A.C.L. Reconstruction

Treatment

Originally it was felt that the knee should be repaired surgically as soon as possible. Now, most orthopedic surgeons feel that the swelling should subside and the patient should work to improve range of motion with physiotherapy for 2-3 weeks. Once this is accomplished the patient can then proceed to an anterior cruciate ligament reconstruction. As stated earlier, surgery does not have to be performed on a sedentary older patient, but it is almost always recommended to a younger, active athlete that they should have anterior crucial tear repaired. With modern techniques it is performed as an outpatient – the patient is discharged from the hospital the same day. The patients will leave the hospital on crutches wearing a knee immobilizer for approximately 10 days while they are up and getting around. When the immobilizer comes off, the patient usually will use a passive motion machine that moves the knee through flexion and extension. Physical therapy is started immediately post-operatively. Treatment of a torn anterior crucial ligament in the older patient usually consists of physical therapy and exercise training as well as potentially brace-wear for some activities.

Surgical Treatment Options

There have been many options described for the surgical treatment of the anterior cruciate ligament. The most popular and currently recognized as the gold standard at this point is an operation where the middle one third of the patella tendon is used as a graft. It is virtually impossible to repair the ligament that is torn. The torn ACL is simply removed and the replaced with the patella tendon graft. Two thirds of the patella tendon is left behind and it will repair itself, not compromising the function of the knee. At each end of the patella tendon a bone block is also taken; one piece from the tibia, and the other from the patella (kneecap). These two bony blocks are inserted into holes that are drilled into the tibia and femur and held into place with screws, which provide stabilization of the ligament graft.

There are other tissues that can be used to substitute for the anterior crucial ligament. Most commonly the second choice are hamstring tendons which are weaved into a graft close to the size of the anterior crucial ligament. We have also used quadriceps tendon and allograft. An allograft is donated cadeaver tissue which is freeze dried until the time of usage upon which time it is thawed out and trimmed to size and used as an ACL substitute. The advantage of an allograft operation is that there is a smaller incision required, the rehab is shorter, and less painful. The disadvantage is that it is not quite as strong as a graft formed from the patient’s own tissue.

O'Donohue's "Terrible Triad"

Mechanics

The anterior cruciate is the main factor causing resistance to the anterior displacement of the tibia on the femur. This is demonstrated when the orthopedic surgeon pulls the tibia forward on the femur performing a test of the anterior cruciate ligament. The tibia will displace much further forward than it should when the ACL is torn. The ligament is tight when the knee is in full extension and has the least amount of tension at approximately 45’ of flexion. Because there are different bands to the anterior cruciate ligament different areas of the anterior cruciate tighten at different angles of the knee.

Physical Examination

Examination immediately at the time of injury will reveal usually at least mild swelling of the knee, but not necessarily. The best test is called a Lachman Test where each of the examiner’s hands are placed just above and just below the knee joint. The lower bone is brought forward with the knee angled at approximately 15’ and the examiner assess the end point. Usually, there is a firm endpoint with an intact ACL when the tibia is pulled forward. When the ligament is torn that endpoint is no longer present. The examiner will also look for increased excursion of the tibia forward on the femur. A Drawer Test is when the knee is flexed to 90’. Essentially, the same test is performed. It is more difficult in an acute situation to perform this test because usually the athlete’s knee is too sore to allow the knee to bend to 90’. A Pivot Shift is a test where the knee is brought from an extended position into flexion. Usually the knee will show a slight and subtle shift as the tibia rotates on the femur and shifts back into proper position. It is actually subflexed in the full extended knee position and returns to its natural position as the knee is flexed. As it returns to its natural position there is a "pivot shift" which takes experience to detect.

Associated injuries are always assessed for at the same time. Joint line tenderness representing torn cartilage and tenderness over the lateral knee which may reflect tearing of the collateral ligaments. O’Donohue’s "terrible triad" injury involves not only the ACL, but also the medial meniscus and the medial collateral ligament. It is unfortunately fairly common.

Natural History of the Torn Anterior Cruciate Ligament

Natural History of the Torn Anterior Cruciate Ligament

If left untreated the laxity which is immediately present only becomes worse. The other structures of the knee try in vain to provide some stability to the knee. Over time and with more usage these other structures stretch out as well, resulting in increased instability and then associated meniscal (cartilage) tears. There is an incidence of approximately 1 in 3 patients who at the time of the anterior cruciate ligament tear will tear their cartilage as well. This progresses with time because in an untreated knee the knee is unstable and produces greater stress on the cartilage. Up to 80% of the knees will eventually develop a cartilage tear. The smooth Teflon lining of the knee which is known as articular cartilage is often damaged at the time of the ACL tear. If left untreated, this will again progressively wear at the knee, causing an increased rate of osteoarthritis development. The patients will alter their gait and will develop a rather specific quadriceps avoidance gait because when they contract their quads during normal walking its slides the tibia forward which is usually stopped by the anterior crucial ligament. The patient will naturally and unconsciously try to prevent this. All these problems mean that the knee will progress to late degenerative changes and osteoarthritis much earlier than in a normal knee. There is not good evidence that bracewear alone will decrease the rate of re-injury to the knee. However, in older and non-active patients there is definitely a role for non-operative treatment by simply modifying their activities and avoiding all situations where they may pivot and damage their knee further.

Treatment of Foot Problems Pt.3

Hammertoes

A muscle imbalance or abnormal bone length can make one or more small toes buckle under, causing their joints to contract.  This in turn, causes the tendons to shorten.  Corns (build-ups of dead skin cells where shoes press and rub) often form on the contracted joint, and may become irritated and infected.

Flexible Hammertoes

When hammertoes are flexible, you can straighten the buckled joint with your hand.  Flexible hammertoes may progress to rigid hammertoes over time.  Corns, irritation, and pain are common symptoms.   Function is often limited as well.

Rigid Hammertoes

A rigid hammertoe is fixed; you can no longer straighten the buckled joint with your hand.  Corns, irritation, pain, and loss of function may be more severe for rigid hammertoes than for flexible ones.

Curled Fifth Toe

The little toe may curl inward underneath its neighbor so that the nail faces outward.  With this inherited problem, the fat pad on the bottom of the toe (normally used for walking) loses contact with the ground.  Corns and pain may result.

Plantar Calluses

Second Metatarsal Plantar Callus

When the second metatarsal bone is longer or lower than the others, it hits the ground first - and with more force than it is equipped to handle at every step.  As a result, the skin under this bone thickens.   Like a rock in your shoe, the callus causes irritation and pain.  The treatment for this is an osteotomy.  The second metatarsal bone is cut, and the end of the bone is then "lifted" and aligned with the other bones.

Heel Spurs

A heel spur is a bony overgrowth on your heel bone (see Plantar Fascitis).  It may be stimulated by muscles that pull from the heel bone along the bottom of the foot.  High-arched feet are especially apt to have too-tight muscles here.  Heel spurs may cause pain  when the foot bears weight.  They can be treated first with an injection, anti-inflammatory medication, as well as arch supports if indicated.  If this fails, they can then be treated with surgical excision and a plantar release.  The band of tight muscles is released to relieve the abnormal stress.  The bone spur is surgically removed.

Neuromas

When a nerve is pinched between two metatarsal bones (usually the third and forth metatarsals), enlargement of the nerve may occur.  Abnormal bone structure contributes to the cause, but too-tight shoes can aggravate the condition.  You may experience sharp pain in your toes that may become severe enough to keep you from walking.

Treatment

Excision: A small portion of the nerve is removed.  As a result of this, a small area is usually permanently numbered, but this is preferable to pain.

Follow-up Care

You can usually bear weight right away, but you must return to have your dressing changed.  Keep your incision dry until the stitches are removed.

High-Arched Feet (Pes Cavus)

The shape of your foot often determines the kinds of foot problems you will have.  Your feet may have unusually high arches due to an imbalance of muscles and nerves, which is usually inherited.   Too high arches can cause various problems - tired or aching feet; and calluses.   High arches are not usually investigated with surgery but most often treated with arch supports.

Flat Feet (Pes Planus)

Flat feet can be hereditary and are caused by a muscle imbalance.  Feet with low, relaxed arches may bring on such problems as hammertoes and bunions; arch, foot, and leg fatigue; calf pain; and an overly tight heel cord (which makes the foot even flatter).  Loose joints move to freely, causing pain and instability.  Flat feet are also usually treated with arch supports.

Orthotics

Orthotics (also called orthoses or orthotic devices) are prescribed, custom0made arch supports.  They fit inside most shoes and "bring the floor up to your feet."

A podiatrist may prescribe them to help correct such problems as high arches and flat feet.  Also, following some foot surgeries, orthotics can help support the correction that was achieved.

To be fitted with orthotics, your podiatrist will first take an impression of your feet.  Your orthotics are then fashioned from leather, plastic, or other materials.  Their fit is checked at an office visit and adjustments can be made as you wear them.  Expect an initial "breaking-in" period; you may need to build up wearing time gradually (as you would with contact lenses).

Surgery Decision

If your bunions or hammertoes are bad enough, they may need surgical correction.  This is a gratifying operation that can provide both pain relief and improved appearance.

Risks

All surgery carries risks including stiffness, persistent pain and swelling, recurrence of problem, damage to nerves, hardware breakage, blood clots in the legs, anesthetic problems, inability to correct the problem, etc.  Make sure you understand the risks and alternatives prior to surgery.

Post-Operative Tips

Your recovery, like your foot problem and surgery, is as unique as you are.  In addition to the previous tips given on follow-up care for each surgery, here are some pointers that can help you recover quickly and without complications, and help get you back on your feet again.

Pain:  To help relive pain and reduce swelling in the first 24 to 48 hours after surgery, apply an ice pack to the affected area and elevate your foot above heart level, as recommended.  Pain is usually most severe the second and third days after surgery, and after you first begin to walk again.

Bathing:  You will need to keep your foot dry.  Getting the stitches wet can lead to infection, so be sure to keep your foot outside the shower or bath.

Weight-Bearing:  Bearing weight and walking can stimulate circulation and promote healing.  But overtaxing a healthy foot can detract from the results of your surgery.

Shoes:  Our team may give you a wide surgical shoe to wear on the affected foot.  A surgical shoe stabilizes and protects the foot as it heals.

Returning to Work: How soon you can return to work depends on the type of surgery you had and the activities you job requires.  You can generally return earlier to a desk job than to physical labor.   Consider beforehand how much time you can take off from work until you are back on your feet.

REPORT TO EMERGENCY IMMEDIATELY IF YOU NOTICE REDNESS, DRAINAGE, INFECTION, CALF PAIN, SHORTNESS OF BREATH, OR HAVE ANY CONCERNS.

Treatment of Foot Problems Pt.2

Anatomy of the Foot

Before you have your foot surgery, it helps to understand how your foot works in supporting you and carrying you from place to place.  Knowing how skin and bone heal following surgery can help you to better understand the importance of post-operative foot care during your recovery.

Ligaments are flexible bands of fiber joining bone to bone.  The foot has over 100 ligaments.  Joints form where two bones meet.  The 33 complex joints in each foot permit flexibility.  Bones form the basic supporting structure of your foot.  There are 26 bones in each foot.  Tendons are tough, fibrous cords that connect muscle to bones.  Muscles help move the feet and toes.  When a muscle contracts, it pulls on a tendon, which in turn moves the bone.

The Healing Process

All foot surgeries involve the skin, and in some cases, the bone inside must be cut as well.  When you understand the healing process, you can help make your foot surgery a success.

Skin heals in phases.   First, it grows together so the stitches can be removed.  The scar may look slightly inflamed; some redness and swelling are normal.  After about six months, the scar blends with the surrounding skin.

Bone also heals in phases.   A bone-like "cement" forms, bridging the affected bone and allowing it to bear weight.  Later, the extra bone is dissolved, and in about six months, the bone is back to normal strength.

Bunions

A bunion is an enlargement of bone in the joint at the base of the big toe.  Bunions are most often inherited.   Tight shoes do not cause bunions, but they can aggravate them.  There are several types of bunions and surgical treatments for each.  Your surgery may be similar to some of the common examples listed.

Positional Bunion

A positional bunion develops when a bony growth on the side of the metatarsal bone enlarges the joint, forcing the joint capsule to stretch over it.  As this growth enlarges, it pushes the big toe toward the others making the tendons on the inside tighten.  This, in turn, forces the big toe further out of alignment.  The bunion presses against the shoe, irritating the skin, and causing further pain.

Structural Bunion

Structural bunions occur when the angle between the first and second metatarsal bones increases to a point where it is greater than normal.  The increase angle of the metatarsals makes the big toe bow toward the other toes.  Sometimes bony growths may form.  Irritation and swelling may often follow.  The tendency toward developing this painful condition is usually inherited.  A structural bunion becomes severe when the angle between the metatarsal bones of the first and second toes grows greater than the angle of a mild structural bunion.  Again, a tendency toward developing this condition is usually inherited.  The big toe bows toward the others, sometimes causing the second and third toes to buckle.  Irritation, swelling and pain may increase when tight shoes are worn.

Degenerative Disease

While not a true bunion, this condition is often associated with bunions.  Bunions, left untreated, can increase wear and tear in the joint of the big toe, break down the cartilage, and pave the way for degenerative diseases such as arthritis.  Pain and stiffness are symptoms of both.

Bunions Pt. 2

Information on Bunions  Shoewear There are a few basic pointers to remember when buying shoes. Do not buy shoes by simply buying the size that you think you should fit into. The shoe must be tried on and worn in the store for several minutes until you make sure that it is not compressing your foot. The shoe itself should look as close as possible to the normal shape of a foot. You should realize that the size and shape of your feet will change as you get older. With age your arch generally flattens out slightly and your foot will become slightly longer. As well the left foot will not always be the same size as the right foot. Shoes should be fitted at the end of the day when your feet are at their largest due to gravity and natural occurrence. You should stand during the fitting process and make sure that you measure width as well as for length of the shoe. Do not expect your shoes to stretch to fit you. Indications for Surgery Pain is the commonest indication for bunion surgery. You may also notice redness and inflammation and usually this means that the bunion has progressed to a point that it will not respond to simple modification in shoe wear. Eventually that major joint of the big toe will become stiff and this makes it difficult for activities such as climbing stairs and sports. Types of Bunion Surgery There are many different procedures described to correct bunions. You should be aware that usually just shaving the bunion off, although it is attractive and minimally invasive, is usually not enough. Initially the foot will look much better but with time the bunion will recur. Arthrodesis refers to surgery performed on the great toe joint where the joint is fused. This is usually reserved for people with very severe deformities when other surgical options are impossible. Bunionectomy refers to the simple removal of the bunion itself. This is seldom used because it doesn’t correct the underlying bone problems. Osteomety is the commonest surgical procedure. The bone is cut and the bones realigned and pinned in place until they heal so that the underlying bone deformity is corrected and the bunion will not recur. The resection arstplasty refers to the removal of the toe joint and this creates a flexible scar that functions as the joint instead. In the past there has been some interest in implanting artificial joints but this has fallen out of favor due to the fact that they usually do not hold up with the normal every day stress that people put their feet through. Surgical Results All patients should understand pre-operatively what they can expect from the surgery. The majority of patients who have bunion surgery are very pleased with their results and have a significant improvement in both their cosmetic appearance as well as the pain. Surgery does not however make it possible to fit into smaller shoes for the purpose of cosmetic reasons. If this is done the bunion generally will recur. You have to wear good shoe wear after surgery. You should also be aware of the risks and complications and alternatives such as infections, nerve injury and recurrence of the bunion and failure of the hardware. Other medical risks such as blood clots in the legs and risks related to the anesthetic must also be considered. Unfortunately no surgery can be formed that is actually risk free no matter what kind of surgery is performed. Generally speaking bunion surgery is safe and effective. Surgery is performed on an outpatient basis unless there is underlying medical problems. The patient will enter and leave the hospital on the same day and the patient will have a choice of different anesthetics such as spinal, general anesthetic and various nerve blocks. The anesthesiologist will discuss this with the patient in detail. Post Operative Care Crutches will need to be worn for the first few days. After that a special boot is placed on the bandage and the patient can weight bear but will have to wear that special post-op shoe for approximately 4-6 weeks to ensure proper healing. This dressing has to be kept clean and dry but usually the patient can get around for day to day activities quite well after just 2-3 days. But they will have to modify their activities during the 4-6 week healing period.

Information on Bunions

BUNIONS What is it? A bunion is a very common foot deformity that develops over the first metatarsal phalageal joint of the big toe of the foot. The joint that joins the big toe to the foot is called the first MTP joint. When it becomes prominent and the big toe starts to become crooked this is known as a bunion. The term referring to deformity of the big toe as it becomes crooked is called Hallux Valgus. It is the bump itself that is known as the bunion. When it gets red and swollen over the bunion because it gets sore this is usually due to an inflamed soft tissue over the underlying bone. Causes The commonest cause of bunions is prolonged wearing of poorly designed shoes such as the narrow high heels that women wear. This is one of the reasons why bunions are much more common in women than in men. There is also a hereditary component to bunions in that many times we will see a grandmother, mother and daughter all with various stages of bunions. 38% of women in the United States wear shoes that are too small and 55% of women have some degree of bunion formation. Bunions are 9 times more common in women than they are in men. History Left untreated bunions will gradually become worse especially if women continue to wear the narrow pointed shoes. Not all bunions progress because if the patient starts wearing good shoewear and they are caught early enough they may not get any worse. In general however, they will certainly not get any better no matter how they are treated. We generally reserve surgical treatment for bunions that are painful. If they are not painful they should simply be observed and shoewear modified. Occasionally the patient will want the bunion corrected for cosmetic reasons.

The Lingering Effects of Whiplash

The Lingering Effects of Whiplash

Soft-tissue Injuries of the Cervical Spine 15-year Follow-up

Key Points from Dan Murphy

1)      At a mean of 15.5 years post whiplash trauma, 70% of whiplash-injured patients continued to complain of symptoms referable to the original accident.

2)      Long-term symptoms from whiplash injury include neck pain, arm paresthesia, back pain, headache, dizziness, and tinnitus.

3)      Women and older patients have a worse outcome from whiplash injuries.

4)      Radiating arm pain is more common in those with severe symptoms.

5)      Between 10 and 15 years after the accident, 18% of the patients had improved, whereas 28% had deteriorated.

6)      Soft-tissue injuries to the cervical spine may give persisting symptoms.

7)      Most whiplash-injured patients reach their final state by two years after being injured, but this study shows ongoing symptom fluctuation between years 10 to 15.

8)      At the 15-year follow-up, neck pain was present in 65% and low-back pain was present in 48%.

9)      80% of women and 50% of men continued to have symptoms at 15 years.

10)   Back pain and tinnitus increased between years 10 and 15.

11)   Symptoms remained static in 54%, improved in 18% and worsened in 28%.

12)   Degenerative changes are associated with a worse prognosis for recovery.

13)   60% of symptomatic patients had not seen a doctor in the previous five years because the doctors were unable to help them.

14)   18% had taken early retirement due to health problems, which they related to the whiplash injury.

15)   Whiplash symptoms do not improve after settlement of litigation.

16)   Most radiating pain is referral from the facets, and not radicular.

17)   Chronic whiplash symptoms will cause an abnormal psychological assessment after 3 months.

18)   In this study, 100% of patients with severe ongoing problems had cervical spine degeneration.

Another sort of vascular headache, from high blood pressure

Another sort of vascular headache, from high blood pressure

People with hypertension do get more ordinary headaches than normotensive individuals.
The specific headache of severe hypertension is seldom seen these days. It is a dull headache at the very back of one's head, on awakening, relieved soon after first arising.

This is part of hypertensive encephalopathy, and resolves very rapidly when treatment is started, even before office blood pressure measurements drop.

Migraine and hypertension can both be manifestations of food intolerance. People tend to grow out of migraine and grow into hypertension, both with the same underlying cause.

Cervicogenic headache and sphenoid sinusitis are other headaches here at the back of our head.

Avoid these Foods

AVOID:

Ripened cheeses (Cheddar, Emmentaler, Stilton, Brie, Camembert)

                              (permissible cheeses: American, cottage, cream, Velveeta)

Herring, pickled or dried

Chocolate

Anything fermented, pickled, or marinated

Sour cream (no more than ½ cup daily)

Nuts, peanut butter

Sourdough bread, breads, and crackers containing cheese or chocolate

Broad beans, lima beans, fava beans, snow peas

Foods containing monosodium glutamate (MSG)-soy sauce, meat tenderizers, seasoned salt

Figs, raisins, papayas, avocados, red plums (no more than ½ cup daily)

Citrus fruits (no more than ½ cup daily)

Bananas (no more than ½ cup daily)

Pizza

Excessive amounts of tea, coffee, or cola beverages (no more than 2 cups daily)

Sausage, bologna, pepperoni, salami, summer sausage, hot dogs

Chicken livers, pate

Alcoholic beverages: (If you do drink, limit yourself to two normal size drinks selected from Haute Sauterne, Riesling, Seagram’s VO, Cutty Sark)

Diet and Headache

Diet and Headache

Below is a list of foods that may trigger headaches. Dietary triggers do not necessarily contribute to headaches in all patients. Certain foods may trigger attacks in certain individuals, but not on every occasion. Be your own expert by trying to log the foods you have eaten before a migraine attack and see whether their removal reduces or eliminates your headaches.

The Economic Burden of WAD

THE ECONOMIC BURDEN OF WAD

Little is known about the individual and societal economic burden of WAD. For instance, little is known about the prevalence of long-lasting work disability due to WAD, which probably the most costly part. This burden is probably largely dependent on the legislation in different countries. In 2002, an independent and temporary Commission on whiplash-related injuries was informed in Sweden, initiated by the four largest motor vehicle insurers. The mandate of the 3-year commission was an examination of the problems of WAD from road safety, medical care, insurance and societal aspects. One of the conclusions of the final report was that the yearly cost for society and for the insurance industry was approximately SEK 1.5 billion (US$201million), while projected costs (i.e. what new cases of WAD arising in a particular year will cost society and insurers by the time the person reaches retirement age) amounted to SEK 4.6 billion (US$648 million). These calculations were based on an annual incidence of 30,000 WAD cases (324 per 100,000 inhabitants) in the year 2002. Since the report’s publication, the number of WAD cases have decreased dramatically to about 16,000 claims in 2008 (173 per 100,000 inhabitants), which, of course, has an impact on the overall costs.

Comparable data has not been found, but there is some evidence from a study that addressed the incidence of WAD in 10 European countries. The administrative data suggests that the total claims cost in Switzerland was 500 million Swiss francs (US$467 million). Switzerland’s population is 80% that of Sweden. Expenditures in addition to the claims cost was not reported in that study. 

WAD and Widespread Pain

WAD and Widespread Pain

One important aspect about the course of recovery from WAD is whether the neck injury is a trigger for subsequent widespread body pain. This has been suggested from cross-sectional studies, but knowing whether widespread pain came before the neck injury remains unclear from this type of study design. A potential aetiological explanation is a neurophysiological disturbance in the peripheral and central nervous system, which, in some stances, leads to an increased sensitivity to pain in other ‘uninjured’ areas. Another possible explanation for widespread pain is that new tissue damage may result from an altered pattern of movement in the body due to the neck pain. The exact aetiology of widespread pain is that new tissue damage may result from an altered pattern of movement in the body due to the neck pain. The exact aetiology of widespread pain is probably complex and multifactorial, but there are no indications that it would be specific to WAD. It can also occur after surgical intervention or any tissue damage. In addition, large prospective studies on pain of other aetiology have demonstrated that psychosocial factors at work, repetitive strains or other physical strains at work, awareness of symptoms and illness behavior may increase the risk of development of widespread pain. Thus, it seems that biological as well as psychological and social factors contribute to the development of widespread pain.

Prospective studies on WAD and its association with widespread pain are sparse and the evidence is not clear. The results from one study suggest a relationship between the onset of neck pain or other associated symptoms as well as self-perceived injury severity, after an MVC, and subsequent widespread pain. However, age, gender, health behavior and somatic symptoms prior to collision were at least as important. Another study investigated the incidence of onset of more extensive pain during 12 months of follow- up of WAD claimants, and associated factors with such an outcome. In that study, a less conservative definition of widespread pain was used and probably have resulted in higher incidences. The main conclusions were that widespread pain was common over a 12-month period (21%), but most improved over the follow- up period. Female gender, poor prior health, greater initial symptomatology (including pain intensity) and more depressive symptoms were associated with the development of extensive pain. The authors also found that local neck/ back pain, raising the question of the potential cause of widespread pain in other studies.

Specificity of Association and Apportionment

Specificity of Association and Apportionment

Most medical conditions are multifactor in etiology; ie, they are reflective of more than one physiologic or environmental process. Evaluation of the results of epidemiologic studies via regression analysis (which weighs the contribution of various factors both individually and the combination on a given event or events) provides data that can be applied when reaching conclusions regarding the degree to which one would expect a given factor to contribute to the medical condition under evaluation but never can provide definitive answers regarding apportionment.

               It is impossible to accurately evaluate to what extent a given factor or exposure was the contributing cause in a multifactorial disease process. Likewise, in certain situations (such as heart disease), the genetic predisposition of the affected individual is a considerable, if not primary, determinant of causality. Assessing the specificity of association is consequently often the most difficult aspect of causality analysis.

               There is a great deal of legal terminology focused on establishing, and labeling, the degree to which an event or injury has led to a particular outcome. The legal determination of causality uses, but does not necessarily rely upon, the medical evidence that supports or refutes a casual relationship between a given event and outcome. Furthermore, it is often societal decision, and not scientifically required to reach conclusions about the presence or absence of a casual relationship. Using the legal definitions of causality, a relationship between an event and a given outcome is classified as “probably” or “possible.” It is probable if the chance of them being related is greater than 50%. It is possible if the chance of a relationship is deemed to be less than 50%. The skill of the attorneys arguing the case, the credibility of the claimant and his or her physician, the ability of the medical expert to present the medical information regarding causality, and the existence of case law (which may have established the de facto existence of a casual relationship unless definitively proven otherwise) all influence the ultimate determination. Statements are often made regarding the probability or possibility of a causal relationship between an event and an outcome in the absence of an objective epidemiologic or biologic rationale for the determination. While the Supreme Court, in Daubert case, held that testimony must be grounded in the methods and procedures of science and based on more than simply subjective belief or unsupported speculation to be held as relevant and reliable, this standard is not routinely used in many jurisdictions. Thus the use of the legal terminology alone can imply a degree of certainty that may be completely unfounded. 

Spinal Dysfunction

Spinal Dysfunction

Lumbosacral Spine

Because back pain is the second leading cause of work absenteeism and the number one cause of Workers’ Compensation claims, it is important to understand the appropriate role of radiologic imaging in the assessment of spinal dysfunction. The goal of any imaging study is to define accurately the path morphologic changes in a specific tissue, organ, or part of the body. Objective categorization of pathologic changes facilitates the interpretation and communication of abnormalities detected on a test, and these same criteria can be used on follow-up evaluation to assess the effects of different forms of therapy (eg, surgical intervention or non-operative rehabilitation). The reproducibility and the reliability of all objective diagnostic criteria must be rigorously evaluated in prospective blinded studies prior to their implementation.

               Patients with neck or low-back pain (LBP) are a challenge to the physician who desires a precise patho-anatomic diagnosis prior to the initiation of therapy. Back pain and neural dysfunction are a frequent symptom complex for many processes afflicting the lumbar spine and Paraspinal tissues. For this reason, a clinical assessing a patient after a work-related injury must consider and exclude a large number of potential causes to explain a patient’s symptoms. Fortunately, most episodes of back pain are self-limited, and diagnostic tests are needed. However, if pain persists or becomes worse, it is usually necessary to order a diagnostic test to provide the additional clinical information needed to choose rationally the appropriate therapeutic modality. Prior to ordering any diagnostic test, a clinician must determine how the information provided by the test will affect patient management and mentally compare projected test costs and expected benefits. The more precise the information provided by a diagnostic test, the greater will be its impact on directing patient care. The value of different tests depends on their sensitivity, specificity, accuracy, risk, cost, and availability.

Persistent Pain as a Disease Entity

Persistent Pain as a Disease Entity

Persistent pain is a major health problem, with between 18% and 50% of the population reporting continuous pain for at least 3 of the last 6 months. Chronic pain has been linked with significant disability. Although pain has been traditionally regarded as a symptom that serves as a warning signal of an underlying disease process, there is accumulating evidence that persistent pain should be considered a disease entity in its own right. Indeed, permanent changes in the responsiveness of both the peripheral and centralnervous systems can persist even after all tissue healing has ensued; thus, persistent pain can become a self-perpetuating condition. The individual is signs of original inciting disease process that initiated the pain. This results in a multitude of consequences that can lead to significant impairment for the individual affected, including physical impairment, mood dysfunction, and social disruption. This is in keeping with the earlier biopsychosocial perspective of CPS.

How Much Weight Should Be Given To Pain in Impairment Ratings?

How Much Weight Should Be Given To Pain in Impairment Ratings?

Whether or not to include PRI in the Guides can be frames as a qualitative yes or no question. However, it is more fruitful to from the issue in quantitative terms by asking the following question: How much weight should be given to pain in impairment ratings? Opponents of PRI, in effect, argue that pain (and other subjective factors) should be given zero weight, so that impairment ratings reflect only objective factors. Many proponents of including PRI in the Guides argue not only that pain should considered in impairments ratings but also that a PRI system should permit patients with severe pain to receive impairment awards with high WPI percentages. An impairment rating system could make a “cautious foray into the difficult waters” of PRI assessment by permitting awards to be made for PRI, but capping these awards at a modest level. This describes the strategy used in the Guides’ Fifth Edition, in which PRI capped at 3% WPI. In the absence of persuasive empirical research on the extent to which pain affects the ability of people with medical conditions to function or the measurement problems that arise when PRI is assessed, any dcision about caps for PRI will be perceived as arbitrary. 

Crucial Issues

Crucial Issues

In our opinion, the most powerful arguments against the inclusion of PRI in the Guides are that (1) PRI assessments are likely to be unreliable and (2) they might lead to systematic errors in assessment, such that persuasive patients can “game the system” and get inappropriately high impairment awards. Both of these arguments derive from the permise that it is very difficult for examiners to determine the extent to which patients are affected by their pain. These difficulties were succinctly captured by Scarry when she said: “To have great pain is to have certainty; to hear that another person has pain is to have doubt.” The problem of reliability and validity of PRI assessment is much more than an academic problem in measurement theory. The Guides serves the societal role of providing the equitable method of compensation individuals who ability to function has been compromised by a medical condition. For the Guides must employ assessment procedures that are reliable and valid, rather than capricious ones that can be manipulated by persuasive patients. Thus, regardless of how severely pain affects individuals with various medical conditions, a PRI assessment system must have reasonable reliability and validity to accomplish the societal goal of fairly compensating them.

In fact, the key issue separating proponents and opponents of impairment due to pain is the weight they place on ease of measurement of PRI vs. relevance of PRI. Advocates for PRI emphasize that pain has great relevance to the ability to function of individuals who have various medical conditions, but these advocates tend to downplay the problems of measuring PRI. Opponents tend to emphasize problems in measurement but ignore the issue of relevance. In principle, empirical research could be performed to determine the strength of the independent contribution that pain makes to the burden of illness borne by individuals with various medical condition, and whether examiners can reliably and validly assess PRI. Considerable research has been done on the first issue, at least for some common painful conditions such as disorders of the lumbar spine. Unfortunately, though, essentially no research has been done on the issue of determining the reliability and validity of PRI assessments. Construct validation research is greatly needed in this area. At this time, as a practical matter, decisions regarding PRI for purposes of the Guides’ Sixth Edition must be based on judgment rather than empirical data.

Chronic Pain Syndrome

Chronic Pain Syndrome

In both the Fourth and Fifth Editions of the Guides, a definition of chronic pain syndrome (CPS) was included that captured the major biopsychosocial characteristics of chronic pain. Indeed, the biopsychosocial approach to chronic pain and disability is currently viewed as the most heuristic perspective to the understanding, assessment, and treatment of chronic pain disorders, and has replaced the outdated biomedical reductionist perspective. This biopsychosocial approach views chronic pain as a complex and dynamic interaction among biological, psychosocial, and social factors that perpetuates, and may even worsen, the clinical presentation. Each person will experience a chronic pain condition uniquely, this accounting for the great individual difference in how pain is expressed. The complexity of a chronic pain disorder is especially evident when it persists over time, as a range of psychosocial and economic factors can interact with pathophysiology to modulate a patient’s report of discomfort and disability healing occurs, all patients experience some degree of physical deconditioning associated with stiffness and muscle atrophy in the injured area. Risk factors for profound deconditioning with the injured area becoming a “weak link” include extended periods of inactivity, inhibition of function due to pain, and fear avoidance. In striking contrast, the traditional and outdated biomedical approach assumes that all pain symptoms have specific physical causes, and attempts to eradicate the cause directly by identifying and rectifying the presumed pathophysiology. However, chronic pain can rarely be understood by the linear, nociceptive mechanism. As will be discussed later in this chapter, there is often an absence of a document-able relationship between pain and pathophysiology.

With the above biopsychosocial perspective in mind, CPS can be described as pain that continues beyond the normal healing time for the patient’s diagnosis and includes significant psychosocial dysfunction. It should be noted that this definition does not include any specific time frame to use in making the diagnosis of CPS. This omission is intentional and reflects clinical reality, in that some conditions would be expected to resolve in several days and others in several months or even years. The diagnosis of CPS should then be temporally connected to the point at which a given condition or conditions were expected to have resolved, rather than to any arbitrary time period for an injury or event. Regardless of when it occurs, CPS is a condition that ultimately adversely affects the patient’s well being, level of function, and quality of life. The major characteristics associated with CPS include the following with 3 or more required for a diagnosis:

Ÿ  Use of prescription drugs beyond the recommended duration and/or abuse of or dependence on prescription drugs or other substances.

Ÿ  Excessive dependence on health care providers, spouse, or family.

Ÿ  Secondary physical deconditioning due to disuse and/or fear-avoidance of physical activity due to pain.

Ÿ  Withdrawal from social milieu, including work, recreation, or other social contacts.

Ÿ  Failure to restore pre-injury function after a period of disability, such that the physical capacity is insufficient to pursue work, family, or recreational needs.

Ÿ  Development of psychosocial sequelae after that initial incident, including anxiety, fear-avoidance, depression, or nonorganic illness behaviors.

Definition of Pain

Definition of Pain

The International Association Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” Pain is a prominent symptom in many acute injuries and illnesses, and often subsides as the medical condition resolves. Since such acute pain is usually short lived, it is not a problem that is considered in an impairment rating system. However, chronic pain is a problem that potentially could be the cause for an impairment rating. The definition of chronic pain is imprecise but, in a general way, it refers to pain that persists over time. For the purposes of the Guides, chronic pain is defined as pain that persists beyond the expected healing time of the medical disorder thought to have initiated the pain. For many sections inthe Guides, chronic pain will be pain that persists beyond 3 months, as most common conditions affecting the musculoskeletal and other organ and systems will substantially heal in this time frame. The nervous system is a notable exception. Although any time point is arbitrary, 3 months should encompass the expected healing time in most situations where there is tissue injury but will allow for situations in which there is no expected healing time.