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Kevin Kelly DC
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KEVIN M. KELLY CHIROPRACTIC INC
Kevin M. Kelly DC
www.kevinkellydc.com

SETTING THE WHIPLASH RECORD STRAIGHT

Today's article is a reprint from Medical Proof of Whiplash by Michael R. Melton & Steven R. Young. I found it pertinent to today's personal injury climate. Enjoy. 

The authors of a recent critical review of the whiplash literature sum up the problem we face today: over $29 billion per year is spent on whiplash injuries and litigation in the US. It is not surprising, considering the financial stakes, that many medical experts have dedicated their professional careers to one side or another of the whiplash controversy. These experts increasingly are relying on medical and engineering literature to support both sides of the debate over the validity of whiplash syndrome.

Unfortunately, a percentage of these studies are flawed, resulting in conclusions that are not supported by the larger body of whiplash literature; 50% of the studies had 3 or more methodological flaws! The researcher team, headed by Dr. Michael Freeman and Dr. Arthur Croft, carefully reviewed 700 studies for specific statements that were considered to be contrary to the current authors' understanding of how the majority of the current literature characterizes the biomechanics, pathogenesis and epidemiology of whiplash syndrome.

Significantly, the studies found to contain flaws are the same studies that are frequently presented in court by defense attorneys and expert witnesses as scientific evidence that whiplash is not real.

I know, shocking isn't it! 

The authors of this research come with some very good credentials:
 
Dr. Michael Freeman is a Forensic Epidemiologist specializing in the application of probability and epidemiologic data to disputed matters. He serves as Clinical Associate Professor of Epidemiology at Oregon Health and Science University School of Medicine, where he teaches a course in Forensic and trauma Epidemiology. Dr. Freeman is also an Adjunct Associate Professor of Forensic Medicine and Epidemiology - Institute of Forensic Medicine, Faculty of Health Sciences, University of Aarhus, Denmark.

Dr. Croft is the director of the Spine Research Institute of San Diego. He has been actively engaged in whiplash research for the past 26 years and co-authored the first textbook on whiplash, Whiplash Injuries: the Cervical Acceleration/Deceleration Syndrome, a book on temporomandibular disorders (Whiplash and Temporomandibular Disorders: an Interdisciplinary Approach to Case Management), and now the first serious textbook aimed at the victims of whiplash and their practitioners, Whiplash and Mild Traumatic Brain Injuries: A Guide for Patients and their Practitioners, along with several other books, textbook chapters, and more than 350 professional papers. He is board certified in Orthopedics (American Board of Chiropractic Orthopedists) and is certified in Traffic Accident Reconstruction (Northwestern University's Traffic Institute), and was appointed as an Independent Medical Examiner by the state of California for several terms. 

Dr. Croft serves in an editorial and/or manuscript reviewer capacity for the Society of Automotive Engineers (SAE), Journal of Forensic and Legal Medicine, Journal of Chiropractic Medicine, Journal of Whiplash Related Disorders, Journal of Manipulative and Physiological Therapeutics, Journal of Musculoskeletal Pain, Journal of the American Chiropractic Association, and the journals Spine, Accident Analysis & Prevention, and Archives of Physical Medicine & Rehabilitation. In addition to his work in the field of chiropractic, Dr. Croft was a drowning homicide investigator, underwater criminal investigator, and trained hyperbaric chamber operator. Until recently, he was the Diving Medical Officer and an underwater search and recovery diver for the San Diego Sheriff's Office.

I'm Dr. Kelly and I welcome your comments.
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A Very Interesting Study

I was reading a study the other day regarding chronic pain from whiplash and after 31 years of specializing in the treatment of whiplash injuries, I was still amazed at the findings. 

The study (1) was performed by numerous authors who are well respected in the study of whiplash injuries (see reference below).

The authors studied 665 patients who presented to a chiropractic office with pain; 419 (63%) reported neck or neck/back pain and 246 (27%) reported back pain only. The authors further analyzed the onset of the pain and found the following: 44% of neck pain was from a MVA (Motor Vehicle Accident), 6% from a lifting injury, 5% from a sports event, 24% from an insidious onset and 16% from other unlisted sources.

The authors found the following trends:

MVA's caused more chronic neck pain than any other etiologic event.
Men with chronic neck pain are four times more likely to attribute that pain to an MVA than men with chronic back pain.
Women with chronic neck or chronic neck and back pain are twice as likely to attribute their injury to an MVA compared with their counterparts with chronic low back pain.

Over the last 50 years countless studies have shown that 20-30% of people experience chronic pain after a rear end collision. This study findings suggest that injuries resulting from MVA's contribute significantly to the population of individuals with chronic spine pain in the United States. It's clear that a substantial number of people suffer from chronic whiplash pain, approximately 15.5 million Americans alone.

I'm Dr. Kelly and I welcome your comments.

1. Freeman MD, Croft, Rossignol AM, Centeno CJ, Elkins WL, "Chronic neck and whiplash: a case-control study of the relationship between acute whiplash injuries and chronic neck pain." Pain Research and Management 2006; 11 (2): 79-83.
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Welcome to summer!

Yes the busiest driving months are ahead for us and especially here in Southern California. When I migrated here some 37 years ago I obviously had no idea how bad traffic congestion would become. Did anyone?

I was reading an interesting study last week regarding traffic accidents and the effects on the spine. The following information comes from Medical Proof of Whiplash, Michael Melton and Stephen Young and is available upon request. This particular article was titled Hidden Spinal Injuries After Whiplash. 

The article points out that since the 1880’s when train accidents were common, physicians considered alleged injuries to be “accident neurosis”, since there was no objective sign of injury. The invention of x-ray did little to illuminate the problem, since there was nothing out of the ordinary when whiplash patients were radiographed. CT scans and MRI’s are better at imaging but in many patients there still show no abnormalities. 

A new study published in Spine, was performed by researchers who looked deeper into the tissue and were able to show concrete evidence of injuries present after a crash. The researchers used cadavers in this study, as other researchers before them have done, however, this study was significant, rather than using isolated spines, they used the intact cadaver and subjected it to a single impact. The specimens were radiographed before the test and placed in a car seat with a lap and shoulder belt. They were then exposed to a collision of 4.4 m/sec or 6.8 m/sec (9.8 & 15.2 mph respectfully). This level of acceleration pulse was chosen on the basis of published reports indicating that 75-90% of whiplash injuries occur at speeds less than 6.9 m/sec (15.4 mph). After the single collision, the specimens were again radiographed. Each specimen was then imaged with CT scans and finally, cryomicrotomy was performed. This is a procedure in which the specimen is frozen and cut into very thin slices. The slices were then photographed and analyzed for lesions.

The radiographs and CT scans did not detect most of the injuries that were present. The authors found that most of the lesions were focused in the area of C5/C6. This again is a significant finding in this study because it confirms what other studies have found – that the lower cervical spine is exposed to the abnormal motions during a low speed collision. Three of the four specimens had injuries to the cervical zygopophysial facet joints, also consistent with most whiplash research.

The authors concluded that the pathological changes identified in this study support previous observations from human volunteer observations with regard to the location of whiplash injury and may assist in the explanation of pain arising from this injury. 

I trust you find this information useful and would encourage you to review the Spine article. 

I'm Dr. Kelly & I welcome your comments
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Immune Responses & Whiplash 

I read several interesting studies recently that compared the objective evidence of whiplash injuries with well known immune system responses.

Researchers know that two chemicals in the body, Cytokines and Chemokines play an important role in the immune response.

Cytokines activate and deactivate white blood cells and immune defense cells and also promote and inhibit a variety of body defenses.

Chemokines promote inflammation by allowing white blood cells to be chemically attracted to injured areas or infected tissues.

Cameron, et al (1) found that rupture of the anterior cruciate ligament in the knee resulted in alterations in the concentrations and types of cytokines in the knee joint. These cytokines can break down the cartilage in the joint, resulting in degeneration.
 
Kang, et al (2) found high levels of cytokines taken from cervical intervertebral discs after surgery. The authors concluded that the high levels of these cytokines were a result of whiplash trauma and are responsible for the degeneration of the disc.

Similar research on cytokines by Kiovioja et al (3) also concluded that these immune system markers were elevated after whiplash trauma. They stated "trauma related activation of the immune system was evidenced by the elevated levels of cytokine-secreting cells".

It is well established that even minor whiplash injuries result in trauma to the tissues of the cervical spine as evidenced by clear biological markers in the blood serum after injuries. 

This research correlates with previous studies linking ankle sprains to increased immune markers and indicates that ligaments may be damaged after whiplash trauma.

We will talk more about the effects of the Chemokines post whiplash trauma next time.

I'm Dr. Kelly and I welcome your comments.

1, 2, 3.  Available upon request
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Whiplash Injury Weakens The Neck

Weakness of the neck after even a minor whiplash injury is often very common. One of the main reasons for this is due to the damage that occurs to the ligaments supporting the cervical spine. 

Recent crash tests using live dummies, there's a contradiction in terms, have demonstrated the acceleration of the head can be 9 times the force of gravity, or 9G's, Basically what this means is if your head weighs 10 pounds, suddenly, in a motor vehicle crash, it now weighs 90 pounds.

Typically in a whiplash injury, the torso moves in one direction while the head moves in the opposite direction. In between the head and the torso, is the neck. The now 90 pound neck! 

The neck weakens due to the fact that the ligaments that hold everything together are not able to withstand the increased forces of a 90 pound neck whipping back and forth so rapidly. This causes the ligaments to stretch beyond their limits. Thus, damage occurs. Ivancic and others at Yale University studied the forces applied to ligaments during a whiplash event. They found that lower cervical spine ligaments exposed to a whiplash trauma can reach about 60 pounds of force in approximately 1/20th of a second.

This research from Yale University was the first of its kind to show that ligaments of the cervical spine are weakened after a whiplash motion. 

That's one for the IVY League!

I'm Dr. Kelly and I welcome your comments.
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Do Some Patients Really Want to Get Back to Work?

Returning patients back to work after a soft tissue injury can be arduous at best. As a treating physician, I am faced with tough decisions like this on a daily basis. Fortunately, a recent study sheds some light on this aspect of patient care. 

Researchers found a definite link between job perception and a person's "intent" to return to work after an injury. Their intent was related to their perceptions of the jobs' physical demand, satisfaction, dangerousness and liking the job. If they didn't like the job, their intent to return was very low.

When compiling my narrative reports I always include work status / disability and use Functional Loss Definitions and Examples as parameters for determining work status. They have been well researched and are accepted as current work status protocols by most insurance companies. 

For instance, let's take the category of work tolerance. A good example of what would preclude one from returning to work would be someone who types all day and has carpal tunnel syndrome. They would not be able use a keyboard, therefore, not able to return to that job. They simply can not perform the usual and customary work duties and should be retrained.

An example or barrier that is NOT a disability related limitation would be someone who chooses not to work certain schedules because of their child's school schedule. This requires some retraining as well, however, psychological issues are not my forte!

Returning patients back to work sometimes takes crawling through the weeds to get to the root of their true disability. It's an art and a science and it's the balance of the two that makes my job so enjoyable!

I'm Dr. Kelly and I welcome your comments.
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THE US GOVERNMENT IS AT IT AGAIN!!!

Yes it never ends does it. 

I received an alert from the National Clearing House the other day, they are the ones who publish guidelines for chiropractic treatment of whiplash related disorders. Well, the recently updated criteria for treatment of whiplash related disorders wasn't good enough so they recently updated it again and I thought you should know. If you're sending your injured clients to a chiropractor for care and I hope you are, they should be aware of these changes as they are vital to settling a case and receiving fair compensation. if you are not sending your injured clients to a chiropractor who understands this important information, call me, I'll help you find someone in your area. Insurance companies often make denials that are not based on US Government standards. Its time we hold them accountable.

I read a review of the new practice guidelines by a colleague, Dr. Dan Murphy DC and I want to share his thoughts: "Clinical practice guidelines have great potential for good, but also for abuse. Consequently, our government keeps an eye on clinical practice guidelines through the United States Department of Health & Human Services and its Agency for Healthcare Research and Quality, where they have created the National Guideline Clearinghouse. The National Guideline Clearinghouse is a “public resource for evidence-based clinical practice guidelines.” It keeps a catalog of high-quality guidelines published by various organizations." You can find Dr. Murphy's entire review at http://thechiropracticimpactreport.com/may-2014/. It's worth reading.

Chiropractic guidelines exist and are sanctioned by the US Government and every attorney who practices PI should have a copy of the information. The Management of Whiplash Associated Disorders Guidelines 2014 can be obtained by contacting the International Chiropractors Association of California:

International Chiropractors Association of California
9700 Business Park Drive
Suite #305
Sacramento, CA 95827
(800) 275-3515

The cost is $87.00. $80 for the book and $7.00 for shipping and handling.

I'm Dr. Kelly and I welcome your comments
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Whiplash Injury: Women have more vulnerable necks

Many research papers have reported that women are much more likely to be injured in a rear end collision than men. Studies by Kraft, Freeman, Burgess, Carroll and Vasavada have all concluded that symptoms ranging from TMJ dysfunction to chronic neck pain all plague women more than men and in a large number of cases, many years after the initial trauma.

These researchers have studied the vehicle forces involved along with the bio-mechanics of the female frame and have noticed striking similarities in the injuries reported. The female frame just simply isn't built for trauma. Is anyone's?

If your female clients seem to complain more about chronic pain than your male clients, the research agrees with them, they're probably not just making it up. You guessed it, women suffer more from chronic pain after whiplash trauma than their male counterparts. 

I'm Dr. Kelly and I welcome your comments.

The above research articles are available upon request.
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Balance Problems After Whiplash

I was reading some information the other day that I thought was quite interesting. It had to do with balance problems after an auto accident. What I thought was interesting was that balance dysfucntion was not associated with dizzyness, as most people might believe. 

The authors found that "dizzyness and vertigo are common symptoms experienced after a whiplash injury and the root of these problems seems to be in injury to the ligaments and discs of the spine".

The authors found that "postural disburances become clinically symptomatic only when several subsystems involved in balance control fail at the same time".

The authors concluded that improvement of mobililty and range of motion immedialty after a crash was paramount in preventing balance problems. Fortunately, Chiropractic care is very effective at improving these functions.

I'm Dr. Kelly and I welcome your comments.
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Recent Chiropractic Studies

I came across a few interesting studies this week indicating the effectiveness of chiropractic care for relieving lower back pain. One study was for osteoarthritis and lower back pain and the other for treating pregnant women with lower back pain. 

The first study was done by Beyerman et. al, and published in JMPT (Journal of Manipulative and Physiological Therapeutics). The authors found that "chiropracitc care was effective in the treatment of osteoarthritis and not only reduced pain but increased overall spinal range of motion". Chiropractic care was also found in this study to be effective at improving the subjects daily activites.

The study on pregnant women was performed by Lisi AJ, and published in the Journal of Midwifery and Womens Health.They studied 17 women with low back pain lasting an average of 21.7 days. The pain intensity was 5.9 on a 1-10 scale. On the Visual Analog Pain Scale, this pain is defined as intermittent moderate pain causing a moderate handicap. In this particular study the onset of pain occurred at 20.6 weeks into the pregnancy. The authors found: "this study shows that chiropractic effectively reduced pain from low back pain during pregnancy, without any adverse effects".

Pretty good stuff if you ask me!

I'm Dr. Kelly and I welcome your comments.
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