drug business is now the most profitable business in America, and today more than 50% of the world’s drugs are consumed in the U.S.?
    • In 1979, the average American was prescribed one drug per year with an average cost of $5.50?
28. • Chiropractic is based on two facts of reality:
    • The body is a self-healing and self-regulating organism (if you cut yourself, it will heal).
    • The nervous system is the master system and controller of the body.
    • Therefore, if there is any interference with nerve function, there must then be interference with healing and regulation. People do not lose their health do to the lack of drugs in the blood, etc…Something inside is interfering with health expression. Let me explain what a vertebral SUBLUXATION is...
29. Following the chiropractic treatment, 93% of the patients had improved. “ The results of this retrospective study would suggest that benefits can occur in over 90% of patients undergoing chiropractic treatment for chronic ‘whiplash’ injury.” Woodward, Cook, et al. (1996). “Chiropractic treatments of chronic ‘whiplash’.” Injury 27(9), p. 643-645.
30. A retrospective study from the journal Injury , in 1996, demonstrated that chiropractic treatment benefited 26 of 28 patients (93%) suffering from chronic whiplash syndrome. Khan, Cook, Gargan, Bannister. Journal of Orthopaedic Medicine 21(1), 1999, p. 22-25.
31. Controlled experimental and clinical trials have yielded convincing evidence that early, controlled mobilization is superior to immobilization for musculoskeletal soft-tissue injuries. The superiority of early controlled mobilization is especially apparent in terms of producing quicker recovery and return to full activity, without jeopardizing the long-term rehabilitative outcome. The Physician and Sports Medicine. Immobilization or early mobilization after an acute soft-tissue injury ? Vol. 26, No. 3; March, 2000, p. 55-63.
32. Chiropractic Adjustments...
    • This controlled movement allows the injured tissues to heal better and quicker
    • This controlled movement improves the fluid exchanges of the disc and synovial fluid, which reduces pain and joint degeneration.
    • This controlled movement initiates a neurological sequence of events that causes pain inhibition. (Decreases the Pain)
    Murphy. Whiplash Overview 2001 .
33. Should I Be Evaluated?
    • Neck Pain
    • Neck Stiffness
    • Shoulder Pain
    • Headache
    • Pain Between Shoulder Blades
    • Back Pain
    • Numbness/Tingling
    • Pain in Arms
    • Pain in Legs
    • Dizziness or Lightheadedness
    • Blurring/Double Vision
    • Difficulty Swallowing
    • Pain in Wrists/Hands
    • Pain in Ankles/Feet
    • Loss of Memory or Concentration
    • Ringing in Ears
    • Pain in the Face/Jaw