by Dr ANTHONY CLARKE, consultant rheumatologist
IN THE LAST issue of Your Expert Witness, Mark Phillips challenged the concept of the likelihood of clinicians being able to predict by how much an injury could bring forward degenerative change. I would like to take that argument further and challenge the related topic of acceleration of socalled constitutional musculoskeletal problems by trauma.
As a rheumatologist with a special interest in chronic pain I am frequently asked to provide an opinion where an orthopaedic surgeon asserts that there are degenerative changes visible on x-ray and that inevitably the claimant would have similar disabling symptoms within two or three years. On what evidence is that opinion based?
A review of the literature suggests that the concept of acceleration first appeared in North America 30 years ago in state-operated workmen’s compensation schemes. The motivation was clear: such schemes are, unlike the UK benefits system, cash limited. Acceleration was, and is, used as a method of limiting the financial liability of such schemes.
It could be argued that if there is a potential constitutional abnormality, then continuing to undertake heavy work will inevitably lead to disabling symptoms in the foreseeable future. This ignores two factors. The first is the ability of many individuals to tolerate pain and other disabling symptoms to allow them to continue with those tasks they find rewarding.
The second is the increasing skill and reduction in physical effort that comes with experience.
It may be possible that acceleration does occur in some circumstances, but that needs to be proven and those conditions that can be accelerated clearly defined. The problem, of course, is the considerable logistic difficulty of undertaking such studies. It would require long-term population studies involving, among other things, repeated radiological examination of asymptomatic people. That is, of course, in direct conflict with radiological protection. It could be avoided by studies involving examination of x-rays taken for other reasons which incidentally revealed abnormalities and following up those patients at a later date to see if they had developed disabling symptoms.
We do have some information in that area, for instance the studies by Verna Wright and colleagues in Leeds 40 years ago, looking at the outcome for military and sports parachutists with spinal injuries and professional footballers with ankle damage, which showed a remarkably good long-term prognosis, as did the studies of fast jet pilots who sustained burst fractures of the lumbar vertebrae after ejection.
The concept of acceleration is a bad one and should stop being used to deny claimants their just compensation following injury. The defendant has to accept the claimant as they find them and should not try to avoid liability by the use of a device that has no logical, scientific or clinical basis.