Range of Opinion in PI Prognosis 2016 - Dr Mark Burgin
06/01/17. Dr. Mark Burgin BM BCh (oxon) MRCGP explains the theoretical approaches that underpin expert range of opinion with regards to soft tissue injury in Personal injury.
Why is there still a range of opinion with regards to prognosis in personal injury when many claimants appear to have substantially the same injuries from the same accident mechanism?
Expert’s prognoses typically tend towards a certain number of months for whiplash associated disorder grade two (WAD2) (1) called the ‘average’ prognosis to achieve consistency in their prognoses.
The value chosen for average prognosis can vary markedly between experts suggesting that experts are being influenced by the litigation process or that they are being deceived by dishonest claimants.
As an expert in soft tissue injury part of my duty to the court is to understand the range of opinion amongst experts with respect to prognoses.
In this article I will describe and consider the strengths and weaknesses of the different theoretical approaches that are taken by experts when deciding their average prognosis.
Variability in WAD 2 prognoses
In most RTA cases the most significant injury is WAD 2 but there will be variation around the average prognosis due to the specific elements of the case.
An expert considers inter alia the mechanism of injury, the injuries sustained, the chronological progression of the injuries, the past medical history from the claimant, the losses as stated by the claimant, the examination findings and their experience.
These factors can differentiate many cases to allow variation in prognosis but there will also be many cases where the prognosis will not differ significantly from the average.
Giving an opinion on recovery times for WAD 2 therefore depends as much on what school of thought that an expert follows as the material facts of the case.
Many experts have more complex approaches particularly in relation to susceptibility (2) but for clarity I will simplify their theoretical arguments into three groups.
It is common experience that acute pain and the associated disabling effects of a soft tissue injury typically improve by 2 to 3 weeks following an accident.
This healing process continues so that by 6 to 8 weeks most injuries are only painful when under stress such as lifting and bending.
Examination findings usually follow a similar path with restricted range of motion and acute tenderness on palpation only present for the first few weeks.
Practitioners in clinical practice most commonly give their patients advice that the soft tissue injury will generally heal by 2 to 8 weeks following an accident and that few will have significant ongoing problems.
The advantage of considering an injury healed when it stops causing disabling effects is that it can improve the speed of recovery by encouraging return to previous activities.
The disadvantage is that claimants say that whilst the pain has reduced by 2 months it has not gone completely and they remain restricted in returning to more strenuous exercise.
Soft tissue injuries recover fastest in the first few weeks but it takes longer for the disordered tissues in the healed areas to become strong and organised.
During the process of reorganisation the injured area remains tender and is more prone to continuing injury, which limits maximal activity.
The reorganisation process typically lasts for 3 to 9 months with significant variability, thought to be due in part to the response of the injured person.
The body reacts to exercise by increasing the strength and size of the structures under stress and reabsorbing those that are not used.
As a result patients who rest will lose muscle tissue generally, delaying recovery whereas those who exercise will reorganise tissues quicker.
The advantage of the medium prognosis is that it reflects a time when most claimants have returned to full activities and the ongoing symptoms are less intrusive.
The disadvantage is that however many months are chosen, there will be many who recover quicker or slower than the ‘average’ prognosis.
Some experts prefer to give average prognoses at the lower end so that if a claimant does not recover a further examination can be performed to ensure they have adequate compensation.
Other experts give prognoses at the higher end so that they do not unfairly penalise those who do not recover promptly without wasting resources by having a second examination.
Damage to the muscular skeletal system causes tearing to the muscles, tendons and ligaments which when healed will form permanent scar tissue.
Scar tissue is not the same as the original tissue and commonly is uncomfortable when under tension or pressure, explaining why medical research consistently confirms that injuries may not recover.
The research evidence available suggests that half of whiplash sufferers should be given a prognosis that is greater than 12 months. (3)
Symptoms and signs may persist in many claimants and where there is no other explanation it is a compelling argument that the continuing problems result from the accident.
Some experts believe that this is because the scar tissue has not properly reorganised so that the area remains tender under tension or that the scar tissue sticks onto other structures causing pain with movement.
The disadvantage with long prognoses is that they slow down the legal process and increase costs and that review of further evidence may lead to a lower prognosis.
There is a range of opinion based upon different aspects of medical understanding of the healing process which leads to different approaches to the average prognosis.
An expert in soft tissue injury must be prepared to justify their approach to prognoses and their ‘average’ prognosis period when they discuss their work with MROs.
Those experts who chose to give outlying opinions must additionally explain how they ensure that they respond reasonably to those cases that recover at a different time to their prognoses.
An expert giving long prognoses who routinely reviews medical and therapy records and reduces prognoses as appropriate can come to the same conclusions as an expert who gives short prognoses and then reviews the claimant to extend those prognoses.
Research suggests that recovery is often slower and more prolonged than expected and average prognosis is less important than trying to understand why this individual has persisting problems.
Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.
and 0845 331 3304 website drmarkburgin.co.uk
(1) Scientific Monograph of the Quebec Task Force on Whiplash-Associated Disorders: Redefining "Whiplash" and Its Management WO Spitzer et al. Spine (Phila Pa 1976) 20 (8 Suppl), 1S-73S. 1995 Apr 15
(2) Dr Mark Burgin 2014 Odd and unusual injuries www.drmarkburgin.co.uk
(3) Linda J. Carroll Course and Prognostic Factors for Neck Pain in Whiplash-Associated Disorders (WAD) Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders Eur Spine J. 2008 Apr; 17(Suppl 1): 83–92