Low Back Pain: Where Is My Pain Coming From?
Low Back Pain: Where Is My Pain Coming From?
Low back pain can emanate from many anatomical locations (as well as a combination of locations), which always makes it interesting when a patient asks, “…doc, where in my back is my pain coming from?” In context of an office visit, we take an accurate history and perform our physical exam to try to reproduce symptoms to give us clues as to what tissue(s) may be the primary pain generators. In spite of our strong intent to be accurate, did you know, regardless of the doctor type, there is only about a 45% accuracy rate when making a low back pain diagnosis? This is partially because there are many tissues that can be damaged or injured that are innervated by the same nerve fibers and hence, clinically they look very similar to each other. In order to improve this rather sad statistic, in 1995 the Quebec Task Force published research reporting that accuracy could be improved to over 90% if we utilize a classification approach where low back conditions are divided into 1 of 3 broad categories:
1. Red flags – These include dangerous conditions such as cancer, infection, fracture, cauda equina syndrome (which is a severe neurological condition where bowel and bladder function is impaired). These conditions generally require emergency care due to the life threatening and/or surgical potential.
2. Mechanical back pain – These diagnoses include facet syndromes, ligament and joint capsule sprains, muscle strains, degenerative joint disease (also called osteoarthritis), and spondylolisthesis.
3. Nerve Root compression – These conditions include pinching of the nerve roots, most frequently from herniated disks. This category can include spinal stenosis (SS) or, combinations of both, but if severe enough where the spinal cord is compromised (more commonly in the neck), SS might then be placed in the 1st of the 3 categories described above.
The most common category is mechanical back pain of which “facet syndrome” is the most common condition. This is the classic patient who over did it (“The Weekend Warrior”) and can hardly get out of bed the next day. These conditions can include tearing or stretching of the capsule surrounding the facet joint due to performing too many bending, lifting, or twisting related activities. The back pain is usually localized to the area of injury but can radiate down into the buttocks or back of the thigh and can be mild to very severe.
Clearly determining why a patient is having back pain is no easy task. It takes the training and evaluation by a licensed professional such as Dr. Gulitz at Mid-Atlantic Spinal Rehab & Chiropractic to determine which tissues are injured and how to best bring about relief of your condition. If you, or anyone you know, is suffering from back pain in Baltimore please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be happy to help!
Dr. Gulitz
This article was reproduced with permission from Dr. Ben Altadonna and “The Practice Building Alliance.”
BY: Mid-Atlantic Spinal Rehab
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The Importance of X-rays following Auto Accidents in Baltimore
The Importance of X-rays following Auto Accidents in Baltimore
We’ve all heard stories of people being involved in roll-over auto accidents and being taken away on stretchers to the hospital. When they get to the ER they are given X-rays and/or CT scans to rule out fractures. You may be surprised to realize that in most cases of rear-end auto accidents or in cases where ambulances do not take automobile occupants to the hospital, most ERs/Urgent Care facilities do not take X-rays of the patients.
On one hand, that may seem reasonable. You might think that it is unlikely that these occupants would have suffered fractures. While this may or may not be the case, it is important to recognize that X-rays following auto accidents in Baltimore need to be administered to monitor the stability of spinal segments following trauma, and not just the presence/absence of fractures.
I often joke with patients that I do not have X-ray vision. Following sudden trauma to the spine it is important to rule out not only fractures (which are admittedly rare), but more importantly, any other relative or absolute contraindications to chiropractic therapy. I’ve seen plenty of examples where hospitals/ERs did not X-ray a patient and then when I did in my office I found evidence of ligamentous laxity that would put them at risk of receiving chiropractic manipulation.
Dr. Arthur Croft in his book “Whiplash and Mild Traumatic Brain Injuries: A Guide for Patients and Practitioners”, Dr. Croft notes “…fractures may be missed simply because the ER doctor did not feel the type of injury warranted radiographs. In a report from a group of 32,117 trauma patients here in San Diego, the single most common error identified in missed cases of pathology was failure to obtain an adequate cervical spine radiographic series.” (page 221).
In my nearly 5 years as a practicing Chiropractor in both Las Vegas, Nevada and Baltimore, Maryland I have seen several cases where a patient either did not get an X-ray at the hospital, or was told that they did not need an X-ray. When I insisted we take some films “just to be safe” we discovered subtle fractures and/or aberrant motion that warranted immediate orthopedic referral. Had I not taken the films, I could have put the patient’s health at risk.
In my office not every patient gets an X-ray. My clinical decision making process depends on the patient’s age, presenting symptoms, history, and my physical examination findings. Patients involved in automobile accidents in Baltimore seeking auto accident therapy will always have an X-ray prior to beginning therapy. There’s an old saying in Chiropractic “to see is to know and not to know is to guess…I don’t want to guess about your spinal condition.”
If you, or anyone you know, has been involved in an auto accident in Baltimore and are in need of auto accident treatment in Baltimore, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to take X-rays and render the appropriate course of rehabilitation.
Dr. Gulitz
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Cervicogenic Headaches and Neck Pain
Cervicogenic Headaches and Neck Pain
Patients with headaches also commonly complain of neck pain. This relationship is the rule, not the exception. Therefore, treatment for headaches must include treatment of the neck to achieve optimum results. The term, “cervicogenic headaches” has been an accepted term because of the intimate connection between the neck and head for many years. There are many anatomical reasons why neck problems result in headaches. Some of these include:
• The first 3 nerves exiting the spine in the upper neck go directly into the head. They penetrate the muscles at the top of the neck near the attachments to the skull and therefore, any excess pressure on these nerves by the muscles or spinal joints will result in irritation and subsequent pain.
• The origin or nucleus of the 5th cranial nerve called the Trigeminal, innervates the sensation to the face and is located in the upper cervical region near the origin of the 2nd cervical spinal nerve, which innervates sensation to the back of the head up to the top. Therefore, problems located in the upper neck will often result in pain radiating up from the base of the skull/upper neck over the top of the skull to the eyes and /or face.
• The 11th cranial nerve that innervates the upper shoulders and muscles in the front of the neck arises from the top 5 to 7 spinal cord levels in the neck. Injury anywhere in the neck can result in spasm and pain in these large muscle groups.
• Other interconnections between the 2nd cervical nerve and trigeminal/5th cranial nerve include communication with the 7th cranial / facial nerve, the 9th cranial / glossopharyngeal nerve, and the 10th cranial / vagus nerve. These connections can affect facial muscle strength/movements, taste, tongue and throat movements, and stomach complaints such as nausea from these three cranial nerve interconnections, respectively.
When patients seek treatment for their headaches, a thorough examination of the neck, upper back, and cranial nerves is routinely performed for the above reasons. It is common to find upper cervical movement and vertebral alignment problems present in patients complaining of headaches. Tender points located between the shoulder blades, along the upper shoulders, on the sides of the neck and particularly, at the base of the skull are commonly found. Pain often radiates from the tender point over the top of the skull when pressure is applied in the upper neck/base of the skull area. Tenderness on the sides of the head, in the temples, over the eyes, and near the jaw joint are also common. Traction or pulling the head to stretch the neck is often quite pain relieving and this is often performed as part of the chiropractic visit and can also be applied at home with the use of a home cervical traction unit. Chiropractic adjustments applied to the fixated vertebra in the upper neck often brings very satisfying relief to the headache sufferer. Exercises that promote movement in the neck, as well as strengthening exercises are also helpful in both reducing headache pain and in preventing occurrences, especially with stress or tension headaches.
As a Chiropractor that routinely treats patients with headaches and neck pain as a result of auto accidents in Baltimore, I see patients with headaches and neck pain every day. If you, or someone you know, can use the help of a Baltimore Chiropractor for headaches and neck pain, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be happy to help!
The above information was reproduced with permission from Dr. Ben Altadonna and “The Practice Building Alliance”.
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How Important is a Good History and Physical Examination?
How Important is a Good History and Physical Examination?
If you are reading the title of the blog post you probably already know where I am going with this. A good history and physical examination is the cornerstone to an accurate diagnosis and an appropriate treatment plan. Without a problem-focused examination and history a patient’s complaints will be missed and the healing process will be protracted.
Sure, this seems obvious enough. When you get injured in a Baltimore auto accident and present to your doctor, ER, or urgent care facility, you expect that the doctor examining you is giving you an appropriate evaluation with appropriate radiographs (x-rays). Believe it or not, this may not always be the case. In this day in age with longer wait times and more patients being seen per day, most providers (whether they be doctors, PAs, nurse practitioners, chiropractors etc) are under more pressure than ever to “treat and street” patients to make room for more patients. In doing so they often go through a history and physical examination in a cursory manner, sometimes missing key injuries sustained by patients. You would be surprised how often the time of day or day of the week dictates how thorough a history and examination is given to any given patient. As you might expect, it has been my experience that more diagnoses are missed on Friday nights when the ERs are busy than are on Monday nights. In my nearly 5 years as a Chiropractor treating acutely injured patients involved in Baltimore auto accidents and baltimore worker’s compensation injuries, I am shocked at how often diagnoses are missed by portal of entry providers.
Dr. Arthur Croft in his book “Whiplash and Mild Traumatic Brain Injuries: A Guide for Patients and Practitioners” (page 211) notes that “…medical school training is woefully inadequate to prepare doctors to examine and understand musculoskeletal disorders, despite the fact that this very class of disorder constitutes the leading causes of disability in the U.S. In a recent study published in the Journal of Bone and Joint Surgery, a validated musculoskeletal cognitive examination was given to medical students, residents, and staff physicians in multiple disciplines of medicine to assess the adequacy of their musculoskeletal medicine training. Only 21% received a passing score.”
In news closer to my area of practice treating patients involved in Baltimore auto accidents, “…fourth year medical students from the University of Chicago were presented with a fictitious whiplash patient to evaluate how they would assess him if he were a real patient. He was a 21-year-old male who gave a history of being a passenger in a car that was struck from the rear…Shortly after the crash, he began to experience neck pain and was transported by ambulance to the ER…Only 21% palpated (touched) the neck, and only 17% asked the patient to turn his head from side to side.”
I am in no way trying to be negative towards portal-of-entry providers who must handle tons of new injured patients every day. All I am trying to do is point out that doctors are busy and sometimes rush through the history and physical examination. By doing so, they put a patient’s health at risk by missing diagnoses and not ordering appropriate diagnostic tests. It is important that you, as the patient, speak up and direct a doctor to your chief complaints to ensure that no appropriate diagnoses are missed.
As a Baltimore Chiropractor who routinely treats patients involved in Baltimore auto accidents, I have been trained to ask the right questions and take an appropriate history so that nothing is missed. I routinely work with other specialists such as orthopedists, pain management physicians, and neurologists who can perform special diagnostic testing if necessary. Rest assured that no matter how complex the motor vehicle collision I will take as much time as necessary to diagnose your condition and to establish an appropriate patient-focused treatment plan.
If you, or anyone you know, has suffered injuries as a result of an auto accident in Baltimore and are in need of auto accident treatment in Baltimore, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!
Dr. Gulitz
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Cervical Radiculopathy following Baltimore Auto Accidents
Cervical Radiculopathy following Baltimore Auto Accidents
In many of my past blog posts I have touched on topics of injuries associated with Baltimore Auto Accidents. One area that I have not spent much time on is the idea of cervical radiculopathy. In simple terms, radiculopathy is inflammation of a nerve root. Anytime the spine is stressed or compressed, such as in a Baltimore auto accident, there can be irritation to nerve roots. This is the case for the entire spine, but for the sake of this discussion, we will only be considering cervical, or neck, radiculopathy.
The nerve roots in the neck comprise all of the motor and sensory fibers that innervate the upper extremity. Incidentally, they also innervate some muscles in the neck and upper back. The motor fibers control motion in the upper extremity (which I activate as I type this blog post) while the sensory fibers convey sensation from the environment (such as heat, cold, pain, light tough vibration, pressure) to the brain.
Following trauma to the spine, such as that often experienced in Baltimore auto accidents, the nerve roots may become injured, manifesting as a myriad of symptoms. Most commonly patients present with neck pain along with numbness and/or tingling and/or weakness into the upper extremity on the affected side. Often times radiculopathy can be confirmed on physical examination and if need be, advanced imaging studies such as MRIs.
As part of the therapy for Baltimore auto accidents that I provide in my office, therapy usually involves heat, electric muscle stimulation, traction therapy, and if appropriate, chiropractic spinal manipulation. Most patients respond favorably within 6-12 weeks to conservative chiropractic therapy. Those that don’t are referred to specialists for additional intervention. The key to recovery is quick intervention. That is, the longer a patient experiences radiculopathy the longer it takes for the symptoms to resolve.
If you, or anyone you know, has suffered a cervical radiculopathy as a result of a Baltimore auto accident and require Baltimore auto accident treatment, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!
BY: Mid-Atlantic Spinal Rehab
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Viscoelasticity- A Special Property of Human Tissues
Viscoelasticity- A Special Property of Human Tissues
Human soft tissue, whether it be muscle, skin, ligament, tendon, nerve, intervertebral disc, or bone all contain a special property known as viscoelasticity. This is a property that allows these tissues to deform depending on the type and direction of force applied. It allows for these structures to start in one place/shape, change as a result of forces applied, and then to “bounce back” to their original size and shape. It is really a remarkable characteristic.
You can liken viscoelasticity to a rubber band. You can stretch them and they bounce right back. However, if the force used to deform them is too strong or occurs to quickly, the tissues are irreparably torn and broken.
If you sit in your chair reading this, you can bend your chin to your chest, and then you can extend it backwards. Provided that you don’t have any underlying problems with your neck, by the time you are done you will have your neck and its tissues in the same shape and condition as it was before you stretched it. Now imagine you are sitting at a stop light and you get rear-ended suddenly. In a matter of milliseconds your neck undergoes the same motion pattern. However, since the impulse occurrs so quickly the viscoelasticity of the neck soft tissue does not allow the tissue to return to its pre-accident shape. This results in torn soft tissues, and a trip to your local Baltimore Chiropractor for whiplash treatment.
While the motion of the neck is within anatomical limits (that is, we can bring our neck to our chest and bring it all the way back) the speed at which this motion occurs in an auto accident is so great as to not allow the viscoelastic structures of the neck to “bounce back” resulting in injury.
As a Baltimore Chiropractor that routinely treats patients with neck pain following a Baltimore auto accident, I routinely treat patients who have torn viscoelastic structures in their neck. If you, or anyone you know, as suffered from a Baltimore Auto Accident and can use the help of a Baltimore Chiropractor, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!
Dr. Gulitz
*This information was taken from “Whiplash and Mild Traumatic Brain Injuries” by Dr. Arthur Croft, page 134.
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No Correlation between Property Damage and Bodily Injury
No Correlation Between Property Damage and Bodily Injury
As a Baltimore Chiropractor that routinely treats clients injured in Baltimore auto accidents (Baltimore car accidents) I routinely see patients whose accidents run the gamut from a simple bumper tap collision to a total loss. Most insurance companies (largely responsible for paying out claims for accidents) would have you believe that there is a direct correlation between property damage to a vehicle and the likelihood of injury to an occupant.
The thought process goes like this: If two cars are involved in a crash with a small crash velocity, particularly a crash where there is no damage to either vehicle, no occupants can be injured. Any claim made for bodily injury must therefore be fraudulent.
I’ll admit. Before I became a Chiropractor I sort of believed this to be true myself. But how did I know it to be the case? I had never done any research, I had just “believed it” inherently.
When I started treating patients as a Chiropractor in Las Vegas I came across a lot of “low property damage” or “low PD” crashes where occupants were claiming injuries to their necks and backs. X-rays, physical examination and orthopedic examination confirmed injury. Professional interest lead me to the literature and research of Dr. Arthur Croft of the Spine Research Institute of San Diego and his post graduate series on Whiplash and Mild Traumatic Brain Injury.
Dr. Croft is one of the leading researchers on whiplash biomechanics/kinematics. As an epidemiologist he has studied all published research on the topic and determined that there is no correlation between crash velocity and injury risk. He states “Using paired comparison methods, the authors were able to demonstrate that when correlating crash delta V and comparing subjects within the same vehicle on the basis of injury risk, it appeared that human factors were more deterministic…than crash metrics.” (p. 98 “Whiplash and Mild Traumatic Brain Injuries”).
This makes some sense. I have seen plenty of older patients who suffer severe injuries that are involved in the same crash as young children/younger adults that walk away unscathed.
At the end of the day, as a Baltimore chiropractor that is involved in whiplash treatment in Baltimore, I do not necessarily concern myself with property damage. I treat injured clients- not injured cars. Often insurance companies will look to deny claims that involve low property damage to vehicles, claiming that they must be fraudulent. Fortunately, my patients know that I have research on my side to fight the insurance companies that look to deny their claims.
If you, or anyone you know, is in need of a Baltimore Chiropractor to treat you for injuries sustained in a Baltimore auto accident, please call Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be happy to help!
Dr. Gulitz
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Baltimore Whiplash and S-Shaped Cervical Curves
Baltimore Whiplash and S-Shaped Cervical Curves
The normal anatomy of the neck (cervical spine) is a C-shaped curve. In rear-end auto accidents that result in whiplash prevailing thought was that getting struck from behind would result in a hyperextension/hyperflexion injury of the neck. That is, first the neck would extend all the way backwards and then it would rebound and hyperflex all the way until the chin touches the chest.
Research has shown that in the milliseconds during a rear-end auto accident the cervical spine actually forms an S-Shaped curve. This is important because it explains why patients with neck pain following an auto accident typically present with pain at the base and the apex of their necks.
During the 150 milliseconds of the rear-end impact the lower part of the neck hyperextends and simultaneously the upper part of the neck hyperflexes, creating an S-Shaped curve. This places extra stress and strain on sensitive tendons, ligaments, discs, and other connective tissue that normal exist in a C-shaped curve formation. The result is inflammation that leads to pain.
Baltimore Chiropractors, such as myself, routinely treat patients with whiplash in Baltimore resulting from auto accidents in Baltimore. If you, or anyone you know needs treatment for a Baltimore auto accident please do not hesitate to contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!
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Adverse Drug Reactions
Adverse Drug Reactions
As a Baltimore Chiropractor that often treats patients involved in Baltimore auto accidents and Baltimore slip and fall injuries, I spend a fair amount of time co-treating my patients with local medical doctors, neurologists, orthopedists, etc. Typically I will assist with the rehabilitation for the patients and the other providers will medicate them. If a patient has muscle spasms, they will be given a muscle relaxer. If they have inflammation, they will be given an anti inflammatory. If they are having difficulty sleeping following their Baltimore auto accident, they are prescribed sleeping pills.
On the surface, these are sound approaches to symptomatic management of painful conditions. However, not is all as it seems. There is a disturbing trend seen between the use of prescription drugs and adverse drug reactions (ADRs). According to a landmark study in the Journal of the American Medical Association (JAMA) in 1994, it was estimated that 106,000 people died as a consequence of ADRs. By some measurements that would rank ADRs as anywhere from the 4th-6th leading cause of death in America! There is a possibility that these numbers are actually under-reported since there are on average 7,000 motor vehicle collision (auto accidents) that lead to death that are caused by ADRs that are not officially attributed to deaths by adverse drug reaction.
By all means if you are involved in a Baltimore auto accident or Baltimore slip and fall injury and you need medicine, go see a medical doctor. They will use their medical expertise to prescribe you appropriate medication for your condition. All I am suggesting is that you think before you blindly take medications without considering the risk involved. It is ok to experience some discomfort- it lets you know your limitations and gives our bodies time to heal while you undergo therapy. Unlike cars which can be replaced if they break down, we are only given one body. Do the best you can to take care of it.
Dr. Gulitz
The preceding statistics were provided by Dr. Arthur Croft in his book “Whiplash and Mild Traumatic Brain Injuries: A Guide for Patients and Practitioners” on page 45.
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Whiplash and Chiari Malformations (Brain Injury)
Whiplash and Chiari Malformations (Brain Injury)
A study in the July 2010 Issue of “Brain Injury” reveals that up to 20 percent of whiplash victims undergo a form of brain injury referred to as a Chiari malformation. The study examined neck MRIs in 1200 whiplash patients and determined that those with neck trauma following a whiplash injury had an increased likelihood of chiari malformation.
So what is a chiari malformation? It is an injury that occurs when part of the brainstem (the cerebellar tonsils) herniate through the hole at the base of the skull (the foramen magnum) thereby exposing the brain stem to potential trauma. Patients with chiari malformations can experience headaches, neck pain, upper extremity numbness/tingling, and balance problems. Many times these chiari malformations require surgical intervention to prevent further injury.
While it is true that whiplash is fairly common and chiari malformations are exceedingly rare, it is a good idea to present for evaluation if you suspect you might have this condition. If you or a friend has recently suffered whiplash from a Baltimore auto accident and are in need of Baltimore auto accident treatment, contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help.
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