Whiplashby Christopher R. Brigham,
MD
Whiplash-associated disorder (WAD) is often challenging.
This current issue of the Guides Newsletter (May - June
2007) focuses on the need for thoughtful assessment of
diagnosis, causation, treatment, disability, maximal medical
improvement, and impairment. In the feature article Alan
Colledge, MD and his co-authors explain that WAD refers to
complaints attributed to a shear-hyperextension then
hyperflexion cervical injury, typically following a rearend
motor vehicle collision (MVC).
Neck pain following motor vehicle collisions is common, but
there is significant variation in the duration of symptoms.
Research suggests chronic whiplash symptoms should be the
exception rather than the rule; and most cases of WAD resolve
without permanent impairment. Many factors influence the
development of chronic whiplash symptoms including preexisting
pathology (physical and/or psychological), the severity of the
injury, individuals' expectations of pain and disability
following a collision, cultural influences, and psychosocial
stressors.
Our review of automobile casualty cases reveals that
litigation, cultural, psychological, and sociological
influences contribute to an epidemic of chronic whiplash
symptoms in the United States; this is also consistent with
the medical literature. In Florida we have found that the vast
majority of the impairment ratings have in reality no
objective basis to support permanent impairment. The typical
troublesome case is an individual involved in a minor motor
vehicle accident, who receives extensive passive modalities
and testing, and who is rated by the treating physician within
four months of the injury as having substantial impairment.
Permanent impairment cannot be assessed until the
individual is at maximal medical improvement (MMI). Therefore
it is essential to determine whether appropriate treatment has
been provided. Many of the treatments provided for WAD are of
questionable efficacy, and not necessary to achieve MMI. In
the Guides Newsletter article there is a detailed
discussion of the use of a simple, comprehensive treatment
strategy that addresses the biopsychosocial nature of
compensable injuries along with the unintended consequences of
their assessment and treatment. This treatment model is known
as SPICE, the acronym standing for its five components:
Simplicity, Proximity, Immediacy, Centrality, and Expectancy.
Impairment rating is based on clinical data obtained when
at MMI. Parties involved in a claim or lawsuit often want to
settle as soon as possible. However, only permanent impairment
should be rated. Recovery occurs in four to six weeks in most
uncomplicated WAD cases. However, for others maximal
improvement in symptoms and physical findings such as cervical
guarding and motions may take a year from the date of injury.
Surgery or intervening injury, exacerbation, or aggravation
may delay MMI further.
Impairment assessment for WAD is performed using Chapter
15, The Spine, and must follow the Principles of Assessment in
Section 15.1 (5th ed, 374 - 379). The Diagnosis-Related
Estimates (DRE) Method is nearly always used to rate WAD since
the impairment is attributed to a distinct injury. Most cases
of WAD result in a DRE Cervical Category I or II (0% or 5-8%
WPI, respectively).
Common ratings errors include: assessing impairment prior
to MMI, basing the rating on unreliable or inconsistent
findings, selecting DRE Cervical Category III based on
subjective radicular complaints without objective evidence of
radiculopathy, assigning DRE Cervical Category IV on the basis
of questionable radiographic studies, use of the Range of
Motion (ROM) Method, and including rating of regions of the
spine or body not causally related. Often the incorrect
rationale for the use of the ROM Method is multilevel
degenerative disk disease and/or degenerative arthritis. These
common age- related findings do not just justify use of the
ROM method. Ratings of WAD performed by treating physicians
are more likely to be erroneous since they by definition are
not independent and they may be less familiar with the
appropriate use of the Guides.
- All impairment ratings should be reviewed by an AMA
Guides expert.
- We are pleased to assist.
_______________________
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_______________________
Upcoming Events
Just a reminder...we will be at the following conferences
listed below. Please feel free to email me if you will be
there so that we may touch base. It's always great to meet
with our clients face to face. Look forward to seeing you! -
Mindy
Brigham
July 18 - 19, 2007
SEAK National Workers'
Compensation & Occupational Medicine Conference
Four Points by Sheraton Hyannis Resort,
Cape Cod,
MA
July 31 - Aug 2, 2007
9th Annual Workers'
Compensation Conference
Capital Hilton,
Washington
DC
October 3 - 6, 2007
WOEMA - Western
Occupational Health Conference
Loews Coronado Bay
Resort,
Coronado, CA
November 6 - 7, 2007
National Workers'
Compensation and Disability Expo
McCormick Place,
Chicago, IL
