Organic Basis for the Pain Associated with Soft Tissue Injuries

By Richard H. Adler, Attorney at Law

A recent study published in Spine, “Acute Injuries to Cervical Joints: An Autopsy Study of Neck Sprain,” by J.R. Taylor, M.D., Ph.D., and L.T. Twomey, Ph.D., establishes an organic basis for pain-associated cervical soft tissue injuries not visible on standard radiography.

Since the objective of this study was to search for cervical soft tissue injuries and lesions, only spines without radiologically visible cervical fractures or dislocations were included. The study was a comparative one of cervical spines from sixteen subjects who died of major trauma and sixteen controlled subjects who died of natural causes. The findings of this study were significant:

15 of 16 spines from victims of major trauma showed linear clefts within the cartilage plate in one or more cervical discs (average of 3 discs affected). The linear clefts, which varied from 3 mm. to 2 cm. in length, ran close to and parallel to the vertebral end-plate.

These linear clefts most often affected the peripheral part of the disc, near the vertebral rim, where the cartilage plate lamellae are continuous with the lamellae of the annulus fibrosus.

These cervical rim lesions lie between the transversely oriented lamellae of the cartilage plate and extend around the lamellae of the annulus. According to the authors, “this represents a split between the tissue planes of the cartilage plate and annulus where these are continuous with each other.” (p. 1118)

“Rim lesions are strongly associated with trauma in this study, but not with degenerative change. They principally involve the avascular cartilage plates but often extend into the outer annulus, which contains blood vessels and nerves, and sometimes into the bony vertebral end-plate, which is highly vascular.” (p. 1119 -1120)

The authors believe that chronic pain associated with soft tissue injuries to the cervical spine may occur because of “delayed healing and pre-disposition to premature degeneration as a result of the rim lesions in the intervertebral discs.” (p. 1121)

The authors conclude that these type of lesions or clefts would cause “acute pain at the time of the injury and would be likely to progress to early disc degeneration, with extension of the clefts and vascularization within the clefts. The discs may degenerate because the clefts separate the center of the disc from its sources of nutrition in the vessels of vertebral marrow and the outer annulus. These degenerative changes would also be likely to contribute to chronic pain and dysfunction of the cervical spine.” (p. 1121)

Since the wide spread use of seat belts, many patients survive motor vehicle accidents, yet many of them have persistent neck pain. Neck sprain without fracture or other objective sign of injury may pose a difficult diagnostic problem for practitioners. This undoubtedly adds to a patient’s distress, because there is no objective display of an injury to account for the pain. On occasion, such patients have been regarded as having a psychosomatic illness with little organic basis. However, this notion has been discarded over the years by strong empirical, clinical, and analytical studies. In fact, a substantial portion of neck sprains remain symptomatic for more than two years with little or no evidence of organic disease.

Current medical research confirms that soft tissue injuries can be very disabling and result in permanent problems. In one study, 45 percent of the patients continued to have symptoms 2 years after their legal cases had been resolved. In another study, 12 percent of the patients who suffered whiplash were still significantly disabled several years after the injury. X-ray studies reveal evidence that a whiplash victim is about 6½ times more likely than the general population to develop degenerative disc disease in the 4 year period following an injury. Additionally, 205 patients with neck pain were evaluated clinically and by repeat x-rays. After 10 years, 32 percent had moderate or severe residual pain. Another study reported that 43 percent of 146 patients followed for 5 or more years had significant permanent disability. In 1985, other researchers reported that 59 percent of patients state their injury caused some interference in their daily lives, especially with work and driving.

The Taylor and Twomey study published in Spine may represent another piece of the puzzle confronting cervical soft tissue injury victims and their health care providers. Mounting evidence indicates that a number of mechanisms may be responsible for the often chronic pain associated with whiplash and other sprain/strain-type injuries. An obvious gap has existed between the conventional teaching, which predicted complete recovery from this type of injury, and focused on the apparent absence of objective evidence to explain chronic pain symptoms. Research into areas such as myofacial disease, pain sensitivity of various soft tissue structures, and soft tissue healing processes have all helped to generate an understanding of the residual problems reported by trauma victims with non-radicular conditions. Physicians who are familiar with, or at least mindful of the accumulating literature, can play a critical role in the fair resolution of a trauma victim’s legal claim. The more information that is available and brought to bear in the case, the greater the likelihood of a just result in the legal arena.

At the law firm of Adler Giersch, P.S., we believe doctors, health care professionals, and experienced counsel form the first line of defense between the victim and debilitating physical injury and financial loss. The medical-legal connection is natural and best serves the interests of the patient-turned-client when both health care and legal communities work together. If we can assist any of your patients, simply have them give us a call. Consultations are without cost.

Very truly yours,
ADLER GIERSCH, P.S.

Richard H. Adler
Attorney at Law

1 M.F. Gargan, G.C. Bannister, “Long Term Prognosis of Soft Tissue Injuries of the Neck,” J. Bone Joint Surgery, 1990, 72B:901-903; C. Hildingsson, G. Toolanen, “Outcome After Soft Tissue Injury of the Cervical Spine,” Acta Orthop Scand, 1990, 61:357-359; I. MacNab, “The Whiplash Syndrome,” Clinical Neurosurgery, 1973, 20:232-251; K.M. Porter, “Neck Sprains After Car Accidents: A Common Cause of Long-Term Disability,” British Medical Journal, 1989, Editorial 298:973-974.

2 T.W. Mead, S. Dyer et al., “Low Back Pain of Mechanical Origin: Randomized Comparison of Chiropractic and Hospital Out-Patient Treatment,” British Medical Journal, 1990, Vol. 300, pp. 1431-1437.

3 Macnab, “Acceleration Extension Injuries of the Cervical Spine,” The Spine, 2nd ed., Vol. 1.

4 Gotten, “Survey of 100 Cases of Whiplash After Settlement of Litigation,” JAMA, Vol. 162, p. 865.

5 M. Hohl, “Soft Tissue Neck Injury,” The Cervical Spine, 1983, p. 285.

6 Donald R. Gore, M.D., Susan B. Sepic, M.S., Gena M. Garoner, B.S., and M. Patricia Murray, Ph.D., “Neck Pain: A Long-Term Follow-up of 205 Patients,” Spine, 1987, Vol. 12:1, pp. 1-5.

7 M. Hohl, “Soft Tissue Injuries of the Neck in Automobile Accidents: Factors Influencing Prognosis,” J. Bone Joint Surgery(M), 1974, Vol. 56, pp. 1675-1682.

Chiropractic and Medicine Re-evaluating Professional Relationships

By Richard H. Adler, Attorney at Law

There appears to be a conspicuous attitude change between chiropractic and medical practitioners. The words of Leon Wiltse, M.D., delivered in his 1985 presidential address to the North American Spine Society, may best express the changing attitude of medical doctors:

Perhaps we can take a lesson from this in dealing with spinal manipulation. The explanation given as to how the manipulation works may be quite wrong by our lights, but its practitioners must be doing something right, or 10 million people a year would not be filling their offices. We need to at least learn about it.

Chiropractors and medical doctors have improved their interdisciplinary communication in recent years, fueled, in part, by published research findings validating the effectiveness of spinal manipulation. For example, an oft-cited text on cervical injury written by chiropractors has been well received by medical doctors. See Foreman S.M., Croft A.C., “Whiplash Injuries – The Cervical Acceleration/Deceleration Syndrome,” Baltimore, Williams & Wilkins, 1988. Moreover, Paul Goodley, M.D., of the American College of Orthopedic Medicine stated in his letter to the editor of the Journal of American Medical Association (September 1988):

Manipulation does have scientific support but, because it is primarily an art in its delivery, as is surgery, we encounter problems in establishing unambiguous statistical evidence. Recent medical text (reference to Kirkaldy-Willis: Managing Low Back Pain, 2d ed., 1988) supports the efficacy of manipulation as a rational approach to certain conditions, and a long universal medical tradition supports it (citing Manipulation Past and Present, 1975, by renowned orthopedist James Cyriax, M.D.).

Additionally, independent and respected health science journals have begun publishing chiropractic research with more frequency. In recent years, journals published and/or endorsed by medical associations have dropped their anti-chiropractic editorial bias. In 1992, for example, the American College of Physicians, in its Annals of Internal Medicine, published medical research regarding chiropractic manipulation for back pain. Medical doctors were asked to reappraise the roles of spinal manipulation and the chiropractic profession because of “recent research favorable to the chiropractic treatment of patients with low back pain.”1 The Journal of Family Practice of the American Academy of Family Physicians published an article by Peter Curtis, M.D., and Jeffrey Bove, D.C., from the University of North Carolina at Chapel Hill. The authors encouraged family physicians to “re-evaluate their relationship with chiropractors” and provided guidelines for referral.2

Other medical doctors have written editorials in medical journals agreeing that there is a “pressing need for family physicians to re-evaluate chiropractic in light of both the increasing role it plays in the treatment of musculoskeletal ailments and the epidemic proportion of low back pain sufferers.” 3

Daniel Cherkin, Ph.D., of Seattle has published research in the United States4 showing that, with respect to back pain, there is a higher satisfaction level expressed by patients of chiropractors than those of medical doctors. Dr. Cherkin comments on his recent study of family physicians in the state of Washington showing “surprisingly little antipathy towards chiropractors.” Thus:

  • Only 3% dismissed chiropractors as incompatible with medical doctors.
  • A clear majority had encouraged patients to see a chiropractor and indicated a desire to learn more about what chiropractors do.
  • 25% viewed chiropractors as “an excellent source of care for musculoskeletal problems.” 5

Dr. Cherkin urged more widespread cooperation in the interest of patients, medical doctors, and chiropractors.

The bridge-building between chiropractic and medical practitioners can be seen at the institutional level as well.

AMERICAN COLLEGE OF SURGEONS

“There are no ethical or collective restraints to full professional cooperation between doctors of chiropractic and medical physicians.”

Such cooperation should include “referrals, group practice, participation in all health care delivery systems, treatment and services in and through hospitals, participation in student exchange programs between chiropractic and medical colleges, and cooperation in research and continuing education programs.”

AMERICAN COLLEGE OF RADIOLOGY

“There are and should be no ethical or collective impediments to interprofessional association and cooperation between doctors of chiropractic and medical radiologists in any setting where such association may occur, such as in a hospital, private practice, research, education, care of a patient, or other legal arrangement.”

“Radiologists are urged to be sensitive to and consider the legitimate radiologic needs of…doctors of chiropractic.”

AMERICAN HOSPITAL ASSOCIATION (AHA)

The AHA “has no objection to a hospital granting privileges to doctors of chiropractic for the purposes of administering chiropractic treatment, furthering the clinical education and training of doctors of chiropractic, or having x-rays, clinical laboratory tests and reports thereon made for doctors of chiropractic and their patients and/or previously taken x-rays, clinical laboratory tests and reports made available to them upon (patient) authorization.”
Medical doctors are clearly becoming more interested in what chiropractors do. At the same time, many chiropractors have developed informal alliances with different medical practitioners, receiving referrals from medical doctors and, in turn, referring their patients to medical practitioners for consultation/treatment when the need arises. Practitioners interested in developing better interprofessional relationships may consider the following suggestions:

  • Meet with a local chiropractor or medical practitioner and make arrangements to observe his/her practice for an hour or two.
  • Talk with one of your colleagues who has developed a good medical-chiropractic interprofessional working relationship.
  • When making a patient referral, remember that the goal is to achieve effective interaction by communicating successfully across professional or specialist boundaries; clarity and brevity are important.
  • When making a patient referral, explain to the patient the reason for the referral, the expected benefits, and that the findings of the second opinion doctor will be reviewed by the treating doctor and patient.
  • When referring a patient to a chiropractic consultant or medical doctor known only through his/her reputation, be sure to call the practitioner personally to ensure that the referral will be welcome and appropriate. Once the call is made by the referring practitioner, the patient can subsequently telephone to schedule the appointment.
  • The referring practitioner should send a brief letter describing in mutually-understood language the reason for the referral, including any pertinent records and diagnostic studies.
  • It is always important to clearly state whether the referral is for diagnostic purposes, analysis of reasonable and necessary care, or whether it is for treatment to supplement or replace care the referring practitioner has been providing.

The referring doctor will anticipate a report from the consulting doctor on the results of the examination. It is a good idea to satisfy this aspect of interprofessional protocol.
We hope this information proves useful to you.

Very truly yours,
ADLER GIERSCH, P.S.

Richard H. Adler
Attorney at Law

1 Shekelle G. Adams, AH, et al., “Spinal Manipulation for Low Back Pain,” Annals of Internal Medicine Int Med, 1992, 117(7), pp. 590-598.

2 Curtis P., Bove J., “Family Physicians, Chiropractors and Back Pain,” Journal of Family Practice, 1992, 35(5), pp. 551-555.

3 Reis R., Borkan J., Hermoni D., “Low Back Pain: More Than Anatomy,” Journal of Family Practice 1992, 35(5) pp. 509-510.

4 Cherkin D.C., Deyo R.A., et al., “Evaluation of a Physician Education Intervention to Improve Primary Care for Low-Back Pain I: Impact on Physicians,” Spine 1991 16(10) pp. 1168-1178.

5 Cherkin D., “Family Physicians and Chiropractors: What’s Best for the Patient?,” Journal of Family Practice, 1992, 35(5) pp. 505-506.