Undiagnosed Shoulder Pain following Baltimore Auto Accident

Undiagnosed Shoulder Pain Following Baltimore Auto Accidents

Some of my faithful blog followers might be asking why I would blog about shoulder pain following a Baltimore auto accident, when I am, in fact, a chiropractor. Traditionally chiropractors focus strictly on the diagnosis and treatment of spinal complaints including headaches, neck pain, and back pain. In many states, including Maryland where I practice, chiropractors can apply for physical therapy privileges, giving them the ability to diagnose and treat non-spinal musculoskeletal complaints.

Due to the successful “click it or ticket” campaigns there are more and more shoulder complaints following Baltimore auto accidents than you might otherwise expect. The shoulder harness can restrain a shoulder and cause an injury to an occupant.

Typically shoulder pain is treated like any other injury that I treat in my office following a Baltimore auto accident. I use a combination of physical therapy modalities (heat/ice, electric muscle stimulation, ultrasound, etc) and then progress to passive stretching and active therapeutic exercises. In the majority of cases the shoulder pain resolves within a few months.

In some cases shoulder pain persists past 6-8 weeks. This makes sense as everyone is different and not everyone responds the same to therapy. For shoulder pain that does not improve quickly, I typically order an MRI to rule out ligament tearing and rotator cuff pathology. Interestingly, MRIs do not catch all shoulder pathology on their own. That is, there are additional testing that I use on occasion to diagnose “tricky” shoulder problems that do not display pathology on traditional MRIs.

For patients that have failed conservative rehab of shoulder pain and have negative MRIs, I usually recommend an arthrogram. An arthrogram is a special application of radiography in which a dye is injected into the shoulder and then the shoulder is imaged in various different positions. It can be combined with MRI or CT scan to give a better understanding of underlying pathology such as partial thickness muscle tears and labral tears.

Once appropriately diagnosed the patient is referred to a shoulder orthopedist for (typically) shoulder surgical intervention. While I do not promote unnecessary surgery and as a chiropractor I personally think that it should be the last resort, I am in favor of surgery when it is the only remedy for an injured patient.

If you, or someone you know has been injured in a Baltimore auto accident and have shoulder pain, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

Dr. Gulitz

More on Croft Guidelines for Whiplash Treatment in Baltimore, MD

In my last blog post I referenced the Croft Guidelines. These are industry accepted guidelines for the length of treatment usually required by people involved in auto accidents that are injured and require auto accident treatment (in Baltimore and across the country). Dr. Croft notes that no two people are the same, so it is acceptable to deviate from these guidelines if need be, but in general they should be adhered to. Once patients begin requiring treatment in excess of the Croft Guidelines it is generally a good idea to get a medical specialist on board to co-treat the patient.

Dr. Croft classifies injury severity into 5 different categories and then gives treatment guidelines depending upon which category a patient falls into:

1. Grade 1: Minimal Severity. No limitation in ROM, no ligamentous injury, no neuro findings

2. Grade 2: Slight Severity. Slight limitation in ROM, no ligamentous injury, no neuro findings

3. Grade 3: Moderate Severity. Moderate limitation in ROM, some ligamentous injury, possible neuro findings

4. Grade 4: Moderate-to-Severe. Limitation in ROM, some ligamentous injury, neurological findings present, probable hard tissue damage (fracture) and/or disc derangement

5. Grade 5: Severe. Requires surgical management/stabilization.

Of note, I would say that the vast majority of Baltimore auto accident injuries present with severity grades 1-3, with grade 2 being the most common.

Using these grading classifications Baltimore auto accident chiropractors such as myself can put together an effective treatment plan for recovery and can keep in mind how much time and treatment may be required.

If you look at table 12.3 here you will see that even patients with grade 1 injuries that have No ROM limitation, no ligamentous injury and no neurological findings still fall into the category of allowing for daily care for a week, 3x/week for 1-2 weeks, 2x/week for 2-3 weeks, 1x/week for less than 4 weeks for a total treatment duration of less than 11 weeks with 21 or fewer total treatments.

Although the research by Dr. Croft and his colleagues dictate that even grade 1 patients may require treatment of around 11 weeks duration, it is interesting to note that most third party payers (insurance companies) generally look to disallow care following 12 weeks, thinking that “everyone is healed by then.” I can tell you from my 5 years experience treating auto accident patients (of which I have seen more than 1000 different cases) in Baltimore and Las Vegas that it is not the case. Often the Croft Guidelines are a useful tool to reference to justify to insurance companies the need for continued care for my patients.

If you, or someone you know, has suffered from a Baltimore auto accident and has experienced whiplash and want help to recover, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

Dr. Gulitz

Croft Guidelines for Whiplash Treatment in Baltimore, MD

As a Chiropractor that spends many hours a week treating patients involved in Baltimore car accidents resulting in whiplash, I often get asked how long any given patient should expect to take to recover from their injuries. Asked another way, patients often want to know how long they should expect to need treatment for their injuries. It is a fair question, since many patients end of missing time from work and leisure activities in order to present for treatment. Unfortunately there is no simple answer to that question. As we have seen in past blog posts, every patient undergoes unique loading mechanisms during Baltimore auto accidents and has different relative risks of injury. As such, it should stand to reason that some patients might not get hurt at all, while others can suffer with debilitating injuries that take weeks or months to heal, while others never fully heal.

Fortunately there is a professionally accepted standard for treatment of whiplash patients that helps to grade the severity of the patient’s presentation. These guidelines are then useful in predicting how long a patient should be under care in order to reach maximum therapeutic benefit (or referred to as maximum medical improvement, MMI).

Keep in mind a few things here:

1) A patient’s ability to return to work, depending on what they do for a living, can occur prior to their being “healed.” I often release patients to work at either light duty or even full duty even while they are having pain.

2) Patients that feel better and have no pain are still healing even after I dismiss them from care. The healing process takes months to years for new connective tissue to effectively replace old, torn, injured tissue. This is why we see patients involved in multiple auto accidents often having more severe symptoms if their second crash occurs in quick succession to the first.

3) Not every patient fits into this guideline. Some patients can be outliers to this guidelines and may require MORE or LESS care, depending on their specific health characteristics and comorbid conditions.

For a link to the croft guidelines, click here.

In future blog posts I will discuss more in depth the different classifications associated with the croft guidelines and which classifications usually present in a chiropractic office.

If you, or someone you know, has suffered whiplash injuries as a result of a Baltimore auto accident please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

Dr. Gulitz

Determination of Causation of Intervertebral Disc Injuries Following Baltimore Auto Accidents

As a Baltimore Chiropractor that routinely treats patients involved in Baltimore auto accidents, I am often called upon to determine causation of injuries. That is, I need to determine do a reasonable degree of medical probability whether or not a patient’s symptoms are causally related to a Baltimore auto accident. In the state of Maryland, the threshold of certainty is 51%. In other words, based upon the patients history, physical examination and objective evaluations (x-ray, MRI, etc), I have to be 51-100% sure that the patient’s complaints (whiplash, headaches, neck pain, back pain, etc) are causally related to the Baltimore auto accident. Clinically I am not concerned about causation, as it is my duty to treat a patient’s symptoms. However, medico-legally the determination of causation is extremely important when assigning fault or financial culpability for an injury.

The issue of clinical causation comes up a lot in my clinical practice. Typically an injured patient claims that part or all of their complaints are causally related to their Baltimore auto accident while the adverse (at-fault) insurance company claims that my patient is either not injured or that their injuries predated the Baltimore auto accident.

Fortunately a well respected researcher, Michael Freeman PhD, combed the literature to determine the appropriate systematic guidelines to make such a determination. A link to his study can be found here.

Mr. Freeman determined that for a clinician to draw causality three criteria must be met:

1. Biological plausibility– There must be a possible link between an injury and a Baltimore auto accident. A Baltimore auto accident could plausibly cause an injury to the spine including the intervertebral discs, but it is not likely that it can cause cancer.

2. Temporal relationship– The outcome (injury) can not pre-date the auto accident (with the exception of pre-existing degenerated non-symptomatic disc injuries which are beyond the scope of this blog post) AND the outcome can not unreasonably post date the auto accident (It is not plausible to relate neck pain 6 months after an auto accident if it did not show up sooner).

3. A lack of a more likely or probable alternative explanation for the symptoms– A patient who is obese but has no signs of prior back pain can not have their obesity blamed for their back pain if the pain first presents following a Baltimore auto accident.

Mr. Freeman concludes that “when using these guidelines in a narrative report setting, the clinician can write that the essential causal elements of biologic plausibility, temporality, and lack of likely alternative explanation have been met for a give case…and that a particular symptomatic disk injury resulted from a particular motor vehicle crash, as a reasonable medical probability.”

Disk injuries are very common injuries following Baltimore auto accidents. It is imperative that any provider understand how to appropriately diagnose and causally relate these injuries, as it affects the ability to properly treat these injuries and bring about symptomatic relief for patients.

If you, or anyone you know was involved in a Baltimore auto accident and have suffered from intervertebral disc injuries, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

Dr. Gulitz

Seat Belt Induced Injuries in Baltimore Auto Accidents

Believe it or not, wearing a seat belt can actually cause injuries if you are involved in a Baltimore auto accident. Don’t get me wrong- this is not a license to unbuckle and drive without a seat belt harness. Seat belts were invented to prevent catastrophic injury and ejection from a vehicle and should be worn any time an occupant gets behind the wheel. Interestingly, the forces that restrain an occupant and prevent ejection can be the cause of other lesser seen injuries in the cases of Baltimore auto accidents.

One of the most important indicators to the possible presences of these seat belt injuries is what is referred to as “seat belt sign.” This is the presence of an abrasion (redness, scraping) located over the abdomen, pelvic region, neck, or breasts (or anywhere a seat belt is worn).

In children the presence of seat belt sign may indicate a SCIWORA injury. This stands for Spinal Cord Injury Without Radiographic Abnormality. Admittedly, I have never seen it in my 5 years of clinic practice to date. During the deceleration phase of the rear-end whiplash injury internal organs can sometimes get compressed between the seat belt and the spine causing organ damage and even dislocation of spinal segments. This can cause severe compression to the spinal cord that can be missed on standard radiographic (x-ray) examination. Presence of a seat belt sign in children should warrant further abdominal MRI in children and may prompt an MRI to rule out SCIWORA.

In addition to the lap belt causing injury, the shoulder harness can injure an occupant as well, depending on where it contacts the neck of an occupant. This is also especially true when the webbing lays across a child/young adult’s neck rather than their chest. This is seen when the webbing is not adjusted to an occupants height appropriately. It can cause seat belt sign on the neck which can indicate damage to the vascular structures of the neck. Most notably, it can cause compression and tearing of the carotid and/or vertebral arteries. Careful evaluation may include doppler ultrasound to the affected structures or MRA evaluation. The discussion of MRA evaluation is beyond the scope of this blog post. Please contact me if you want more information.

Finally, women are especially susceptible to seat belt sign following a Baltimore auto accident as well. Due to the anatomy of their breasts, they can develop seat belt sign across their breasts. In some cases this can cause break down of fatty tissue in the breast region, known as traumatic fat necrosis. This can lead to a change in the shape and look of their breast tissue. There has been some research indicating that this can lead to breast cancer, although research in that category is not conclusive at this time. Additionally, women who have artificially augmented their bosoms can suffer from a traumatic capsulotomy where their augmented breasts begin to display asymmetry following a whiplash injury or where their breast implants actually get punctured as a result of a motor vehicle collision in Baltimore.

Once again, these seat belt signs are certainly not very common and even when present, do not necessarily indicate internal damage as described above. I always tell patients that they know their body better than I do and that if they suspect there may be internal damage that they should talk to their providers about having more thorough examinations be performed.

If you, or anyone you know, has suffered from an auto accident in Baltimore and have seat belt sign or other forms of whiplash, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

The preceding information was found in the book “Whiplash and Mild Traumatic Brain Injuries” by Dr. Arthur C. Croft (pages 202-203.)

Dr. Gulitz

Neck Exercises Following a Baltimore Auto Accident

As a chiropractor that routinely treats patients with neck pain following Baltimore auto accidents, it is not uncommon for me to treat patients with a combination of both joint and muscle pain and dysfunction. Traditionally Chiropractors have been thought of as providers that only engage in only passive therapies- that is treatment where a patient has the therapies done TO them, instead of by them. To some degree this is true. I offer patients electrical muscle stimulation, ultrasound, intersegmental traction, and even spinal manipulation which are all passive modalities. Research has shown that in addition to passive treatments, more active treatments such as muscle stretching and resistance exercises help patients to decrease pain, increase ranges of motion, and decrease healing time. More interestingly, the faster a patient resumes active therapies following their injury, the faster they heal.

At Mid-Atlantic Spinal Rehab & Chiropractic we offer both passive and active modalities to help our injured patients heal from whiplash following Baltimore Auto Accidents.

Assuming that a patient has an injury to the joints and muscles of their neck, lets take a look at a few exercises we would likely have them perform in the office. Keep in mind- no two patients are the same and some patients may require additional or different exercises depending on their specific condition and injury. These exercises are to be considered a guideline for neck stretching. Please contact me or another healthcare professional if you have questions before performing any of these stretches on your own.

1. Side Bending Stretch (Lateral Flexion). A link can be seen here. You lean your ear to your shoulder as far as you can. Make sure to repeat both sides and not push past perception of pain.

2. Turning Stretch (Rotational Stretch). A link can be seen here. You turn your chin towards your shoulders as far as you can. Make sure to repeat both sides and not push past perception of pain.

3. Chin out/Chin Back (Protraction/Retraction Stretch). A link can be seen here. You “jut” your chin forward and bring it back (think about making a “double chin”), paying particular attention to not extend your neck. Typically extension will bother your condition following whiplash, although this is not always the case.

4. Isometric Resistance Stretching. A link can be seen here. This is the addition of light resistance, either by utilizing a hand, a towel, or a small ball to engage muscles actively while restricting joint motion. These are considered a progression over the first three stretches we discussed and should be worked up to over time.

If you, or someone you know, has suffered whiplash and has neck pain as a result of a Baltimore Auto Accident, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help.

Dr. Gulitz

Measuring Activities of Daily Living following Baltimore Auto Accidents

As prolific readers of my blog, many of you know that I spend a fair amount of time discussing diagnosis and treatment of patients who have experienced headaches, neck pain, or back pain following Baltimore auto accidents. Appropriate diagnosis and treatment are paramount for the Baltimore auto accident patient since patients want to feel better as fast as possible following an injury.

One of the services I provide to my patients that many other local providers do not is an analysis of a patient’s activities of daily living. That is, I try and figure out what degree their pain and discomfort impacts their normal activities of daily living, or ADLs.

I understand that the patients I treat in this office are not just “my patients”- they are also bosses, employees, brothers, sisters, husbands and wives. They have responsibilities to themselves and their families outside of my office. Pain is more than a physical thing when it impacts other areas of life. While I understand that often times neck and back pain are not “life threatening” this pain is often “quality of life threatening” when a mother has too much back pain to lift up her child without back pain, or when a father has too much back pain which prevents him from going to work and earning money for his family.

In my office we discuss not only the pain a patient is feeling, but also the impact that that pain has on their activities of daily living. There are three main areas of ADLs that we discuss and one other area, that while important, most patients do not usually openly discuss with me:

1. General Activities– sitting, standing, bending, lifting, walking, lying down, sleeping, and driving.

2. Duties Under Duress– working, housework, dressing, personal hygiene, and child care

3. Enjoyment Activities– using the computer, watching television, reading, exercising, (other personal enjoyments).

*4. Loss of Consortium- If couples are unable to be intimate and engage in a sexual relationship due to pain.

Most times when a patient feels better with the Baltimore auto accident treatment provided in this office they are able to resume their ADLs and are able to be discharged from treatment without ADL impairment. Sometimes, however, that is not the case and a patient is released with residual pain and residual impact on ADLs. While unfortunate, the documentation allows me to effectively communicate this disruption in their lives to their personal injury attorney so that they can be compensated for these problems and the disruption that it has caused to them personally.

If you, or someone you know, has suffered from a Baltimore auto accident and require treatment, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

Dr. Gulitz

More On Disc Herniations Resulting from Baltimore Auto Accidents

In the last blog post I mentioned the prevalence of disc herniations in the asymptomatic population. We discussed that despite prevailing thought that approximately 50% of the population has an asymptomatic (painless) herniated discs, we discovered that the true number is probably closer to 20%. The other 80 percent of population that has herniated discs get to be this way due to the gradual breakdown of the discs, usually initiated by a series of micro traumas, and can also result from overt traumatic events such as falls, and motor vehicle collisions (Baltimore Auto Accidents).

So now that we know how prevalent these injuries are, what exactly IS a herniated disc? I am sure we have all heard about “slipped” “prolapsed” “blown out” “ruptured discs” and “shredded” discs, but what does it all mean?

Fortunately the American Society of Neuroradiology and the North American Spine Society have come together to release terms that all doctors and laypeople can use to discuss disc pathology in order to better understand what is going on.

1. Disc Bulges– A common term denoting less than 3 mm of extension beyond the normal disc margin. There can be symmetrical bulging or asymmetrical bulging (right sided vs. left). These are not considered herniated discs.

2. Disc Protrusions- A type of disc herniation where the distance of protrusion is less than the width of the base.

3. Disc Extrusions- A type of disc herniation where the distance of protrusion exceeds the width of the base.

3b. Sequestered Disc Fragments– These are a specific type of disc herniation where the extruded disc fragment has penetrated the outer annular fibers and has broken loose.

A visual of the different type of disc injuries can be seen here.

An important thing to consider as a Chiropractor that treats patients involved in Baltimore auto accidents resulting in disc bulges, disc protrusions and disc extrusions is that everyone is different. That is, just ordering an MRI and having an MRI report does not tell me how to best help a symptomatic patient. Typically, I concern myself with the degree, if any, there is neurological compression in the spine. That is, typically the bigger disc injuries (disc extrusions) cause more neurological findings such as numbness, tingling, or weakness, and need to be treated more cautiously. Provided that there are no signs of stenosis or lower motor neuron lesions, it is typically safe to perform Chiropractic spinal manipulation/mobilization to the affected spinal levels. As always, patient preference is taken into account and patients that are fearful of being adjusted will instead be focused on corrective therapeutic exercises and spinal mobilization, similar to what they would do if they were being treated by a physical therapist.

Most patients with disc bulges and protrusions respond favorably to chiropractic care. Those that do not respond to care are referred to an orthopedic spinal specialist for a second opinion and future treatment recommendations. Although every case is unique, as a general rule, most bulges and protrusions do well with chiropractic care, while most extruded discs with and without sequestered fragments are typically not as responsive to care and are referred out to a specialist quickly.

If you, or someone you know has suffered from a disc bulge, disc protrusion, and/or disc extrusion as a result of a Baltimore auto accident and are in need of treatment, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

Dr. Gulitz

Disc Herniations resulting from Baltimore Auto Accidents

Before we discuss different types of disc inflammatory processes in my next blog post, I’d like to discuss some popular myths regarding disc herniation in the “asymptomatic population.” The asymptomatic population refers to people like you who walk around without neck and back pain. When I treat patients involved in Baltimore auto accidents if they are not improving with therapy quickly I will usually refer them for an MRI of the neck and/or lower back to determine if there is any stenosis or disc herniation resulting from the Baltimore auto accident. Many times once I get the results the patients (and the insurance company responsible for paying for or denying care) want to know if the disc inflammation found on MRI predated the auto accident or if the cause of the disc herniation was the auto accident itself.

There is a popular misconception that as many as 50% of the asymptomatic population have at least one disc herniation in their neck or lower back. According to Dr. Arthur Croft in his book “Whiplash and Mild Traumatic Brain Injuries: A Guide for Patients and Practitioners” this myth began with an article published in the journal Spine in 1984. According to Dr. Croft, the original authors have since changed their opinion with the prevalence of asymptomatic disc herniations ranging from 4-28%, with the majority of experts today agreeing that 20% is probably the most appropriate number. Despite the latest research that puts the number closer to 20% the old 50% myth prevails.

The reason this is important is because the insurance company handling the claim (the company representing the driver who caused the Baltimore auto accident) will always attempt to marginalize, or downgrade the severity of the injury following a Baltimore auto accident. If they can effectively accomplish this they can discontinue paying for chiropractic therapy and rehabilitation and limit your recovery, thus improving their bottom line financially.

The bottom line according to Dr. Arthur Croft is that “…disc herniations are not common among asymptomatic persons.  They are generally the result of a gradual breakdown of the disc, usually initiated by a series of microtraumas, and can also result from overt traumatic events such as falls, motor vehicle collisions (auto accidents), etc.” (p.159).

In my next blog entry I will discuss the different types of names of disc herniations and what they mean clinically. I will also discuss certain types of therapy that we use to treat patients with acute disc herniations resulting from Baltimore auto accidents.

Until then, if you, or anyone you know has suffered from neck pain or back pain and suspect you may have a herniated disc as a result of a Baltimore auto accident and require Baltimore auto accident treatment, please call Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be happy to help!

Dr. Gulitz

The Difference in Effectiveness of Medical vs. Chiropractic Care
In The Treatment of Acute and Chronic Back Pain

Have you ever considered what type of provider is the best suited to treat back pain?  Since there are so many treatment options available today, it is quite challenging to make this decision without a little help.

To facilitate, a study looking at this very question compared the effectiveness between medical and chiropractic intervention.  Over a 4-year time frame, 2780 patients were followed with questionnaires. Low Back Pain patients were treated using conventional approaches by both MDs (Medical Doctors) and DCs (Doctors of Chiropractic).

Chiropractic treatments included spinal manipulation, physical therapy, an exercise plan, and self-care education.  Medical therapies included prescription drugs, an exercise plan, self-care advice and about 25% of the patients received physical therapy.

The study focused on present pain severity and functional disability (activity interference) measured by questionnaires mailed to the patients. It was reported that chiropractic was favored over medical treatment in the following areas:

•    Pain relief in the first 12 months (more evident in the chronic patients)
•    When low back pain radiated below the knee (more evident in the chronic patients)
•    Chronic low back pain patients with no leg pain (during the first 3 months)

Similar trends favoring chiropractic were seen for disability but were of smaller magnitude.  All patient groups saw significant improvement in both pain and disability over the four year study period.

Acute patients saw the greatest degree of improvement with many achieving symptom relief after 3 months of care.

This study also found early intervention reduced chronic pain and, at year 3, those acute low back pain patients who received early intervention reported fewer days of low back pain than those who waited longer for treatment.

While both medical care and chiropractic treatment approaches helped, it’s quite clear from the information reported that chiropractic should be utilized first.

These findings support the importance of early intervention by chiropractic physicians and make the most sense for those of you struggling with the question of who to see for your lower back pain.

My recommendation is to try chiropractic care first. If it is going to help you, it will do so quickly (2-6 weeks). If it fails to help, you can be referred for appropriate diagnostic imaging and/or referred for specialist evaluation.

If you, or someone you know, is experiencing acute or chronic back pain, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

Dr. Gulitz

The above was reproduced with permission of Dr. Ben Altadonna and “The Practice Building Alliance.”