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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