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SOFT TISSUE INJURY 101
Presented by Dr. Paul Ettlinger
DR. PAUL ETTLINGER
• BS in Biology from UMBC, 1992• DC from Logan College of Chiropractic in St. Louis, MO, 1995• Licensed in Maryland with Physical Therapy privileges• Opened Health Quest Chiropractic & Physical Therapy in
June, 1998• Lecturer to local businesses• Former Insurance Committee Chairman for MCA• Extensive post-doctorate training in soft tissue injuries and
rehabilitation• 100 post-graduate hours of training in Forensics (NBOFC)• Provider of Independent Medical Examiner services
87% of Bodily Injury claims included sprains/strains*
* Insurance Research Council 2003
WHY ARE WE HERE?
• Basic anatomy• Definition of terms• Aspects of treatment• Factors influencing healing/length of treatment• Signs of over-utilization• Property damage vs. personal injury• Q & A
SOFT TISSUE INJURY 101
TAKE-HOME MATERIALS
• Copy Of Presentation• Sample Documents• Definitions/Explanations• Research Citings• Contact Information
Cervical spine (7)
Thoracic spine (12)
Lumbar spine (5)
SacrumCoccyx
BASIC ANATOMY – SECTIONS OF THE SPINE
MOTION OF THE NORMAL NECK
BASIC ANATOMY – THE VERTEBRAE
Spinous ProcessSpinal Cord
Annulus
Facet Joint (Covered By
Capsule)
Spinal Nerve
Transverse Process
Nerve Root
BASIC ANATOMY – LIGAMENTS OF THE SPINE
Intratransverse Ligament
Posterior Longitudinal Ligament
Anterior Longitudinal Ligament
Intraspinous Ligament
Supraspinous Ligament
Facet
Ligamentum Flavum
Capsulary Ligament
BASIC ANATOMY – LIGAMENTS OF THE SPINE
Ligaments attaching spine to pelvis
BASIC ANATOMY – SUPERFICIAL MUSCLES
BASIC ANATOMY – INTERMEDIATE MUSCLES
DEFINITION OF COMMON TERMS
• SOAP – Subjective, Objective, Assessment, Plan
• Palpation – examine by touch
• Lordosis –forward curvature of the spine in the cervical and lumbar regions
• Muscle Spasm – involuntary contraction of a muscle limiting normal range of motion
• Contusion – the skin is not broken but the subsurface tissue is injured (bruise)
• Abrasion – scraped spot or area
• Lesion – localized, abnormal structural change in the body
DEFINITION OF COMMON TERMS
• Sprain – injury to ligaments
• Strain – injury to muscles
• Radiculitis – inflammation of a spinal nerve root
• Flexion/Extension/Lateral Bending/Rotation –spinal ranges of motion
• Dermatome – area of skin that is supplied with the nerve fibers of a single spinal root
• Acute – typically within the first three months of injury
• Chronic – injury that lasts more than three months
• Edema – buildup of fluid in surrounding tissues
• Strain/sprain: • Tear or disruption to muscles and/or ligaments
• Lumbar/cervical radiculitis:• Injury to a nerve that causes radiating pain
• Cervical/lumbar disc injuries:• Bulge, herniation or rupture
• Contusions/abrasions:• Cuts and bruises
• Post-Concussion Syndrome
COMMON MVA INJURIES
• Severe disc herniation/rupture
• Fractures/dislocations
• Rotator cuff and other extremity injuries
• Instability of joints
MORE SEVERE MVA INJURIES
HERNIATED DISC
Spinal Cord
Annulus
Herniated Disc
Spinal Nerve
MRI OF HERNIATED DISC
MRI OF SPINAL STENOSIS
Initial Symptoms Often Develop Within 24-72 Hours
WHEN DO PATIENTS ‘FEEL’ THE INJURY?
• Pain and stiffness
• Difficulty walking, standing or sitting
• Unable to lift
• Trouble sleeping
• Negative impacts on social life and traveling
• Vague neurologic (contracoup) symptoms
COMMON SYMPTOMS/LIMITATION
RISKS OF NO/DELAYED TREATMENT
• Painful scar tissue
• Loss of range of motion
• Increased pain with normal activities
• Accelerated degeneration
• Chronic, life-long problems
Primary Care
ER/Urgent Care
Orthopedist
Chiropractor
Physical Therapist
INITIAL TREATING DOCTORS/PROVIDERS
• Superficial heat and ice
• Electrical stimulation
• Ultrasound
• Traction
• Spinal manipulation
• Massage/mobilization
• Therapeutic exercises
CONSERVATIVE TREATMENT MEASURES
CO-MANAGEMENT/REFERRAL
• Primary Care Physician
• Neurologist/Neurosurgeon
• Pain Management Physiatrist
• Orthopedic Surgeon
• Psychologist
• Pillows
• Braces/orthopedic supports
• Topical analgesics
• Activity restrictions
• Temporary disability/off work/light duty
• Pain medications
SUPPORT MEASURES
Acute Inflammatory Stage(1-2 Weeks)
Repair / Regeneration Stage(3-4 Weeks)
Remodeling / Reconditioning Stage(4-8 Weeks)
STAGES OF HEALING
TOTAL TYPICAL RECOVERY PROCESS = 8-12 Weeks“Myth”
MAXIMUM MEDICAL IMPROVEMENT
• The condition is stabilized and not likely to improve with surgical or active medical treatment
• The degree of impairment is not likely to change by more than 3% within the next year
• The patient is not likely to suffer sudden or subtle incapacitation
• Age and gender• History of neck or CAD injury• Head restraint below head’s center of gravity• Rear vs. other vector impacts• Use of seat belts• Body mass index• Occupant out of position or head turned• Seat location• Anticipation• Size of other vehicle
INCREASED RISKS FOR ACUTE INJURY
Smoking Habits
FACTORS INFLUENCING HEALING
Stenosis
IMPACT OF PATIENT MINDSET
• Unrealistic expectations
• Psychosomatic issues
• Psychological disorders
• Unhappy at work
• Seeking attention
• Determine mechanism of injury• Determine causation of injury• Establish proper diagnosis• Prescribe appropriate treatment plan• Document recovery, including impact on ADLs• Reach MMI/prognosis
PROPER CASE MANAGEMENT
• Narrative Reports- Initial: Documents diagnosis, treatment plan and
causation- Progress: Documents improvements and
adjustments to treatment plan- Discharge: Documents level of MMI and any
possible residuals
• SOAP/Exam Notes – Legible and thorough• Radiology Reports
- Findings: Detailed description of evaluation- Impressions: Summary of results
PROPER DOCUMENTATION
POOR CASE MANAGEMENT
• No explanations for gaps in care
• Multiple occupants have same frequency and duration of treatment
• Treatment does not support diagnosis
• Excessive treatment/testing without supporting documentation
• Poor documentation/no correlation to ADLs
AMMUNITION FOR INSURANCE COMPANIES
No/low property damage = no injury!X
MYTH VS. FACT
Minor
Impact
Soft
Tissue
• Phrase coined by automotive industry in 1990s
• They claim Low/No-Damage Car Crash = No Injury
• Used flawed studies - Crashes were staged to avoid injury- Newer, stiffer vehicles and seats
designed to resist damage at higher speeds
- Ignores elasticity, which can double transfer of force to occupants
ELASTICITY = ACCELERATION
MOTION OF THE NECK IN AN IMPACT
1. Ability of vehicle to transmit or absorb energy2. Direction of the impact3. Direction person is facing4. Awareness of the impending
collision
KEY FACTORS IN SEVERITY OF INJURY
WHEN THERE’S A CAR ACCIDENT …
“The amount of damage to the automobile bears little relation to the force applied to the cervical spine of the occupants. The acceleration of the occupant’s head depends on the force imparted, the moment of inertia of the struck vehicle, and the amount of collapse of force dissemination by the crumpling of the vehicle.” (Carroll, McAfee and Riley, “Objective Findings for Diagnosis of Whiplash” Journal of Musculoskeletal Medicine; March, 1986.)
WHEN THERE’S A CAR ACCIDENT …
In a typical whiplash mechanism at 10mph, “the head snaps back with the equivalent of several tons of force.” (“Whiplash Injuries: Neurophysiological Basis for Pain and Methods Used for Rehabilitation” Journal of the American Medical Association; November 29, 1958, pp. 1750-1755.)
1.5 tons @ 10 MPH 25 tons of FORCE
CHANGE IN VELOCITY (DELTA V)
THE HEAD AND NECK
“(In an accident) the head, which weighs five kilograms and is balanced over the cervical spine, being supported by only two small articular surfaces no greater than a thumbnail, is also thrown backwards, pulling the cervical spine with it.” (Robert Maigne, MD, “A New Approach to Vertebral Manipulations” CC Thomas, 1972.)
TRANSFER OF ENERGY
“To take an extreme example:
If the car (hit) was stuck in concrete, the damage (to the vehicle) might be very great but the occupants would not be injured because the car could not move forward.
Whereas, on ice, the damage to the car could be slight but the injuries sustained might be severe because of the rapid acceleration permitted.” (Macnab, In the Spine, Saunders, 1982, p.648.)
ACCELERATION PLUS AWARENESS
“When the impact is unexpected and the victim is unable to brace, injury results because the neck is unable to adequately compensate for the rapidity of head and torso movement resulting from the acceleration forces generated at the time of impact.” (Teasell & McCain, Pain Cervical Trauma, Williams and Wilkins, 1992, p.293.)
DIRECTION OF IMPACT
“When the direction of force is from the side, or when a frontal or rear force occurs while the head is turned to one side, the spine is less flexible and the force is expended upon the articulations where the small bone elements may be fractured.” (Turek, Orthopaedics Principles and their Applications, Lippincott, 1977, p.740.)
KEY FACTORS IN SEVERITY OF INJURY
SEVERITY OF PROPERTY DAMAGE IS NOT A RELIABLE
PREDICTOR OF INJURY!
1. Ability of vehicle to transmit or absorb energy2. Direction of the impact3. Direction person is facing4. Awareness of the impending collision
QUESTIONS?
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