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Academy of Chiropractic’s

MD Relationship Program

Spinal Biomechanics 

How Do YouDefend[Document Causality] a Trauma Patient Who Demonstrates Ligament Laxity and Moderate to Severe OA [Osteoarthritis]

PART II

From:  William J Owens Jr DC DAAMLP

 

The other day I had released the following Consultation. Below this introduction is the second part.  

Dr. Duane Paterson asked the following question.  It is an important one so I thought as I wrote this up to answer his question I would share it with the group.

"Is there research to indicate that osteoarthritis can cause instability, and if so how do you defend a trauma patient who demonstrates ligament laxity and moderate to severe OA?"

 

PART 2- “how do you defend a trauma patient who demonstrates ligament laxity and moderate to severe OA?”

 

Now that we understand that the bodys natural reaction to injury is stabilization and HYPOMOBILITY not excessive motion, I want to first talk about the vocabulary used in the original question, and how we need to make sure we are working asdoctorsand not as legal consultants which will show a certain level of bias.  Instead of using the word DEFEND [which was a good word to use to ask the question], we want to demonstrate that we are simpling using the TRUTH to determine the cause of the injury. My concern is what happened to the patient, how we stabilize it and how we fix or manage it, that is it. As doctors we dont care what the lawyer thinks, what the court thinks etc, what we care about is the truth. With that being said, we now need to move on to discussing what happens when a significant traumatic force is applied to a degenerative joint and/or a fibrotic or calcified ligament in the human spine. What is important to understand is that a traumatic force canbreak througha stiff, hypomobile joint segement to create excessive motion. That excessive motion is in contrast to the natural processes of the body and it can create confusion when determining a causal relationship to the injury. In fact, research has shown that it takes LESS ENERGY to make a HYPOMOBILE joint HYPERMOBILE since the integrity of the pre-trauma joint is compromised due toSTIFFNESSThe best example is a green twig vs a brown/dry twig...

 
Lets take a look at some references that showcase how stiff ligaments respond to trauma and how to PROPERLY DOCUMENT the patient’s findings, in 2008 Newgard et al stated, Physical intolerance of the body to the traumatic forces in an automobile crash are more likely to result in significant injury and should be considered more significant than other co-morbid factors. Physical intolerance factors listed in this paper were changes in "bone density, lean muscle mass, [and] pliability of tissues"  They continue by stating,As occupants age, they become inherently more fragile and less tolerant to the multitude of forces involved in an MVC. Medical fragility, as measured by crash-related mortality rates, has been previously demonstrated.  They go on to state,This study found there is no real cut off point relating to age. Pre-existing changes (AKA medical fragility) are the key factors. Therefore, the physiological age of the body is a more important prognostic factor than actual chronological age and arthritic degeneration, no matter the age of the occupant, This is a key risk factor (one of many) rendering an increased incidence of bodily injury. 1

 

When we take a look at spinal ligaments in particular, in this case in the lumbar spine, Iida et al (2002) reported, The mechanical strength of human lumbar posterior spinal ligaments decreases with age and facet degeneration, particularly in the ligament substance.” 2

 

This is similar to what Mattuci et al reported in 2012, In general, the current study reported higher values of failure force and stiffness and lower values of failure elongation, and trends are present for the failure force and stiffness [in this case meaning RESISTANCE TO FORCE, not calcification] of the ALL to decrease with increasing age.  The state further,Age effects have also been observed in the LF (ligamentum flavum), ISL (interspinouse ligament), and SSL (supraspinous ligament) at the lumbar level, where the tensile strength and elastic modulus were found to decrease by a factor of 4 between the ages of 20 and 80 for the LF and to decrease by 50% between the ages of 40 and 80 for the ISL and SSL.

 

These findings are all associated with the physiologic responses to aging which is also the same as response to a prior trauma. Either way the bodies response is predictable, that predictability results in a weak and stiff joint where elastic properties are severely reduced.

 

Mattuci further states, “Values measured from the younger specimens of this study were consistently stronger and stiffer than results from previous studies involving older test specimens.” 3

 

In conclusion what we see is it is not CHRONOLOGICAL AGE that maters when we are considering the body’s response to trauma but PHYSIOLOGICAL AGE.  Degenerative changes can be found in any person at any age…the difference in causally is whether there is excessive motion in the motor unit.   

 

References:

1. Newgard, C. D. (2008). Defining the "older" crash victim: The relationship between age and serious injury in motor vehicle crashes. Accident Analysis and Prevention, 40(4), 1498-1505

 

2. Iida, T., Abumi, K., Kotani, Y., & Kaneda, K. (2002). Effects of aging and spinal degeneration on mechanical properties of lumbar supraspinous and interspinous ligaments. The Spine Journal2(2), 95-100

 

3. Mattucci, S. F., Moulton, J. A., Chandrashekar, N., & Cronin, D. S. (2012). Strain rate dependent properties of younger human cervical spine ligaments. Journal of the mechanical behavior of biomedical materials10, 216-226.

 

 

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