Low Back Pain with Radiation Following Baltimore Auto Accidents

Low Back Pain with Radiation Following Baltimore Auto Accidents

As many of you who follow my blog realize, I enjoy writing about the area of whiplash injuries associated with Baltimore auto accidents. Although on the surface you may think that if you’ve seen one auto accident you’ve seen them all, each case and its individual differences are really interesting to me.

One area that I have not spent much time on is the idea of lumbar radiculopathy which usually results in low back pain with radiation of pain symptoms. The radiation of pain can be down the front of the leg, down the back of the leg, across the flank, or even into the groin region. Many people refer to all radiation of pain down a leg to be “sciatica” but that is not the case. I will talk about that more in another blog post. For those who pay close attention to detail you may remember a blog post I made several months back about cervical radiculopathy- a similar occurrence in the neck. It’s nice to know people are reading :).

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 the lower back, or lumbar radiculopathy.

The nerve roots in the lower back comprise all of the motor and sensory fibers that innervate the lower extremities (legs). The motor fibers control motion in the lower extremity 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 in a myriad of symptoms. Most commonly patients present with low back pain along with numbness and/or tingling and/or weakness into the lower extremity on the affected side. There may or may not be associated hyporeflexia (decreased reflexes) as well. Often times radiculopathy can be confirmed on physical examination and if need be, advanced imaging studies such as MRIs are used to better understand the degree of impingement of any other soft tissue structures such as intervertebral discs.

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. In many cases patients make a complete recovery.

If you, or anyone you know, has suffered a lumbar 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!

Dr. Gulitz

Phases of Healing Following Baltimore Auto Accidents

As a Baltimore Chiropractor that routinely provides Baltimore auto accident treatment for patients injured in Baltimore auto accidents, I am often asked how long I will treat any given patient for. That is, from day 1 being “the accident” and day “x” being release from therapy, how long will it take?

It’s a complicated question and one that really does depend on the specifics of the injury. What types of vehicles were involved in the crash? What was the mechanism of injury? What about patient factors (age, weight, pre-injury health status, previous injures, etc.)? Are the patients smokers? Drinkers? Diabetics?

The answer that I generally give is: I don’t know how long it will take. I inform patients that healing occurs both inside and outside of my office and will CONTINUE even after I dismiss the patient from care. That is, I don’t need to be actively treating an injured individual for them to continue to heal. More importantly, most patients don’t realize that just because they feel better and I release them they are not yet “back to normal.” They are still healing and their tissues will be healing for up 24 months.

So how do I know this? Its all in the research…

In 1988 the American Academy of Orthopedic Surgeons publish a paper that researched how long it takes soft tissues such as ligaments to fully heal. Hereis a link to their research paper for those who care to read it.

They determined that there are three phases of healing:

1. Phase 1: Acute inflammation: First 0-72 hours. Microscopic swelling, blood pools to injured areas, focal inflammation and immobilization. (Think about how stiff your neck is immediately following a Baltimore auto accident)

2. Phase 2: Repair Phase (6-8 weeks). Inflammation decreases and new repair tissue is deposited. New collagen is deposited on top of injured tissue and begins to integrate itself into the tissue matrix, albeit haphazardly.

3. Phase 3: Remodeling Phase (from 8 weeks to 2 years!). This is the phase that most people are unaware of or choose to ignore. The newly deposited collagen tissue is stressed and put under tension so as to properly align with old collagen tissue. This is why chiropractors and physical therapists perform active exercises for injured areas that are painless. It allows the muscles and tendons to heal in the proper orientation. This is also the reason why patients that are released pain free in this phase and get involved in a second Baltimore auto accident shortly thereafter usually feel like they are “back to square one” after a second crash.

Many insurance companies that pay for Baltimore auto accident therapy following a Baltimore auto accident injury would have you believe that you should be “healed” following 8 weeks of therapy. This misinformation is not supported by scientific research or my clinic experience.

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

Dr. Gulitz

Medical Co-Management in Baltimore Whiplash Treatment

As a Baltimore Chiropractor that routinely treats acutely injured patients with whiplash, headaches, neck pain, and back pain following Baltimore auto accidents, I have seen plenty of patients that have delayed beginning chiropractic care/rehabilitation because they wanted to get some medicine for their pain. Typically a patient would schedule an appointment with their primary care provider, go to an urgent care, or go to the Emergency Room. There are problems with these models, in that these providers are not specifically trained in musculoskeletal medicine and often miss subtle injuries that require attention. I have spoken about ERs that miss subtle skeletal fractures in past blog posts.

From a patient perspective I understand the desire and “need” for medications following acute injury. These patients are people like you and me- they want to return to work and provide for their families. While Chiropractic care combined with physical therapy and soft tissue treatment will help heal them and restore their tissues to their pre-injury state throughout a course of treatment, they can not make a patient feel better “overnight”. That’s the value of medication in the acute injury paradigm. Patients can feel better and resume normal life activities as they heal under my care.

In an effort to ever improve the quality of care available to my patients, I have teamed up with Dr. Kevin Carr M.D. of Carr Medical Specialties. He is the ex-medical director of Jai Medical Clinics in Baltimore. He recently started a private practice in Baltimore and will be moonlighting at Mid-Atlantic Spinal Rehab & Chiropractic to assist in the evaluation and treatment of auto accident patients with whiplash. He is able to provide medication and trigger point injections, as needed. Currently he is available on Tuesday mornings from 9:00a-1:00p and Thursday afternoons from 3:00p-7:00p.

If you, or someone you know has been injured in a Baltimore auto accident and have whiplash, headaches, neck pain, or back pain, please contact Mid-Atlantic Spinal Rehab & Chiropractic. With the offerings of Carr Medical Specialties we are quickly becoming the go-to location for acute whiplash rehabilitation in downtown Baltimore.

Dr. Gulitz

Effective Management of Baltimore Whiplash

As I write this blog post it occurs to me that it’s been nearly 2 years since I left Las Vegas to move to Baltimore to open my own Chiropractic practice that focuses on treating patients involved in auto accidents, whiplash, motor vehicle collisions, and other forms of personal injury. One of the most important things I learned while working in Las Vegas was the effective evidence-based management of whiplash patients. Chiropractors often see their care criticized by third party payers and other health professionals. Many people consider care rendered in a Chiropractic office as “MUSH”. MUSH is an acronym for: manipulation, ultrasound, stim (electric muscle stimulation), and heat. The implication is that all care rendered is passive (i.e. the patient lays there and the services are rendered TO the patient). Most research indicates that regardless of the type of therapy you choose to use to recover from a Baltimore auto accident, the early introduction of active care has been shown to have the best results for long term prognosis.

At a recent continuing education conference on the management of Whiplash injuries generally accepted treatment guidelines were reviewed. As I sat in my chair thinking “this is obvious, I do this everyday” it amazed me how many other providers were not doing for their patients what I’ve been doing since my first day. Apparently the other providers have been putting out “MUSH.”

For uncomplicated whiplash cases, many chiropractors utilize the “Croft Guidlines” for whiplash care. It details the maximum treatment length for uncomplicated cases (no neurological findings, no extremity weakness, etc.)

Utilizing the Croft Guidelines, we can break up rehabilitation therapy into three phases of care (lasting on average 4-16 weeks post Baltimore car accident:

1. Acute Care (first 1-5 weeks). 3-5 visits per week, focusing on pain management (often co-treating with medical providers), emphasis on early return to work and normal activities

2. Subacute care (next 2-6 weeks): Decreased frequency of visits to 1-2x/week, a de-emphasis on passive modalities with an emphasis on active care (rehabilitative exercises, stretching, strengthening)

3. Rehabilitative care (next 1-5 weeks): One visit every week to every other week, continued emphasis on self-care strategies, home exercises, return to normal activities of daily living.

Generally speaking, a re-evaluation of the patients condition is performed every 10-12 visits (or one month, whichever comes first). Provided that a patient is progressing, they move into the next stage of care. If they are getting worse or not improving with care patients are either referred for a specialist evaluation or referred for advanced imaging such as MRI or CT scan, depending on the condition and presentation.

One thing to consider is that these are merely GUIDELINES. They are not hard and fast rules. Patients who are older, who smoke, who are diabetic, or who are on blood thinners generally do not heal as fast as those that are younger and healthier. Some patients do better quickly and some do better slower than the guidelines.

If you, or anyone you know, has suffered whiplash as a result of a Baltimore car accident, and need the help of a Baltimore chiropractor that treats these conditions every day, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

Dr. Gulitz

Immobilization Following Whiplash in Baltimore

As a Chiropractor that treats patients with neck pain following Whiplash in Baltimore, I routinely see patients referred to me from medical doctors that come in wearing a cervical spine collar (soft neck collar). Many of these patients have already had radiographs taken (x-rays) which have been cleared and are negative for fracture or dislocation. Those patients sometimes continue to wear the soft collar due to medical advice and sometimes they continue to wear them out of fear of harming themselves.

Almost without exception soft collars are NOT NECESSARY following neck trauma due to Baltimore car accidents.

The Bone and Joint Decade review notes “there is consistent evidence from 2 RCTs (randomized control trials) and one nonrandomized study that soft or rigid collars alone or in combination with other treatments were not associated with greater pain or disability reduction in the short or long term (up to 1 year) in persons with acute WAD (whiplash) when compared with advice to rest, exercises, and mobilization, and usual or no care.”

A link to the Bone and Joint Decade article can be found here.

If you are injured in a Baltimore auto accident and develop whiplash with neck pain, by all means get the medical care you need. If an EMT puts a collar on you to stabilize your neck so that you can go to the emergency room for x-rays, you should comply. Once you are “cleared” and your neck is “stable” do yourself a favor and do not wear a soft collar. The prolonged immobilization can actually slow your ability to heal by limiting motion to the tissues of the neck.

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

Dr. Gulitz

Shoulder Injuries due to Baltimore Car Accidents

As a Baltimore Chiropractor that treats many patients involved in Baltimore car accidents, many people may think that I focus my examination and treatment purely on the spine. I suppose if I were not a Chiropractor I’d think the same thing. But this isn’t true. As a treating provider for these patients it is my obligation to diagnose and treat all musculoskeletal complaints causally related to the car accident, whether they are spinal complaints (neck pain, back pain, headaches) or extra-spinal complaints such as shoulder, elbow, wrist, hand, hip, knee, or ankle injuries. Technically I can also diagnose non-musculoskeletal injuries such as concussions, but that’s a topic for another blog post.

Let’s talk about shoulder injuries. Provided that there is relative motion at the shoulder joint (let’s say a patient is bracing on the steering wheel with one or both hands during an impact, or, say, the seatbelt harness is pinning a shoulder against the driver’s seat during an impact) there can be injuries to the soft tissue of the shoulder. Take a look at this image for an example.

Shoulder Injury Pain and Suffering Award Reduced

Injuries to the shoulder come in many forms. Symptoms from whiplash usually run the gamut from simple sprains and strains to rotator cuff tears, AC joint separations, glenoid labrum tears, or even impingement of the supraspinatus tendon. After a physical examination of the patient I will usually taking plain film radiographs (x-rays) to rule out an obvious issue of fracture or dislocation. Provided that the shoulder is stable I will begin therapy for the shoulder that involves electrical muscle stimulation and/or ultrasound to help with pain and to increase blood flow to the region. Over the course of therapy I will take a patient through range of motion exercises and eventually progress towards stretching and strengthening activities.

Most patients who suffer shoulder injuries as a result of Baltimore auto accidents do well with conservative treatment of these conditions. Some, however, are not so fortunate. Provided that 3-4 weeks of therapy have gone by and a patient is not improving I will usually refer for an MRI of the shoulder. An MRI can take a closer look at the sensitive soft tissue structures of the shoulder and determine if there are any ligament or muscle tears responsible for ongoing discomfort and disability. Once I have a better understanding of the injury I make a determination as to whether continued conservative management is appropriate or if the patient requires referral to an orthopedic surgeon for evaluation of pain and instability.

The shoulder is a complex region. X-rays are, admittedly, limited in their usefulness in many cases following trauma. In the vast majority of cases most patients do well with conservative physical therapy modalities, exercises, and strengthening. For those patients that do not improve, MRI and/or referral to specialists are sometimes appropriate.

If you, or anyone you know, was involved in a Baltimore car accident have suffered a shoulder injury, please call Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

Dr. Gulitz

Auto Accidents in Baltimore and Washington D.C.

In an attempt to bring the discussion of safe driving to the forefront, AllState recently published its results for the safest (and least safe) cities to drive in the U.S. Once again at the bottom of the list are Baltimore, MD and Washington D.C. AllState ranked the top 200 cities in the U.S. by population and looked at the number of non-fatal auto accidents per capita in a one year period ending in July 2012.

A link to the 2013 report can be found here.

Baltimore ranks number 193 out of 194 safest cities to drive in in the U.S. Drivers in Baltimore are 86.1% more likely to be involved in an auto accident than drivers in the rest of the U.S. Baltimore residents statistically will be involved in an accident every 5.4 years.

The dubious honor of “winner” for least safe roads goes to Washington D.C. with a rank of 194 out of 194. Drivers in Washington D.C. are 109.3% more likely to be involved in a crash than drivers in the rest of the country. D.C. residents are likely to be involved in an accident every 4.8 years.

Hats off to Fort Collins, Colorado who ranks #1 with the least auto accidents per capita this year. Fort Collins residents are 28.1 percent less likely to get in an auto accident as compared to the rest of the country. Fort Collins residents are only expected to be involved in an accident every 13.9 years.

Population density and city planning (old thin roads, lack of major city transportation) has made the Baltimore and Washington Metro areas some of the least safe in the country. With that having been said, it is up to all of us drivers to take proper precaution and not contribute to the problem. Notably, texting and driving is becoming an epidemic, with some reports indicating that it is more likely to lead to teen death behind the wheel than drunk driving.

Be safe out there!

Dr. Gulitz

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.”

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

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”.