Before I discuss the specifics of this case I would like to give some background information and definitions concerning causation. This information is not common knowledge and is important to understand.  There are 3 main text books that I used for this information. The American Medical Association: Guides to the Evaluation of Permanent Impairment, fifth edition, the American Medical Association: Guides to the Evaluation of Permanent Impairment, sixth edition, the American Medical Association: Disability Evaluation, second edition. All 3 text books are widely accepted, peer reviewed and published by the American Medical Association.

Definitions:

Causation - An identifiable factor that results in a medically identifiable condition.

American Medical Association: Guides to the Evaluation of Permanent Impairment, fifth edition, page 600.

Cause - In general, anything that produces an effect. In medicine, cause refers to an identifiable factor that results in injury or illness. The cause or causes must be scientifically probable following causation analysis.

American Medical Association: Guides to the Evaluation of Permanent Impairment, sixth edition, page 610.

Reasonable Degree of Medical Certainty - Causal opinions in reports and testimony must be given

in terms of reasonable medical probability or certainty. (more probably than not)  Probability, simply

means that something is more likely than not (51% or greater chance of occurring). If the confidence is equal to or less than 50% it is merely a possibility. Legal probability, then, simply means that something is more likely to occur than not.

Causality requires determination that each of the following has occurred to a reasonable degree of

medical certainty:

• A causal event took place.
• The patient experiencing the event has the condition.
• The event could cause the condition.
• The event caused or materially contributed to the condition within medical probability.

American Medical Association: Guides to the Evaluation of Permanent Impairment, sixth edition, page 25.

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 or exposure or injury was sufficient to cause the illness or injury in questions.

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  - i.e., 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 (i.e., the absence of other factors, especially pre-existing disease that could have caused or contributed to the problem).

American Medical Association: Disability Evaluation, second edition, page 96

Criteria for Asserting the Existence of a Causal Relationship

Temporal Relationship        Cause should come before effect.  The interval between the two should be consistent with what is found in reports or studies of similar exposures/injuries.

Mechanism                            Must be anatomically and physiologically plausible.

Contiguity                              Should be a clear relationship between cause and effect, with an

(Dose-Response/Duration)  increase in exposure (dose or duration) leading to an increase in effect

Consistency                          Exposure should consistently cause the disease or injury under investigation.

Specificity                              Should be a relative absence of other factors or conditions which "explain" the disease.

Coherence                             Presumption of work-relatedness in an individual case should be consistent with the medical literature.

American Medical Association: Disability Evaluation, second edition, page 25

On page 17 of the AMA Guides to the Evaluation of Permanent Impairment, fifth edition, it says that "if the clinical findings are fully described, any knowledgeable observer may check the findings with the Guides criteria."  It further states that, "any other observer or physician following the methods in the Guides to evaluate the same patient should report similar findings."

Atlanta Georgia, Stone Mountain Georgia, Doctor Car accident

Everyone puts a lot of stress on their backs every day from the process of bending and lifting, even those people who don't have a job that requires frequent heavy lifting. Think of how many times a day you bend down to pick something up: laundry, your pet, a piece of paper, etc. Continued bad form when lifting, even something small, can cause unneeded stress on your back and make it more prone to injury.

There are two common mistakes made in lifting. The first is using the wrong muscles, the back muscles, instead of the leg and buttock muscles. You should always bend your knees when lifting heavy objects so you have a solid foundation for your spine. You should keep your trunk vertical when bending down and lifting something. A horizontal trunk can put pressure on the lower back amounting to hundreds of extra pounds. This pressure can eventually compromise a disc or sprain or strain a back muscle.

The second common error is lifting an object too far from the body. Get close to what you are lifting. It decreases the pressure on your spine. Try to start with the center of the weight no more than 8 inches from your body, then lift the object with a straight back using your leg and buttock muscles. These are simple principles that will help you minimize injury to your back when lifting.

Just to illustrate, if you lift a 10-pound weight at arms length, it will put 150 pounds of pressure on your back. Lifting an object that weighs 86 pounds puts over 700 pounds of force on the discs in the lower back. An object that weighs over 86 pounds should not be lifted more than a distance of 12 to 13 inches and should not be lifted more than once every five minutes if possible. The heavier the object, the shorter distance it should be lifted. If the object must be lifted higher, assistance or a machine should be utilized. In the case of mandatory occupational lifting, positions or loading platforms should be adjustable to the height of different people. Try not to reach when lifting items higher than chest level. Lifting objects higher than chest level puts considerably more stress on your lower back. When lifting items above your head, make sure to use a stool or a ladder.

Another important guideline to follow is to limit twisting when lifting. This adds more force to your back. If you must turn when lifting, pivot your feet instead of twisting your back. In addition, always be sure of your footing. A sudden change in footing or a trip can cause enormous amounts of added stress on the back.

Another problem with lifting is fatigue. The more you bend and lift, the more fatigued your muscles become. When muscles are fatigued they are more prone to injury. Frequent breaks when lifting are preferable to help rejuvenate strength.

Always use both hands when lifting and lift slowly and deliberately. The ideal situation is to have someone or something to help you when lifting, but if that's not possible, follow all the above listed guidelines to minimize your risk of injury.

Following is a review list of dos and don'ts when bending and lifting:

Don'ts

• Don't lift things when your feet are too close together. If your feet are closer than shoulder width you'll have poor leverage, you'll be unstable, and you'll have a tendency to round your back.
• Don't lift with your knees and hips straight and your lower back rounded. This is the most common and stressful bad lifting move. Twisting the trunk during this bad move compounds the problem.
• Don't tense and arch the neck when lifting. This crams your neck joints together and causes pain especially if maintained for a long period of time.
• Don't lift and/or carry an unbalanced load.
• Don't lift and bend too much in a short period of time.
• Don't lift objects that are too heavy for you.
• Don't lift heavy objects directly following a sustained period of sitting, especially if you have been slouching.
• Don't lift things overhead with your neck and back arched, if possible.

Dos

• Do place your feet and knees at least shoulder width apart or front to back in a wide-step position. This will help you bend at the hips, keeping your back relatively straight and stress free.
• Do lean over or squat with the chest and buttocks sticking out. If you do this correctly, your back will be flat and your neck will balance in a relaxed neutral position.
• Do take weight off one or both arms if possible. When you squat down or push back up, use your hand or elbow as support on your thigh or any available structure. This takes some of the compression and strain off of the lower back.
• Do balance your load on either side if possible, or switch sides so that both sides are equally stressed.
• Do level the pelvis or tuck in your buttocks and suck in your abdomen, when reaching or lifting overhead. Keep your chest up and use a step stool to keep the low back and neck in neutral alignment.
• Do walk around and use backward-bending and/or stomach-lying positions before or after bending or heavy lifting, especially if you've been sitting for a while.

The materials on this Web site are for your general educational information only. Information you read on this Web site cannot replace the relationship that you have with your health care professional. We do not practice medicine or provide medical services or advice as a part of this Web site. You should always talk to your health care professional for diagnosis and treatment.

Everyone puts a lot of stress on their backs every day from the process of bending and lifting, even those people who don't have a job that requires frequent heavy lifting. Think of how many times a day you bend down to pick something up: laundry, your pet, a piece of paper, etc. Continued bad form when lifting, even something small, can cause unneeded stress on your back and make it more prone to injury.

There are two common mistakes made in lifting. The first is using the wrong muscles, the back muscles, instead of the leg and buttock muscles. You should always bend your knees when lifting heavy objects so you have a solid foundation for your spine. You should keep your trunk vertical when bending down and lifting something. A horizontal trunk can put pressure on the lower back amounting to hundreds of extra pounds. This pressure can eventually compromise a disc or sprain or strain a back muscle.

The second common error is lifting an object too far from the body. Get close to what you are lifting. It decreases the pressure on your spine. Try to start with the center of the weight no more than 8 inches from your body, then lift the object with a straight back using your leg and buttock muscles. These are simple principles that will help you minimize injury to your back when lifting.

Just to illustrate, if you lift a 10-pound weight at arms length, it will put 150 pounds of pressure on your back. Lifting an object that weighs 86 pounds puts over 700 pounds of force on the discs in the lower back. An object that weighs over 86 pounds should not be lifted more than a distance of 12 to 13 inches and should not be lifted more than once every five minutes if possible. The heavier the object, the shorter distance it should be lifted. If the object must be lifted higher, assistance or a machine should be utilized. In the case of mandatory occupational lifting, positions or loading platforms should be adjustable to the height of different people. Try not to reach when lifting items higher than chest level. Lifting objects higher than chest level puts considerably more stress on your lower back. When lifting items above your head, make sure to use a stool or a ladder.

Another important guideline to follow is to limit twisting when lifting. This adds more force to your back. If you must turn when lifting, pivot your feet instead of twisting your back. In addition, always be sure of your footing. A sudden change in footing or a trip can cause enormous amounts of added stress on the back.

Another problem with lifting is fatigue. The more you bend and lift, the more fatigued your muscles become. When muscles are fatigued they are more prone to injury. Frequent breaks when lifting are preferable to help rejuvenate strength.

Always use both hands when lifting and lift slowly and deliberately. The ideal situation is to have someone or something to help you when lifting, but if that's not possible, follow all the above listed guidelines to minimize your risk of injury.

Following is a review list of dos and don'ts when bending and lifting:

Don'ts

• Don't lift things when your feet are too close together. If your feet are closer than shoulder width you'll have poor leverage, you'll be unstable, and you'll have a tendency to round your back.
• Don't lift with your knees and hips straight and your lower back rounded. This is the most common and stressful bad lifting move. Twisting the trunk during this bad move compounds the problem.
• Don't tense and arch the neck when lifting. This crams your neck joints together and causes pain especially if maintained for a long period of time.
• Don't lift and/or carry an unbalanced load.
• Don't lift and bend too much in a short period of time.
• Don't lift objects that are too heavy for you.
• Don't lift heavy objects directly following a sustained period of sitting, especially if you have been slouching.
• Don't lift things overhead with your neck and back arched, if possible.

Dos

• Do place your feet and knees at least shoulder width apart or front to back in a wide-step position. This will help you bend at the hips, keeping your back relatively straight and stress free.
• Do lean over or squat with the chest and buttocks sticking out. If you do this correctly, your back will be flat and your neck will balance in a relaxed neutral position.
• Do take weight off one or both arms if possible. When you squat down or push back up, use your hand or elbow as support on your thigh or any available structure. This takes some of the compression and strain off of the lower back.
• Do balance your load on either side if possible, or switch sides so that both sides are equally stressed.
• Do level the pelvis or tuck in your buttocks and suck in your abdomen, when reaching or lifting overhead. Keep your chest up and use a step stool to keep the low back and neck in neutral alignment.
• Do walk around and use backward-bending and/or stomach-lying positions before or after bending or heavy lifting, especially if you've been sitting for a while.

The materials on this Web site are for your general educational information only. Information you read on this Web site cannot replace the relationship that you have with your health care professional. We do not practice medicine or provide medical services or advice as a part of this Web site. You should always talk to your health care professional for diagnosis and treatment.

How do you approach something you dread? Do you put it off until the last minute? Some of us claim to work better under pressure which is just another way of saying you're a procrastinator. Or are you the "up and at ‘em" type that attacks challenges early on? Get the worst task over with so everything else looks easy. The latter approach is the one I'm going to persuade you to use.

Let's suppose you start an exercise program but you've only been doing it a couple of days and you dread every minute of it. Let me digress for a moment. What if I told you that I wanted you to wake up every day and swallow a live frog first thing out of bed? Pretty insane, huh? Now I've heard of people swallowing a raw egg (like Rocky Balboa) first thing in the morning but never a live frog. Now, eating a live, slimy animal first thing of the day would virtually guarantee that it's the worst thing that happens to you all day. By comparison getting a flat tire on the way to work or spraining your ankle playing basketball after work would still be much easier than eating a live frog at daybreak? Get my point?

Now, back to the exercise program. Suppose you did your push-ups, sit-ups, jogging, excerise bike or aerobics first thing out of bed each day. Wouldn't that make the rest of your day look relatively easier? You've just completed 25 minutes of calorie-burning activity before your eyes were even wide awake. Cleaning out the garage, folding laundry or finishing that report for your boss today all look relatively easy now, don't they?

So, by "swallowing the frog" first thing in the morning you'll kick-start your day virtually assuring yourself the day will only get better and better!

One of the problems with whiplash diagnosis for many years was the lack of objective evidence of injury. Recent studies, however, have given us new tools that we can use to pinpoint organic lesions in many patients.

Now, two new studies show that neck muscles show objective, anatomical changes after whiplash injury.

The first study¹ set out to see if there were detectable changes in the neck muscles of whiplash patients. Previous studies have shown that patients with spinal pain also show fatty infiltration of the muscles on MRI. The authors of this study studied 79 female whiplash patients and 34 healthy control subjects, all between the ages of 18-45. Each subject had a neck MRI focused on the cervical spine muscles.

The authors found:

• Whiplash patients had significantly larger cross section of the deep multifidus muscles at the C3-C7 spinal levels.
• Other spinal muscles in the whiplash patients showed an increase in size as well.
• There was no correlation between fatty infiltration and BMI or age.
• Symptom duration or severity did not seem to affect the degree of muscle changes.

The authors write that these, "alterations in the deep muscles may provide valuable insight into the common functional impairments observed in patients with persistent [whiplash."

Because these deep muscles play a critical role in postural control and balance, disruption of these muscles may result in other symptoms of whiplash, such as dizziness or vertigo.

The changes in muscle were found to occur as quickly as three months after injury.

Whiplash Different from Other Neck Pain

The same group of researchers decided to perform another study² that compared the difference between whiplash patients and people with "chronic, insidious-onset neck pain." Their theory was that if disuse of the neck muscles was responsible for the fatty deposits in the muscle, it should be found in patients with non-traumatic neck pain as well as whiplash patients.

The study examined 23 women with chronic neck pain. Each subject was imaged with MRI, and was tested with pressure and thermal pain threshold tests.

The authors of the second study found that, "the results of this study provide preliminary data that female patients (18-45 years) suffering from persistent insidious-onset neck pain do not show quantifiable MRI changes in the fat content of the cervical extensor musculature and that their levels of fat mirror those with no history of neck pain. In addition to a lack of muscle changes, participants with insidious-onset neck pain did not demonstrate widespread sensitivity to sensory stimuli and the presence of these features is consistent with abnormal central pain-processing mechanisms; such as seen in some subjects with acute and chronic WAD."

These studies provide important insight into the problem of whiplash:

• Motor vehicle collision patients show objective evidence of muscle changes on MRI.
• Whiplash injuries are different from non-traumatic neck pain.
• Because fatty infiltration occurs only in whiplash patients, the cause of this phenomenon may be damage to the nerves of the spine.

1. Elliott J, Jull G, Noteboom JT, Galloway G. MRI study of the cross-sectional area for the cervical extensor musculature in patients with persistent whiplash associated disorder (WAD). Manual Therapy 2008;13:258-265.
2. Elliot J, Sterling M, Noteboom JT, Darnell R, et al. Fatty infiltrate in the cervical extensor muscles is not a feature of chronic, insidious-onset neck pain. Clinical Radiology 2008;63(6):681-687.