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Shaw Chiropractic CARPAL TUNNEL SYNDROME A common complaint of patients suffering the sequela of whiplash trauma is delay onset of carpal tunnel syndrome. Some schools of thought have attributed the mechanism of injury to the hand grip on the steering wheel which is subject to violent motion during rear impact accidents. This hypothesis will not hold up to scrutiny for a number of reasons. First, is the fact that this condition occurs equally between drivers and passengers. Secondly, most drivers do not report gripping the steering wheel tightly at the time of impact and a significant number of cases have occurred in cases where the hands were not on the steering wheel at all. Last, in almost all cases, the symptoms are either immediate or within a short period of time. A more viable model of the post-traumatic genesis of CTS is provided by the double crush phenomenon in which a patient with pre-existing, but sub-clinical, increased carpal tunnel pressure now suffers the second crush in the form of cervical root or brachial plexus compression. This second crush may be due to disc protrusion, contusion of the nerve root, radicular fibrosis, muscular compromise of thoracic outlet, etc. The cumulative effect of CTS can result in pain and parasthesias anywhere along the nerve. The most common causes of CTS are cumulative traumas which can contribute to the post-traumatic condition. These cumulative traumas include the use of vibration tools, typing, sports, etc. The onset of menopause may also be a contributing factor. Orthopedic and neurological tests are commonly performed by the physician. Some tests are Ellis's finger flexion test which indicates tenosynovitis, the Pinch test which elicits numbness in the median nerve distribution, and Allen's test for circulation in the hand. Common tests include Phalen's test and Tinel's sign. Deep tendon reflexes, muscle strenghth and sensation testing are extremely valuable. Of course, when more sophisticated tests are required nerve conduction velocity studies with electromyographic sampling can provide objective evidence of nerve damage. CTS and Double Crush Syndromes are more common then you may suspect. You should expect the attending physician to be aware of these syndromes and be prepared to provide you with the necessary documentation which will assist you with your settlement negotiation. DAILY NOTES Doctors' office visits can be a source of valuable information. There are several components necessary in these notes which are considered to be the standard. The common abbreviation is called SOAP notes. SOAP stands for Subjective findings, Objective findings, Assessment, and Plan. The subjective findings are the description of symptoms and experiences the patient relates to the doctor as a result of their injury or condition. The objective findings are those that the examiner finds on that visit. The assessment is the portion of the report that denotes the current evaluation and protocol. The plan is what treatment is performed and what the result was. A typical soap note for an office visit might be as follows: 04/21/94-Mary Jones presents today stating that she continues to have headaches and that her neck is sore. She states that she is unable to sleep for more than 2 hours without waking up in pain. She says that ice packs help. Our objective examination reveal suboccipital spasm and point tenderness in the C2-C6 paraspinal muscles. Cervical ranges of motion are still restricted and suggest early deposition of fibrotic scar tissue. The patients complaints are consistent with our exam findings. The response to date has been slow but satisfactory and the patient continues to demonstrate gains. Treatment today includes spinal manipulative therapy and adjunctive modalities. These are tolerated well. She is to continue her rehabilitation program as scheduled and is advised to avoid precipitating activities. The doctor's notes should paint a picture of the severity of the patient's injuries and provide a logical explanation for the treatment. Documented results or lack thereof may clarify to others who may read the notes the reasons that a permanent impairment or complete resolution are forthcomming. This is the thermometer the attorney and adjuster should use to determine the validity and severity of the claimants injuries and often times can give more information and documentation then the so called "objective tests" such as MRI or CT. Used prudently, the daily treatment notes are the most valuable tools available to the attorney when attempting to settle a clients case.
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