Owners Manual for Injury Prevention
Bruce Kaler, M.D. Seattle, Washington, USA
Published by Bruce Kaler at Smashwords
Copyright Bruce Kaler 2010
Discover other titles by Bruce Kaler at Smashwords.com:
Turnabout - http://www.smashwords.com/books/view/387
The Owner’s Manual for Allergy Sufferers - http://www.smashwords.com/books/view/485
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Owners Manual for Injury Prevention
Introduction
I have always tried to promote healthy life choices for work and play. I believe the choices you make at home, at work and at play, all contribute to your well-being and the fitness and safety of others around you too.
My hope is this book will continue to provide helpful information for you and your family about common medical dilemmas. I want to be your partner, maintaining your health and inspiring you to reach your goals at work or play. After more than thirty years working in medicine one of my most passionate goals is to provide quality medical care while containing costs for you and your family. My professional experience has included general family practice, occupational medicine as well as emergency medicine and urgent care.
The information in this book is a primer for understanding the frequency of common medical problems that occur at work or play. With that understanding, I hope to prevent some of these injuries and facilitate your treatment, should you have an injury, by you being an active and informed participant in your care.
If a medical condition is life- or limb-threatening, or has severe wounds or amputations, patients should go to the emergency room. If the medical condition is non-life-threatening, convenient urgent care can be a less costly and faster alternative to the hospital based facility. Even if you have a family physician, they are often not available when you need to be seen. There is no need to delay unnecessarily when you can have convenient access to quality heath care. However you must make informed decisions about your medical needs. These choices start with understanding common problems and how to prevent them. Should you become injured having some background information about the problem will go a long way to insure you make better choices about your care. Being an informed participant can make a big difference in your successful recovery.
Contents
Back Injury
Back strain is one of the most common injuries in the workplace or home. Most acute back strains that seek medical advice get better in 12 weeks or less. Nonetheless, some are a great deal more problematic. Health care expenses of $20 billion dollars a year in the United States are for the treatment of back injuries. When the associated loss of productivity and other indirect costs are considered, the total expense may be in excess of $50 billion annually. Since 90% of adults will likely experience a back injury some time in their life, the basis for cost reduction lies in understanding how these injuries happen. Prompt treatment and emphasis on injury prevention is a win-win investment with huge dividends for everyone involved.
Understanding a little about your back can help protect it from injury. Muscular strains of the back account for most causes of back pain. Separating common muscular strain from more important causes of back pain involving the discs, pinched nerve or other musculoskeletal diseases can be difficult. If your pain does not subside with over the counter ibuprofen, rest and icing in a few days, you should consult your health care provider for further evaluation. Sometimes their expertise and additional imaging studies such as X-ray or MRI are necessary to evaluate the source of your pain. Along with a physical therapist and/or chiropractor, a treatment plan tailored to your condition is developed.
Muscular strain of the lower back is clearly the most common presentation. Muscle fibers and the ligaments that hold the vertebra together become microscopically torn and frayed. Theses soft tissues respond with pain, inflammation and muscle spasm. Even worse is damage to the cartilaginous disc between the vertebras that acts as a cushion. These internal shock absorbers between each vertebra in the spinal column can be damaged or torn. Many times the damage is subtle but involves a bulge or protrusion of its spongy substance out to the side, which allows it to put pressure on a nerve branch as it exits the spinal cord. This condition known as a "pinched nerve" or herniated disc" is what causes pain, numbness or weakness that travels into the buttocks or down the leg. Also know as sciatica for the sciatic nerve that provides sensory nerves to this region, can lead to much greater functional limitations and challenges to treatment. Poor conditioning, obesity, smoking, prior back injury and incorrect lifting techniques are the most common risks that lead to injury.
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Back injuries are most often preventable. Chronic overuse from years of abuse due to occupational hazards does happen, but acute strains from over exertion still comprise the majority of injuries. Most are muscular in nature and respond to simple conservative treatment measures. Some do require more invasive treatments to repair other damaged components of the back. The latter, which require longer rehabilitation, drive up the total cost. We know that early intervention and aggressive use of the most cost effective modalities can return people to work and activities of daily life faster. OSHA and the National Safety Council have noted that only the common colds and flu account for more time loss from work than back injuries.
Treatment is usually grouped into three areas. The foundation of therapy is time, rest, medication, and physical therapy. This is known as conservative treatment. Medications such as an anti-inflammatory, muscle relaxant and narcotic pain medicine can provide temporary comfort along with cold packs and massage. Mobilization of the injured area as early as possible can be started by simple stretching and basic exercises. Both chiropractor and physical therapist can help as well as teach better body mechanics and plan a daily home exercise program to promote systematic recovery. Thus physical therapy and re-strengthening remains the foundation of treatment throughout the process regardless of severity. Patients will likely need to modify their work responsibilities with restrictions that reflect their temporary weakened condition.
A second more invasive modality used if progress is lacking in selected patients is epidural steroid injections (ESI). Using a fluoroscope or CT scanner to guide a needle to the problem area, ESI can help reduce inflammation by injecting a combination of numbing medicine and cortisone anti-inflammatory. Surgery is always the last resort and limited to patients who have clear structural abnormalities that have failed to respond to more conservative measures. One of the biggest treatment challenges is the length of time required for improvement. Mild cases may respond in as little as 2-4 weeks. While most cases will resolve within 12 weeks, some can take much longer. The goal is early intervention and aggressive treatment to return people back to productive activities as soon as possible.
Avoiding injury begins with proper conditioning. By stretching and strengthening the back muscles daily, you can improve strength and flexibility of lumbar and core muscles. A physical therapist versed in sports or occupational medicine can help design a simple routine for your individual needs. Even if you engage in very strenuous activities, physical work or sports, you can likely benefit from doing focused exercises for your core muscles. The core muscles supporting your trunk and back are essential to almost all activities. Everyone is a "professional athlete" in a fashion, whether you are engaged in strenuous physical labor or an office worker. As we age more attention is required to maintain just a minimum level of fitness for activities of daily life. If you are doing a very physical job, participate in recreational sports, gardening or yard work you need to train to stay strong and fit enough for even the most mundane activities.
Using thoughtful body mechanics and good lifting technique keeps you safe and efficient. First, assess the task and your surroundings. Be honest about your limitations and do not be shy about getting help to lift. Be sure there is enough room to maneuver and no obstacle is in your intended path. Stand close to the object, feet about shoulder width apart. Appropriate footwear with non-slip sole is important to stabilize yourself. Squat, bending the knees and avoid bending at the waist whenever possible. Keep your back straight and erect. Frequently overlooked in protecting and supporting the back, tightened abdominal muscles during lifting helps you work efficiently while staying safe. As you begin lifting with a slow smooth motion, keep the object close to your body. Do not be in a hurry and avoid quick jerking movements. The idea is to have strong core muscles stabilizing the torso and back while allowing the much stronger muscles of the legs and buttocks to do the lifting. Turn by moving the feet rather than twisting and overreaching. Remember you too are a pro who needs to train using good technique to accomplish your goals without injury. Stay strong for your livelihood and the rest of your life.
Neck Injury
The neck is the connecting bridge between the spine and the brain, made up of seven boney vertebrae with cartilaginous disc pads that act as cushions in between each vertebra. As the neck supports the head it is relatively unprotected and vulnerable compared to the rest of the spine. Neck pain is very common but most of the time is a benign temporary condition.
Injuries most often affect the soft tissue muscles and ligaments. Larger traumatic forces can damage the discs between vertebrae or even the boney parts of the vertebra causing a more serious problem. Neck injuries are most commonly associated with motor vehicle accidents, contact sports, or a fall. Head, neck and shoulder injuries frequently occur together. Consulting a health care provider is prudent since determining the source of pain and symptoms can be difficult. Great care in initial treatment and diagnosis is necessary with the neck design of exceptional range of motion and important functions. Underlying problems of aging, overuse, degenerative changes and inflammation often make the neck even more vulnerable to injury and cloud the diagnostic process. Pain that does not subside with simple rest, icing and over the counter anti-inflammatory needs further evaluation. Prompt consultation with a medical professional is important if you experience decreased range of motion of the neck, pain, numbness or weakness that radiates to the arms or legs.
The mechanism of injury should help focus the treating professional to the location of the problem. A thorough exam documenting the full extent of the symptom pattern will help dictate the treatment plan. With nerve root irritation in the acute phase, symptoms that radiate into the upper extremities, the source of the problem can be confusing requiring additional diagnostic testing. This may include, plain x-rays, magnetic resonating imaging (MRI) or a nerve conduction study (EMG). The EMG is helpful in verifying a pinched nerve and where along the nerve the pressure point is located. With an acute whiplash injury from a car accident or other trauma associated with pain and numbness radiating down an arm, disk injury would be suspicious. These cartilaginous shock absorbers situated between each vertebra are vulnerable to twisting or severe flexion motions of the neck that are violent. This can cause a bulging, herniated disk as well as tear to a disk. In either case, a portion of the disk is out of its normal position putting pressure on an adjacent nerve as it exits the spine. The pain and numbness will follow the path of the nerve branch. This is also known as the proverbial "pinched nerve".
Early diagnosis and intervention is always helpful. Understanding the full extent of the condition, mild or severe, provides great peace of mind as well as early initiation of treatment. Beyond the basics of treatment, other modalities may include physical therapy, chiropractic or acupuncture. Rest, gentle stretching and early mobilization, within reason, can help avoid stiffness and muscle atrophy compounding the original injury. Medications typically include an anti-inflammatory, muscle relaxant, and pain medicine. Physical therapy, which includes early gentle mobilization, home exercise program, and plan for transitional activities, is at the foundation of treatment. Chiropractic adjustment can also be helpful in many cases. Fortunately, only a small percentage of neck injuries require surgery. All modalities of conservative therapy are encouraged including guided imagery steroid injections and other medications for management of nerve related pain.
Accidents can be unpredictable and out of our control. Basic safety measures at home or in the workplace are paramount to injury prevention. The impact of overuse injuries can be reduced with thoughtful use of body mechanics. Maintaining general good health with special attention to good posture is foremost. Chronic weakness and poor posture without thought to ergonomics leads to repetitive motion injury. Take frequent breaks to change position, do simple stretches and restore good posture. Posture considerations include the neck in a neutral or anatomic position when sleeping, car or plane travel, working at a desk or rough job site. Sports injuries are also a contributor to neck and back problems. Since car accidents are a frequent source of neck problems, seat belt and head restraint use with a properly positioned seat and steering wheel can pay big dividends. With a small amount of effort the original "pain in the neck" can be avoided.
Head Injury
Occupational head injuries are common to most industries. Dangerous settings in the construction and manufacturing trades are obviously more at risk. However offices, transportation and warehouse work have led to significant traumatic brain injuries as well. Falls can occur in any place. Car accidents are also part of most everyone's life. Most of the head injuries that occur are mild to moderate in severity and do not typically require hospitalization. Nonetheless, concussion or post-concussion syndrome is the source of substantial problems for the workplace, individuals and their families. Between 30 and 80 % of head injuries result in some form of post-concussion syndrome (PCS).
The exact reason for symptoms from PCS is not clear but the common pattern of behavior is easily recognized. To understand what is happening to the brain we can compare a sharp blow to the forearm. There is certainly pain after the accident. The arm may feel unusual and not work well. Nothing is broken and symptoms resolve spontaneously and completely. A similar thing can happen to the brain after direct trauma to the head.
After the accident there is pain. The pain is usually substantial and feels deep-seated inside the head. The person feels "funny". Only a momentary lapse in memory or feeling dazed is possible. The brain temporarily may not work quite right, exhibiting a wide range of random symptoms. However nothing is broken and it goes away spontaneously. Common symptoms of PCS can include headache, dizziness, fatigue, memory loss, light sensitivity and difficulty concentrating. Behavior can be affected incidentally or profoundly. Personality change, irritability or anxiety is not unusual. Other changes can be difficulty regulating emotions, poor coordination, or temporary learning disability. The precise cause of symptoms remains unclear and is a source of disagreement among researchers. We do not understand whether there are actual microscopic changes in brain structure or why neurotransmitters, the chemical messengers between brain cells, are somehow altered by the trauma. Imaging studies of the head and neck (CT and MRI) are usually normal. Symptoms of PCS are nonspecific and sometime are seen in other conditions. Women are more likely to have problems than men are. Being over forty years of age, having other preexisting medical or behavioral problems increase the risk of developing PCS. It also increases the chance of slower recovery regardless of gender. Depression and post-traumatic stress disorder can complicate recovery. These also tend to confuse the origin of symptoms experienced by the victim. Experts disagree often about which came first moreover, if the trauma was the source rather than the pre-existing condition.
Treatment is largely symptomatic. There is no specific modality that alters the course of PCS. Most symptoms resolve in a matter of two weeks to three months. Medication for pain relief and managing headaches is important. The psychological and emotional impact plays a significant role. Counseling and cognitive behavioral therapy can be very useful for many patients. The frustration of the symptoms and feeling out of control can easily contribute to depression or anxiety. Reassurance for the patient, employer and family members is important. Understanding that there are no dangerous findings and having perspective about the slow improving course can help all involved. Most of these patients reach complete resolution of their symptoms. More than half will resolve in one month while two thirds of PCS patients clear in three months. Physical therapy can improve restoration of normal routine, return to pre-injury work and be adjunctive rehabilitation of the mental status. Fortunately only a small percentage of patients will have long-term (up to one year) problems beyond three months.
Prevention is focused on a safe work place environment. Use of good body mechanics while being mindful of your surroundings and co-workers is important. Dangerous industries like construction, law enforcement, warehouse work and manufacturing necessitate use of protective gear such as approved hard hats and goggles. Proper training in use of equipment and tools can be time consuming but worthy investments. Keeping the work environment orderly with adequate space for appropriate tasks is important in the office as well as a rugged construction site.
A concussion is a complicated problem that needs thorough initial evaluation. Seek medical attention for head injures even if they seem mild and no loss of consciousness. Severity of symptoms and initial imaging studies can detect serious problems early and be the reassuring basis for ongoing treatment. Post concussion syndrome can be temporarily debilitating. Even though the patient may have no "red badge of courage" understanding and accommodation are in order for rehabilitation. Transitional duties are helpful for a gradual return to work. Supportive medical attention with a compassionate family and workplace can help facilitate recovery.
Shoulder Injury
The shoulder, with its enhanced mobility, is one of the more difficult to understand joints. It provides strength and stability supporting the hand and arm while maintaining the ability to move in a complex circular motion. The central rotation comes from a "ball and saucer" design with numerous pulley attachments to direct its movement. The head of the upper arm bone (humerus) has a ball that glides smoothly over a highly polished saucer covered with cartilage known as the labrum. Spinning in place on its saucer, the rotator cuff stabilizes and drives the shoulder through its extensive range of motion. The rotator cuff is a group of four muscles that attach to the edge of the saucer to provide coordinated stability as well as move the shoulder through its wide range of motion. Injuries to its tendons connected the edge of the saucer (labrum) are common shoulder injuries. Rotator cuff tears occur most often doing strenuous overhead work, which requires resistance. A sudden jerking motion may overwhelm the attachments causing a tear in one of the tendons. Falling on to an outstretched arm may also transmit enough force through the shoulder to do the same, especially when the humeral head tries to dislocate off its position on the saucer (labrum). Dislocations can usually be repositioned or "reduced" by a medical provider in the field or under anesthesia. Recovery time will depend on many factors. Age or level of fitness may influence the extent of damage. If the tear is small, time, rest and aggressive physical therapy can achieve a good recovery. Surgical repair of larger or complete tears followed by several months of physical therapy to recover strength and shoulder mobility achieve the best results.
A fall or direct blow to the shoulder typically strikes the upper shoulder at its peak. Instinctively we tend to tuck and roll on to the shoulder as we fall. The point of impact is directly over a small gap at the end of the collarbone known as the AC joint (acromion-clavicular joint). The short strong ligament that holds these bones in a stable position tears. This injury known as a shoulder separation is distinctly different from the shoulder dislocation. Small separations may also heal with rest and physical therapy, while only the most severe require surgery. Fractures to the shoulder are not nearly as common as soft tissue injuries. Clavicle breaks usually heal well with time and rest over 4-6 weeks. Fractures to the humerus or upper arm also less common more often than not are treated conservatively. Physical therapy is always the foundation of treating any shoulder injury. Inactivity in combination with an injury can result in a very stiff and weak shoulder. With special attention, severe permanent stiffness is avoided.