Part III of III: Spinal Soft Tissue Injuries – Points to Consider During Evaluation

This is part III in a three part series that will address spinal soft tissue injuries from a personal injury perspective.  In this issue we will discuss points to consider during the evaluation of soft tissue injuries.  Part I was published in the September 2012 newsletter and covered the basics of soft tissue injury and how to differentiate sprain from strain. Part II was published in the October 2012 newsletter and discussed symptoms and treatment of spinal soft tissue injuries.

The purpose of this newsletter is to assist attorneys in understanding the challenges that these types of injuries may present and in identifying potential arguments that may be presented during negotiations.

There are many factors to consider during the evaluation of spinal soft tissue injury including:

• Mechanism of Injury:  The neck is most susceptible to injury as a result of automobile accidents or other injuries.  This is because the neck is built for mobility rather than stability.  With having to support the heavy head, excessive range of motion (i.e. whiplash) may occur easily in frontal and side impact accident.  In rear end impacts, the headrest is a safety device to prevent excess motion and reduce injury. 

• In rear end impacts, consider the speed of impact. In higher impact accidents, the “sudden stop” by the headrest may contribute to strain type injuries or result in blunt force trauma to the neck.

• Consider whether the headrest was in the proper position. For example, if the plaintiff is tall but the headrest was set low, it may actually act as a fulcrum and contribute to injury.

• Note if the vehicle is an older vehicle without a headrest.  If it is a truck, note whether there was there a head strike on the back glass.

• Lumbar strains are most likely to present in frontal or side impacts. In rear end impacts, the seat backs are designed to provide protection and reduce injury. This may be a more successful defense argument in lower impact cases.  In moderate to high impact accidents, lumbar strain may still be frequently seen.

• Consider whether the injured party was properly strained; if the injury occurred in a child, were they in a proper child restraint?

• Onset of Symptoms: It is helpful to look at the complaints immediately after the accident.  Did the claimant report pain to the police officer? Was there EMS or ER treatment? As discussed above, immediate complaints may suggest a more significant soft tissue injury.  However, delayed presentation within 24-72 hours after injury can be reasonably explained but may be argued as being suggestive of less injury.

• Age of the Plaintiff:  While children may certainly develop soft tissue injuries, they are usually considered less susceptible because of their pliable joints and naturally increased range of motion.  Treatment of children is typically more conservative than the norm for adults.  Physically active adults with good muscle tone may be less likely to sustain injury than adults with poor muscle tone.  The elderly, especially if they have loss of muscle mass, may be more prone to injury and slower to heal.

• Other Medical Conditions: There are certain medical conditions that may make a plaintiff more susceptible to injury or more likely to require additional treatment including: degenerative spine conditions, inflammatory conditions (such as rheumatoid arthritis), diabetes, lupus, or other conditions that impacts the muscles or nerves.

• Duration and Frequency of Treatment: A common point of negotiation between the plaintiff and defense is often the length of treatment.  The defense will argue that most soft tissue injuries will heal with or without treatment.  In general, they will rely on standard disability guidelines which demonstrate expected treatment time frames of 6-8 weeks with approximately 18 visits to a chiropractor or 10-12 visits to a physical therapist  (Official Disability Guidelines, 2012).   Some chiropractors will quote the Croft Guidelines which may suggest up to 76 visits or more  (Painter, DC, 2010).  The primary consideration should be factors specific to the individual such as any complicating factors that might contribute to or prolong injury, consistency in complaints, functional level, objective evidence of injury, compliance with treatment, etc. Determining these factors is dependent upon strong documentation in the medical records.

• Treatment Modalities:  Modalities are the individual therapies provided by the chiropractor or physical therapist.  These are typically passive services meaning that it is a treatment done to the patient rather than something they have to actively participate in.  Examples include hot packs, electrical stimulation, ultrasound, massage, manual therapy, etc. While there is literature that will support that these modalities may be effective in reducing pain or inflammation, likewise there is literature that questions the efficacy and cost benefit of these services, especially after the initial couple of weeks.  Again, the defense will typically look at the extent to which these services are utilized for suggestions of excessive treatment and will often rely on published guidelines to establish a “norm” in the range of 2 modalities per visit (3 for severe strains) tapering down as improvement occurs  (Olson, DC, 2000). Regardless of how many modalities are utilized, the records should clearly support why they are medically indicated.

• Less Common Treatments/Tests:  In a patient with a diagnosis of strain, it should be expected that the defense will look closely at less common procedures and tests such as:  MRIs, TENS units, IDD (intervertebral disc decompression), spinal ultrasound, ESIs and other injections (epidural steroid injections), or any surgical procedure.  Additional documentation, such as prior medical records to establish the injured party’s baseline medical condition, will often be required.  When utilized, the medical decision making and medical necessity of these procedures should be well documented in the records.

The most important point for both the plaintiff and defense to consider is that every injury is different as is every injured party.  The same accident can produce a wide variety of injury types and severity in different individuals. The treatment needed and the response to treatment will vary.  While the defense needs to consider that there will be variations from the “norm”,  it is also important that the medical records objectively support the injury, why the treatment is medically necessary and explain any factors that might contribute to this variation.  The team at University Park Legal Nurse Consulting is available to assist you in evaluating these claims.

Works Cited

Chiropractic Canada. (2012). Effectiveness of Chiropractic Treatment. Retrieved August 11, 2012, from Canadian Chiropractic Association: http://www.chiropracticcanada.ca/en-us/FactsFAQs/EffectivenessofTreatment.aspx#1

Ernst, MD, E. (2002, October). Chiropractic Care: Attempting a Risk-Benefit Analysis. American Journal of Public Health, 1603-1604: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447290/

Legorreta, A., Metz, R., Nelson, C., Ray, S., Chernicoff, H., & Dinubile, N. (2004). Comparative Analysis of Individuals with and without Chiropractic Coverage: Patient Characteristics, Utilization and Costs. Archives of Internal Medicine, 1985-1992: http://www.ncbi.nlm.nih.gov/pubmed/15477432

Official Disability Guidelines. (2012, June 5). Sprains and Strains of Other and Unspecified Parts of Back. Retrieved August 11, 2012, from Official Disability Guidelines: http://www.disabilitydurations.com/bp/847.htm

Olson, DC, R. E. (2000). Procedural Utilization Facts – Chiropractic Care Standards. Woodstock, GA: Data Management Ventures.

Painter, DC, F. (2010, February 20). Whiplash Care Guidelines. Retrieved August 11, 2012, from The Chiropractic Resource Organization: http://www.chiro.org/LINKS/GUIDELINES/ART_CROFT.Chap12.shtml

Shiel, Jr., MD, W. C. (2012, February 03). Neck Strain. Retrieved August 11, 2012, from eMedecinehealth: http://www.emedicinehealth.com/neck_strain/article_em.htm#neck_strain_overview