Fundamentals

Fundamentals

Medical causality is imputed when the association between a medical condition and a given exposure (physical, biologic, or chemical) is such as to lead one to believe that the condition would not have occurred in the absence of the exposure. The temporal relationship between the exposure or injury and the medical condition (or symptoms suggestive of the condition) is the first factor that must be assessed. The illness or disease should occur after the exposure (referred to as “temporal ordering”) and within a time period that is reasonable given the nature of the exposure (temporal contiguity). In certain situations (such as asbestos, lead, and benzene exposure) there is a long latency between the time of exposure and the appearance of disease. Hence, regardless of whether a temporal relationship appears to be present, determining causality also requires one to assess whether a causal relationship is biologically plausible.

               A causal relationship is biologically plausible when:

               1. The relationship between the medical condition and the exposure or injury can be explained anatomically or physiologically.

               2. The duration, intensity, or mechanism of exposure or injury was sufficient to cause the illness or injury in question.

               3. There is evidence suggesting that the exposure is consistently or reliably associated with the process under investigation in the population under investigation or in peer-reviewed literature.

               4. Cause and effect are contiguous--ie, there is a readily understandable relationship between the two, in which an increase in the magnitude of the exposure reliably leads to an increase in the severity of its alleged effect upon the injured or exposed person, and vice versa.

               5. There is literature providing biologic or statistical evidence indicating that the symptoms or disorder could develop as a result of the exposure (coherence).

               6. There is specificity of the association for the injury (ie, the absence of other factors, especially pre-existing disease, that could have caused or contributed to the problem).

               The independent examiner is obligated to evaluate the validity and strength of all postulated causal mechanism. Mechanisms that appear weak, or are clearly flawed, must be identified as such and accepted as likely only when at least two other criteria for biologic plausibility have been met. Optimally one would wish to satisfy all criteria. There are, however, circumstances when contiguity cannot be demonstrated, as some exposures lead to disease in a noncontiguous fashion. Specificity of association is also difficult to illustrate definitively given the multifactor nature of many disease processes. Literature supportive of causality is generally available, but must be closely scrutinized before relying upon it as it is often poor quality.

Causality

Causality

The independent medical examiner is expected to address causality unless it has already been accepted by the insurer, is presumptive (ie, automatically accepted based on case law or legislation), or has been established through litigation. Causality always must be addressed when the referral source has significant doubts regarding the legitimacy of a claimant’s complaints as related to the initial injury (or alleged injury). Even in the presence of a clear causal relationship between an accident and subsequent physical pathology, one may need to state whether an exacerbation, recurrence, or aggravation of a prior condition occurred and apportion liability accordingly.

               

When examining a claimant who seems credible and insists that one or several medical problems were caused by a given event or exposure, many physicians accept this as fact, even though a careful analysis of the situation would clearly indicate otherwise. The independent examiner is hired to evaluate the claimant objectively, and is expected to base determinations of causality upon commonly accepted physiologic, epidemiologic, and statistical principles, rather than make decisions empirically or based solely on the claimant’s history and the apparent believability thereof. Multiple definitions of causation and their application are discussed in the AMA Guides fifth, and in greater detail in the Guides companion, Master the Guides Fifth. 

Brain Principles Pt.3

 Brain Principles

PRINCIPLE #3

When your brain is troubled, you have trouble in your life.

A troubled brain leads to trouble in your life. It is harder for you to be your best self or to achieve what you want out of life. Plus, you often act outside your own values, morals, and desires. Making poor choices and engaging in unhealthy behaviors are more common when your brain is not working at its best. With a troubled brain, it is much more challenging to follow a treatment plan, and even if you do manage to break free from your addictions, you are far more likely to relapse.

Brain Principles Pt.2

 BRAIN PRINCIPLES

PRINCIPLE #2

When your brain works

   right, you work right.

It has become clear that when your brain works right, you work right. A healthy brain makes it so much easier for you to be your best possible self, to be happier with your life, to be successful in your work, and to have loving relationships. When your brain is working at optimal levels, you are more likely to make good decisions, be reliable, and be an effective employee, friend, lover, parent, or child. Having a healthy brain also greatly increases your chances of sticking with a treatment program so you can overcome addiction.

Brain Principles Pt.1

Brain Principles

PRINCIPLE #1

  Your brain is involved in 

        everything you do.

Your brain controls how you think, feel, act, and interact. From the moment you wake up, it is your brain that plays the central role in your life. It is your brain that urges you to reach for that first morning cigarette or tells you to refrain from smoking. It is your brain that lets you stop drinking coffee after a single cup or pushes you to empty the whole pot.

          Your brain is involved in every decision you make. It also influences who you are and what you do: from social aptitude to athletic skills, parenting style to management approach at work, artistic talent to the type of music you like, Look at any aspect of behavior - from relationships, school, work, religion, and sports - and in the middle of all behavior is brain function. The impact of your brain affects your body too. Whether you live a long healthy life, suffer from a debilitating condition, or have your days cut short by a terrible disease, your brain is the center of it all.

Musculoskeletal Pain and Chiropractic Care

Musculoskeletal Pain and Chiropractic Care

This study evaluated chiropractic treatment and its cost effectiveness in caring for manual labor workers who complained of musculoskeletal problems. Of the 34 patients involved in the study, 13 complained of neck/arm pain and 19 of back/leg pain. 57% of the patients complained of symptoms lasting over 3 months. The subjects averaged 3.23 chiropractic treatments a month if they suffered from neck/arm symptoms, and 5.32 treatments a month if they reported back/leg symptoms. The course of treatment lasted six months. The researchers assessed the patient’s pain, functional outcomes, quality of life, perceived improvement, and employee satisfaction over 6 months. As well, they monitored the cost to the employer prior, during, and after the study period.
Throughout the study and its evaluations, back/leg patients displayed larger treatment benefits.
The Functional Outcome category, which is the patients’ ability to perform normal daily tasks, included the areas of mobility, body care, ambulation, house management, and work. Chiropractic modestly improved the subjects’ lives in body care, house management, and ambulation. The category Quality of Life, on the other hand, included social functioning, emotional disposition, general health, vitality, and body pain. The patient’s level of body pain, vitality, and emotional well being also improved with the treatments.
Patient satisfaction reports were very high. In both groups, those who did not feel “cured” at one month definitely did by six months. 84% of the back/leg patients found the treatment beneficial, and 77% of the neck/arm patients were pleased with their treatment outcomes.
In appraising the overall costs of treatments and sickness, the researchers reported that the employer’s overall costs fell by 30% in the first year of the arrangement and by a further 20% the following year. The extensive treatment costs, however, absorbed 40% and 82% of these savings.

Chiropractic Treatment of Disc Herniations

Chiropractic Treatment of Disc Herniations

This study examined 27 patients in a private chiropractic practice who presented with neck or back pain and who had MRI-documented cervical or lumbar disc herniations that corresponded with clinical findings.
“Patients were treated with a course of chiropractic care consisting of traction for the cervical spine or flexion distraction in the lumbar spine in the acute phase of care, in addition to interferential/ultrasound combination and cryotherapy. In the subacute phase, rotational manipulation was judiciously added, as were isometric and flexibility exercises. In the chronic stage of care, distraction manipulation and rehabilitative exercises were continually employed. Rehabilitative exercise included extension exercises in addition to pelvic tilts, lifts and knee flexion stretching.”
“Treatment frequency was typically four to five times/wk for weeks 1 and 2, then three times/wk with decreasing frequency as the patient progressed. Duration of active care varied from 6 wk to 6 months.”
“When patients reached the point at which their VAS [visual analog scale] score was ?2, their exam findings reversed and their extremity pain resolved, a repeat MRI was obtained. This scenario occurred as early as 6 wk after initiation of care.”
If the patients did not reach these milestones, follow-up MRI was performed 1 year after the initiation of care.
The study found that 22 of 27 (80%) had good clinical outcomes; 17 of the 22 (77%) “had not only good clinical outcome but also evidence of reduced or resolved disc herniation upon repeat MRI scanning.”
Five patients (18.5%) had a marginal or poor outcome, but none had worse clinical signs or pain ratings at the end of the study.
At the beginning of the study, all 27 patients had left work because of the severity of the pain; at follow-up, 21 (78%) were back to work in their former occupations.
VAS scores decreased from an average of 6.9 before treatment to 1.9 following treatment.
One important issue that the author addresses is the controversy of whether manipulation is contraindicated for disc herniation. After reviewing the literature, and from his clinical findings, he concludes that manipulation is indeed safe for disc herniation: “…in the cervical and lumbar spine, rotational manipulation most likely cannot be implicated in disc failure or exacerbation of a disc herniation, and for rotational forces from a manipulation to be involved in disc failure, facet fracture must occur first.” No complications occurred in this study.

Recent Onset Headache

Recent Onset Headache

This study examined 100 consecutive patients who presented at neurological unit with headache of recent onset (described as headache that "appeared for the first time ever in the last 12 months. Patients with past history of headache were excluded except, if a change of character of the previous headache had been the reason for the referral.") Every patient was examined by a physician and given a CT scan with and without intravenous contrast. Some of the patients were given lumbar puncture, blood tests, MRI, and magnetic resonance angiography, if needed.
90% of the patients had headaches for the first time, while 10% had previous—but now different—headaches.
The study reported that the neurological examination was normal in 80% of the patients. Further investigations, however, turned up some very serious conditions: Intracranial neoplasm (21%); subacute meningitis (5%); intracranial hematoma (3%); and hydrocephalus (2%). In all, "Headaches were considered organic in 39 (39%) of the 100 patients, and in 21 (26%) of the 80 with normal neurological examination."
"It has been suggested that with recent-onset headache, a CT or MRI should be obtained if the headache is severe or occurs with nausea, vomiting or abnormal signs. However, headache in four patients with intracranial tumors in our study was mild, no nausea or vomiting occurred, and was not aggravated by Valsalva nor did it awake them during the night, and were unassociated with abnormal neurological signs."
"We suggest that neuroimaging studies should be performed in all adult patients with non-vascular headache of recent-onset, and no previous history, irrespective of the characteristics of the headache..."

Headache, Diet, and Exercise

Headache, Diet, and Exercise

Two new studies have been published that examine the role of diet or exercise in headaches.
The first¹ was a survey given to 112 migraine sufferers. The researchers found that 70% of migraine patients felt that diet played a role in their headaches, and the most common triggers of a headache attack were, 1) chocolate, 2) skipping a meal, and 3) alcohol.
The second study² examined the role of aerobic exercise in tension-type headaches in seven women. The women maintained a daily headache and medication diary for two weeks pre- and post-intervention, as well as during a six-week aerobic exercise regimen. This class consisted of "10 to 15 minutes stationary and moving warm-up and stretches; 20 to 30 minutes of low-impact cardiovascular training, and 10 to 15 minutes of cool-down and stretching exercises." The women attended the class three times a week.
Headache levels did not change for the women. However, there were significant reductions in medication usage, depression, and anxiety. "...clients may turn to exercise in lieu of analgesic medications to manage their headache pain. With respect to decreased anxiety and depression levels, it is possible that engaging in aerobic exercise may improve mood which may alleviate some of the distress caused by chronic headache, and thus improve the quality of these patients' lives."

Stress, Hunger, and Headache

Stress, Hunger, and Headache

This study evaluated two recognized headache triggers—hunger and stress. The study participants were 56 students who had suffered from both migraines and tension-type headaches for at least six months.
The researchers created four different test scenarios for the patients: stress, with no food; stress, with food; no stress, food; and no stress, no food. The 56 subjects were randomly assigned to one of the test groups.
When testing the triggers separately, 58% of the food-deprived subjects reported headaches. Previous studies had associated hunger with migraines, yet this study found that hunger can also trigger tension-type headaches. In fact, the researchers measured forehead EMG levels, and found that the "no food" patients had significantly elevated EMG readings.
The researchers found that stress was indeed a potent trigger for headache—93% of subjects reported the start or a worsening of headache symptoms during the "stress, with food" experiment.

Whiplash-Associated Headache

Whiplash-Associated Headache

Psychological symptoms are often associated with both headaches and whiplash. This study examined patients who suffered from headaches (along with the neck pain) following whiplash by using the SCL-90-R, a self-report, psychological symptom checklist that is used to assess distress. In previous studies, patients with post-traumatic headaches had scored higher on the questionnaire than patients with no chronic pain; also post-traumatic patients have indicated a higher rate of psychological distress on the SCL-90-R than migraine and tension headache sufferers did.
The study's goal was to get a psychological distress profile of patients who suffer from headache induced by whiplash injury, and to then compare those patients distress to that of previously published distress levels of traumatic and non-traumatic headache patients.
The authors found that patients with headache as a result of whiplash scored similarly to patients with other types of post-traumatic headache and to patients with whiplash but with no headache. When the whiplash patients were compared to non-traumatic headache sufferers, however, significant differences emerged. Patients with non-traumatic headache pain scored evenly on all of the test subscales, while whiplash patients scored higher in just a few different scales: somatization, obsessive-compulsive, depression, and hostility.
The authors explain their findings:
"The reactive pattern of distress exhibited by patients with post-traumatic headache and whiplash-associated headache is more suggestive of a direct secondary response to pain and disability, resulting from trauma, rather than of a more diffuse etiology. Thus, somatization can be interpreted as belief by the patient that something in the head or neck does hurt; the obsessive-compulsive subscale elevation reflects the interference of pain with cognitive functioning and subsequent insecurity; depression occurs because the pain does not go away; and hostility arises when the accident is not the patient's fault, or when doctors and solicitors cannot find and/or deny a cause or a cure."
This study is the latest of a large group of studies that show that organic pain may be at the root of whiplash-related distress. As the authors state, "These differences [in distress patterns] are prima facie grounds to resist the temptation to ascribe whiplash-associated headache to situational stress and 'tension,' and, instead, to consider the possibility of an organic pain source."

Chiropractic Treatment for Migraine

Chiropractic Treatment for Migraine

Migraine headaches are estimated to cost the U.S. over $17 billion each year. While it is clinically recognized that migraines can be related to cervicogenic conditions, the exact nature of this relationship is unknown. This study set out to test the effectiveness of chiropractic treatment for migraines.
123 participants diagnosed with migraines according to the International Headache Society standard completed the study. Each participant experienced a minimum of 1 migraine per month, and had at least 5 of the following indicators: inability to maintain normal activities/need to seek dark and quiet, pain located around the temples, "throbbing" pain, symptoms of nausea, vomiting, aura, photophobia or phonophobia, migraine triggered by weather changes, migraine worsened by head or neck movement, diagnosis of migraine by a specialist, and a family history of migraine.
The study consisted of three stages. In the pretreatment stage, researchers collected data on migraine incidence, intensity, duration, disability and use of medications, this data was used as a baseline to compare with study results and data collection continued throughout the trial. For the second stage of research participants were split into a control group (40) that received a placebo treatment using electrodes and an experimental group (83) that received a maximum of 16 treatments of chiropractic spinal manipulative therapy (CSMT). The last 2 months of the study involved data collection for comparison purposes.
Results showed that those that received chiropractic treatment had significant improvement in migraine frequency, duration, disability and lowered medication use in comparison to the control group. Improvements in migraine frequency and duration for the chiropractic group are illustrated below. The area of greatest improvement was medication use, with a significant number of participants reporting that their medication use was down to zero by the end of the trial. Five participants reported that migraine symptoms were worse after 2 months of CSMT, but they did not report intensified symptoms at the post treatment stage.
The authors report that their study with a 6-month duration is more valid than some previous studies because studies with shorter durations are too short to allow for the cyclical nature of migraines. Limited sample size and lack of consideration for what aspect of CSMT caused the improvements are some limitations of this study. Researchers also suggest that an improved study method might be to treat the control group with a sham form of CSMT rather than a treatment that does not mimic chiropractic. Despite some limitations this research adds to the body of evidence that suggests chiropractic manipulative therapy can be an effective treatment for migraine and headaches. The authors conclude:
"A high percentage (83%) of participants in this study reported stress as a major factor for their migraines. It appears probable that chiropractic care has an effect on the physical conditions related to stress and that in these people the effects of the migraine are reduced. However, further studies are required to assess how chiropractic SMT may have an effect on migraine morbidity."

Anxiety and Fear of Pain in Headache patients

Anxiety and Fear of Pain in Headache patients

The of psychological issues—especially anxiety and fear—in recovery from pain is a complex one, and one that is unfortunately not dealt with often enough in clinical practice. It is easier to deal with the physical mechanisms of pain than the social and emotional. A new study from Canada studied the role of Anxiety Sensitivity (AS)—or the tendency to become fearful—in patients with headache.
Since no study to date has assessed AS in headache patients, the authors investigated whether headache patients with higher AS would report more cognitive, affective, and behavioral deficiencies as compared to those with medium or low AS scores. They also were hoping to determine the behaviors that predict fear of pain and lifestyle changes in this study sample.
72 patients were involved in study; 85% were female, and � of these patients suffered from migraines. The patients took the ASI, and scores for all patients were high, approaching or exceeding the average for obsessive-compulsive disorder, generalized anxiety disorder, and social phobia. The anxiety sensitivity groups did not differ in the severity or change of lifestyle due to headache. Yet, those with high anxiety sensitivity scores had more adverse effects—such as greater depression, anxiety, fear of pain, incidence of avoidance behavior, and cognitive disruptions.
Anxiety sensitivity, pain-related cognitive disruption, and pain experience were predictors. The authors hoped determining the predictors would help formulate target treatment or intervention. The authors recommend AS intervention mixed with traditional approaches to pain management:
"The present results support the application of AS intervention within the context of chronic and recurrent pain. However, at least for patients with recurrent headaches, some lifestyle changes attributed to pain appear to be mediated primarily by the severity of the pain experiences and, to a lesser extent by the physiological anxiety, cognitive anxiety and escape/avoidance behavior...Consequently, an effective means of dealing with pain severity, whether pharmaceutically or cognitive-behaviorally based, remains a target for treatment that is of immediate importance."
Thus, a patient's expectations and anxieties regarding pain need to be examined, along with the physical aspects of the pain.

Botulinum Toxin Treatment of Cervicogenic Headache

Botulinum Toxin Treatment of Cervicogenic Headache

This study assessed the effectiveness of botulinum toxin A injected in five cervical trigger points as treatment of chronic headaches stemming from a whiplash injury. Twenty-six patients, (11 men and 15 women, between 29 and 75 years old), completed the study. Patients were divided into a group of 14 who were treated with a dilution of botulinum toxin A, and a group of 12 who received placebo treatment (saline injections).
Follow-up assessments occurred at two and four weeks post-treatment. The outcome measures used were subjective head pain and objective range of neck motion. The treatment group showed reduction in pain and improved range of motion at the two-week follow-up. At the time of the four-week assessment, 11 of 14 in the treatment group showed significant improvement in both range of motion and pain as compared to pre-treatment levels. The placebo group showed no improvement on either outcome measure at the four-week assessment, although a portion of the placebo group reported improvement in pain at the two-week follow up. None of the patients reported any shoulder or neck muscle weakness or other side effects.
The authors write:
"This study offers no definitive insight into the pathophysiology of chronic cervical- associated headache but does demonstrate at least a short-term response of this condition to BTX-A trigger point injections in 11 of 14 subjects treated. This positive response is clinically similar to that observed in reports of temporomandibular dysfunction, tension headache, blepharospasm, and dystonias. It is, therefore possible that peripheral pain in these and other conditions shares a common pathology within myofascial tissues."
Due to the small sample size, and brief follow-up period no specific conclusions can be drawn from this study, but results do suggest that further research into the effectiveness of this therapy is justified.

Whiplash Symptoms - Headache

Whiplash Symptoms - Headache

Neck pain is the second most common symptom experienced after a whiplash, reported by over 90% of patients.
Like neck pain, headache also can have a variety of different causes from an auto collision. The first step in treating post-traumatic headache is to diagnose the root cause of the pain. The following sections describe the different causes of headache and how to approach treatment.

Headaches Caused by Neck Injury

Cervicogenic headaches—or headaches that originate in the cervical spine—is a very common source of headache after an auto collision. Chiropractic can be especially helpful in treating these types of headaches.

Nerve Injury

Sometimes the nerves of the neck can be injured during the violent motion of an auto collision. These damaged nerves can result in headache.

Muscular Injury or Tension

Muscular tension is another common source of headache after whiplash. Myofascial tension can be caused by referred pain, direct injury to the muscles, or stress.

Migraine

Migraine-like headaches are reported by some patients after an auto injury. It's likely that these migraine-like headaches are just a more severe form of cervicogenic or tension-type headache.

Brain Injury

Headaches are a common symptom of brain injury, which can occur during an auto collision—even when there is no direct head impact.

Chiropractic Versus Active Exercise for Low Back Pain

Chiropractic Versus Active Exercise for Low Back Pain

Previous studies have shown that chiropractic can be an effective treatment for some patients with low back pain. This new study looked at patients with chronic back pain, with the aim of determining which subgroups of patients find chiropractic beneficial.
For the study, the authors recruited patients from a Chicago suburb; a total of 225 patients met the study requirements. The patients were then randomly assigned to the flexion/distraction (FD) group (123 patients), or the active trunk exercise protocol (ATEP) group (112 patients).
To be included in the study, the subjects had to have pain between L1 and S1 that had lasted at least 3 months.
The authors describe the treatment the subjects received during the study:
“The FD technique was performed on a specially constructed table with a moveable headpiece, a stationary thoraco-lumbar piece, and a moveable lower extremity piece. With the subject lying prone, the clinician placed one hand over the lumbar region at the level of interest and used the other hand to flex, laterally flex, and/or rotate the lower extremity section of the table. FD consisted of two biomechanical components. The first component was a series of traction procedures using the flexion range of motion directed at a specified joint level. The motion from the traction procedure resulted in opening of the posterior joint space and a consequent reduction in intradiscal pressure. The second component was a series of mobilization procedures using a possible combination of ranges of motion targeted again at a specific joint level. Most patients moved from the traction component to the mobilization component within 4 weeks of care.”
“ATEP was administered by licensed physical therapists and consisted of flexion or extension exercises, weight training, flexibility exercises, and cardiovascular exercises dependent on patient symptoms. The aim of the program was to strengthen the muscles surrounding the spine and increase flexibility. Methods used to develop stabilizing exercises were consistent with those of O’Sullivan and colleagues. The therapists in the study met as a group to choose the specific exercise regime for study purposes and met monthly to reinforce treatment consistency. Biomechanically, the ATEP did not concentrate on a specific joint level but sought to impact the lumbar spine as a whole.”
After the course of treatment, the authors examined the data to see how each group fared. They found the following:

• Both sets of patients experienced improvement of their pain and symptoms.
• Subjects in the chiropractic group “had significantly greater relief of pain than those allocated to the exercise program.”
• Patients who had chronic pain categorized “with moderate to severe symptoms, improved most with the flexion-distraction protocol.”
• Patients with recurrent pain and moderate to severe symptoms fared best with ATEP.
• The chiropractic treatment was more effective for patients with radiculopathy.
• “Overall, flexion-distraction provided more pain relief than active exercise…”
• Chiropractic patients were more likely to finish the treatment protocol: 13 patients dropped out from the chiropractic group, while 25 dropped out from the ATEP group.

This study shows that low back pain patients cannot be simply lumped into one group and all treated in the same manner:
“The differences in treatment results according to subgroup analyses make biological sense. The FD intervention was intended to provide motion and forces directed at specific intervertebral level. The ATEP on the other hand was intended to concentrate more on strengthening the muscles surrounding the spine and increasing flexibility. As such, a greater decrease in VAS among patients with radiculopathy should be expected for the FD group where changes in disc pressure may be most important.”

Treating Headaches with Chiropractic

Treating Headaches with Chiropractic

Many people suffer from chronic headaches. Some headaches can be attributed to stress or tension, but the latest medical literature¹ reports that some cases of chronic headache are caused by a problem in the neck—and that they are often misdiagnosed or unrecognized by physicians.
These headaches are known as "cervicogenic headaches," since they have their "genesis" in the cervical spine. They arise when the nerves, joints, or muscles of the neck are injured or strained. Pain signals from the neck can get mixed with nerve pathways of the head and face, and can create pain in seemingly unrelated parts of the body.
Cervical spine dysfunction can cause pain in any part of the head, and cervicogenic headaches are usually focused on one side. These types of headaches can last for many hours or days, and are usually described as a dull, aching pain. Neck movement, injuries, or an awkward posture can trigger these headaches. Medication may relieve pain temporarily, but if the root cause of the pain is not eliminated, the symptoms will just return down the road.
The first step in treating headache is to take a careful history and perform a thorough physical exam. This will help us determine the precise source of your pain, and help us design an effective treatment plan.
Chiropractic can be a great way to treat headaches, since we work specifically with the spine to make sure that it is functioning properly. If you suffer from regular headaches, contact our office for an appointment.