1 Sue Rideout-Vivian, MD, CCFP, CIME 16 Forest Road Suite 303 St. John s, NL A1C 2B9 Phone No: (709) Fax No: (709) Pager No: Closed Claim Study for Auto Insurance - Medical Consultant Report Submitted January 18, 2005 MY MANDATE My role during this study was to assist the Board and advise with regard to the development of the closed claim study. The mandate given includes: - assist the Board and the actuarial consulting firm on refinement of the Closed Claims Study questionnaire; - assist in the development and understanding of various injury definitions; - in a limited degree, assist in the interpretation of the classification of damages under specific injury types and other heads of damage. QUALIFICATIONS Qualifications required for the position include: experience in diagnosis, treatment, and management of injuries arising from automobile accidents. With regard to my qualifications I will expand further on my background. I was a family physician in the city of St. John s from July of 1988 to August 1998 on a full time basis. During that time I worked as an emergency physician at both St. Clare s and the Grace emergency rooms on a part-time basis. As such I have had extensive hands-on experience in the diagnosis and treatment of injuries resulting from motor vehicle accidents. Between August of 1998 and January of 2000 I was involved in part-time family practice and part-time occupational medicine. In January of 2000 I became a full time occupational physician, although I maintain a small number of family practice patients. Between January of 2000 and August of 2003 some of my work involved examinations of clients of insurance companies. 1
2 Since September of 2003 I have been in private occupational medicine. My work involves services as a part-time medical consultant with Workplace Health Safety and Compensation Commission. I also see employees of Health Canada with regard to medicals, return to work assessments, and fitness for work assessments. My work also includes seafarers medicals, civil aviation medicals, independent medical examinations, and a small amount of time in family practice. I am a Certified Independent Medical Examiner (CIME) and do independent medical examinations requested by lawyers. At times these involve insurance claims. This is a small part of my practice. I have no contracts with insurance companies. In the past, specifically in 1999, I attended the World Congress on Whiplash Associated Disorders in Vancouver, British Columbia. This was an extensive congress involving the research, medical, safety and engineering, and insurance aspects of Whiplash Associated Disorders. Please see Appendix 1 for my curriculum vitae. CLOSED CLAIM STUDY QUESTIONAIRRE The starting point for the Closed Claims Study was to use injury types as used in the previous Closed Claims Study completed in the late 1990 s. I was asked by the Board to review the questionnaire from the previous study to clarify the injury types and provide clear descriptions of what was intended to be included in each injury type. Based on my clinical experience, I advised the Board to make modifications to the injury types used in the previous study to better reflect the types of injuries seen. For example, in the initial study neck strain or sprain was included as one injury type. Back strain or sprain was considered another injury type. In my experience the majority of injuries seen in motor vehicle accidents fall within these two types. In order to properly assess the number of minor injuries it was felt that both neck strain or sprain and back strain or sprain should be further sub-divided. These were subsequently divided into mild, moderate and severe to give six categories as opposed to two. I felt that this would better reflect the range of severity of such injuries. As well, knee injuries, shoulder injuries, and other strains or sprains were divided into minor and other, again to reflect the grade of severity that can exist in these types of injuries. Post concussion syndrome was added to reflect the difference in severity between this syndrome and a simple concussion. Disc injury and Headaches were eliminated as they were covered in other injury categories. I developed the breakdown into Mild, Moderate and Severe based on my clinical experience, my training in occupational medicine, and review of medical literature. This included information from the 1999 World Congress on Whiplash 2
3 Associated Disorders, which also included some information from the Quebec Task Force Guidelines on Whiplash Associated Disorders. Also used was the Physical Medicine Research Foundation BC initiatives - Whiplash Associated Disorders - A Comprehensive Syllabus. Once the injury types were determined, descriptions were provided for each of the injury types to ensure consistency of reporting. These detailed injury type descriptions were enclosed with the questionnaires to the insurance companies. In addition, I gave presentations in St John s and Halifax to explain these to the insurance companies participating in the Closed Claim Study(See Appendix 2). CLOSED CLAIM DATA COLLECTION Each of the insurance companies collected the injury data from their files and recorded the data in the questionnaire based on the detailed explanations provided. This data was then forwarded to the Board for analysis in the Closed Claims Study Report. IMPLEMENTATION OF A CAP As a part of the analysis of the data with respect to the implementation of a cap on pain and suffering, it was necessary to assess which of the injury types reported in the questionnaires would be considered to be minor for the purpose of imposing a cap. Government provided three different definitions of Minor Injury to be considered (Appendix 3). INJURY MAPPING Once these definitions were provided I reviewed each injury type and mapped each injury using Definition (1), Definition (2), and Definition (3). This mapping (Appendix 4) shows the percentage of the injuries which would fall outside of the definition of minor injury and therefore would be entitled to compensation without restriction by the cap, under each definition. The percentages set out in the mapping are based on my best clinical judgment, past clinical experience and training in occupational medicine, as well as literature review. Where appropriate, ranges were adopted to reflect the unique experience of each patient in the context of injury severity, recovery time, individual differences in response to therapy, treatment approaches, and unique injury characteristics. 3
4 Definition (1) If we look at Definition (1) as provided by government, this definition relates only to neck and back strain or sprain. Therefore all other injury types using this definition cannot be considered to be a minor injury and may qualify for 100% compensation. Under this definition any injury that has not resolved in six months is not considered a minor injury. Therefore, moderate and severe neck and back strains and sprains cannot be considered to be a minor injury. This is based on the descriptions of moderate and severe used in the questionnaire. Under mild neck strain or sprain I estimate that 15-35% will not fall under the cap. This group are mild by virtue of the injury type description but are not minor under the terms of Definition (1). That is the injury may not have resolved within six months, may have reduced the person s enjoyment of life, or may have caused substantial interference with the person s ability to perform day-to-day activities. I have generated the following example to illustrate circumstances which may be considered a mild injury for purposes of determining injury type but would not likely be considered to be minor under definition (1). A 35 year old pilot sustained a whiplash injury. One week later he saw his family doctor because of neck pain. He had spasm and decreased range of motion of his neck. He was unable to fly because of this. His doctor told him to rest. He was seen one week later with no improvement and was given medication. Two weeks later he still had symptoms and was referred to massage therapy. He attended massage therapy for two months without sustained improvement. He was still off work because he still did not have full range of motion of his neck. His family doctor then referred him to physiotherapy. He went to physiotherapy but had no improvement after six weeks. On review of the modalities used, it was noted that these were all passive modalities. After discussion with the physiotherapist, a more active approach was taken. He was discharged from physiotherapy two months later. He had to be assessed by the Civil Aviation Medical Examiner and was cleared to return to flying seven months after the motor vehicle accident. I estimate that for various reasons, as in the above example, 15-35% of people with mild neck strains or sprains will not fall under the cap when Definition (1) is applied. When looking at mild back strains or sprains, I estimate that 35-50% will not fall under the cap. Similar reasoning can be applied as in mild neck strains or sprains. 4
5 Definition (2) There are two significant differences between Definition (1) and (2). The first is that definition (2) is applicable to all the injury types, and not just neck and back. The other is that under definition (2) the person is still having substantial interference in his/her day-to-day activities or work-related activities twelve months after the occurrence of the motor vehicle accident, rather than the six months set out in definition (2). Substantial interference means that the person is still, 12 months after the occurrence of the event giving rise to the cause of action, (i) suffering a reduction in his or her enjoyment of life, (ii) unable to perform any one or more of the essential elements of the person s day to day activities, or (iii) unable to perform any one or more of the essential elements of the person s work-related activities. Given this definition, it is obvious that the first eight injury types can not be considered minor and may receive full compensation. This includes those deceased, quadriplegic, paraplegic, those with permanent brain injury, those with amputations, those with permanent loss of a sense, and those with internal organ injury. Under the Fracture of weight bearing bone category, I estimate that 25% of these people will have no problems at one year post injury. This group includes particularly fractures of the toe(s) and non-displaced fractures of the tibia and/or fibula. Most of this group will have resolved in the one year period. The femur and heel fractures take longer to resolve and may go on to have permanent impairments. A very small number will resolve completely within a year. With regard to Other fractures I suggest 40-60% will have ongoing problems at one year and may receive full compensation. As with Fractures of weight bearing bones, this range takes into account the variety of fractures grouped into this category. This range includes a fracture of the little finger to a severe fracture of the pelvis. In the categories Permanent disfigurement or scarring and Serious burn it is suggested that all will receive full compensation based on the injury type description. With regard to Serious lacerations, given the description of injuries in this category, only 10% will be expected to fully resolve within a year. In the three categories of Neck strain or strain, based on the injury type description all injuries in the severe category will receive full compensation under definition (2). In the mild category 10-25% are expected to be unresolved in one 5
6 year and will get full compensation. This can be explained by the example given relevant to this category in the discussion of Definition (1). For the Neck strain or sprain moderate category I estimate that 70-80% will be entitled to receive full compensation under this definition. This is a more serious neck injury and more likely to have recurrent or chronic symptoms. However, 20-30% would not have substantial interference in their lives 12 months after the injury, and therefore will be subject to the cap. In the explanation of this definition it is noted that medical treatment may be required for up to one year. However, 70-80% of these injuries would be expected to still have ongoing or recurrent problems after one year despite not receiving medical treatment. As with Neck sprain or strain, severe back strains or sprains based on the injury type descriptions will all receive full compensation under Definition (2). In the mild back strain or sprain category, I would estimate 25-35% will be unresolved in one year and therefore would be entitled to full compensation. In the moderate grouping, the injury is more severe and more likely to have chronic or recurrent symptoms. Under Definition (2), I would estimate 40-70% will receive full compensation. With regard to the Minor and Other categories of Knee injury, Shoulder injury, and Other strains or sprains, those in the Minor category will all fall under the cap based on the injury type descriptions. Similarly, all those in the Other category would all receive full compensation. Under the Temporomandibular joint dysfunction category, generally most resolve within one year. However, I would estimate 25-40% will continue to have problems greater than one year. Of that group a large percentage will continue to have ongoing problems. I would expect that those with Fibromyalgia and Chronic Pain Syndrome will all get full compensation. For those with a simple concussion, all would likely fall under the cap as they would be expected to resolve within one year and not cause substantial interference in the person s life. The more serious concussions fall in the Post concussion syndrome category. Of this group 30-60% would be expected to continue to have problems at one year and will receive full compensation. All contusions and all minor lacerations and burns will resolve relatively quickly and therefore be subject to the cap. Similarly, the cap will be applied when a person is just shaken up. In terms of Psychological/emotional injury, 60-80% in my experience will have ongoing problems at one year. This category contains a wide range of diagnoses. The majority of those with just insomnia or anxiety will have resolved 6
7 in one year, whereas a great number of those with port-traumatic stress disorder will go on to have some degree of permanent problems. Definition (3) Under Definition (3), minor personal injury means an injury that does not result in permanent serious disfigurement or permanent serious impairment of an important bodily function caused by continuing injury that is physical in nature. As with Definition (2) the first eight injury categories refer to injuries that will likely receive full compensation based on the nature of the injuries in these categories. In the Fracture of weight bearing bone category, 40-60% would be expected to receive full compensation. Most of this group will have femur or heel fractures or severe crushing or comminuted fractures of the foot or lower leg. A small percentage of these will have fractures that went on to non-union, a condition that can occur with any fracture. In particular, heel fractures do not heal well. In the Other fractures category, I would estimate that 20-40% will qualify for full compensation. Again this is the group with the more severe injuries such as pelvic fractures, comminuted wrist fractures, crushing type injuries. Permanent disfigurement or scarring and Serious burn(s), by injury type explanation, all will receive full compensation. I would expect that 20% of serious lacerations will resolve without permanent disfigurement or impairment. In looking at Neck strain or sprain-mild and Neck strain or sprain-moderate, I would expect that 5-15% and 20-30% will receive full compensation. This is consistent with clinical experience, which shows that the majority of people with whiplash of mild or moderate severity will have their symptoms resolve in 2 years. Under the category Neck strain or sprain severe, 90-95% would be expected to receive full compensation. This is consistent with the severity of the injuries in this category. In the Back strain-mild category I would estimate that 10-20% will receive full compensation. This is because a group of people will have ongoing symptoms, which will seriously impair their ability to perform their usual daily activities or regular employment. An example of this would be a labourer required to lift at a heavy to very heavy level of strenuousness on a regular basis. In the Back strain-moderate category, 10-25% would be expected to have permanent impairment. Most will resolve although will have a longer recovery time than those in the mild category. 7
8 In Back strain-severe category, 90-95% will receive full compensation. This is because of the severity of the injuries in this group. A percentage of people in this group will develop osteoarthritis down the road and go on to recurring and/or permanent problems. People with injuries in the categories Knee injury-minor, Shoulder injuryminor, and Other strains or sprains-minor will likely all be subject to the cap, by description of the type of injuries in these categories. I would estimate that 70-90% of those in the knee injury-other category will get full compensation. In my experience 10-30% will have full resolution after therapy and/or surgery. Some of the group having surgery will have some limitations despite the surgery. Others will go on to have osteoarthritis in the joint down the road. In the Shoulder injury-other category, I would estimate that 60-80% will get full compensation. Twenty to forty per cent of this group will get full resolution with therapy and/or surgery, even though there may be a prolonged recovery period. I estimate that 30-50% of the Other strain or sprain-other group will receive full compensation. This reflects the diversity of the injuries in this group. For example most wrist strains will resolve whereas a severe ankle strain may continue to cause recurring problems. Most temporomandibular joint problems resolve in one year. However, 20-30% will cause onging problems. This may range from use of a bite plate at night to chronic pain resulting in impairments of eating and speech. Under Definition (3) people with fibromyalgia and chronic pain syndrome would all be expected to receive full compensation, based on the nature of these conditions. Under Definition (3) all simple concussions would be subject to the cap. Of those with Post concussion syndrome I would estimate that 80% will be subject to the cap as most resolve without permanent impairments even though there can be a long recovery time. All Contusions will be subject to the cap, as well all Minor laceration(s) and burn(s). People just shaken up will also be subject to the cap. In the Psychological/emotional injury category, 20-30% will receive full compensation. Again there are a wide variety of diagnoses in this category. In particular, those with post-traumatic stress disorder are more likely to have ongoing or recurrent problems. 8
9 LIMITATIONS 1. The percentages given under the different definitions were developed based on my best clinical judgement and clinical experience. Through the mapping process, I am attempting to determine what percentage of each injury type falls outside of each of the provided definitions of minor injury. Where appropriate I have suggested a range of injuries which may be expected to fall outside of the minor injury definition. It should be noted, however, that as in most cases, there are injuries that fall significantly outside the ranges. 2. The ranges that I have suggested do not reflect very mild injuries, where the injured party does not seek medical attention, given that these people would not form part of my clinical experience. 3. I ve applied my best medical judgment to this analysis. Another physician, in particular a specialist, may assess different ranges based on their clinical experience. 4. Detailed explanations of each injury type were given to each insurance company. In addition further presentations and explanations were provided throughout the Closed Claim Study. However, I did not examine the files to check how the data from each file was categorized into injury types. 5. While I evaluated the mapping based on my medical knowledge, other factors which may impact upon the results of the implementation of a cap on particular injuries would include the language of the definition which is implemented, judicial interpretation of the definition, psychosocial factors, and claim settlement practices. 6. This report was prepared to assist in the closed claims study and is not intended for any other purpose. Original signed by Sue Rideout-Vivian MD, CCFP, CIME Medical Consultant 9
11 SUSAN RIDEOUT-VIVIAN, MD, CCFP, CIME CURRICULUM VITAE Rideout-Vivian, Susan Caroline (Sue) 16 Forest Rd, Suite 303 St. John s, NL A1C 2B9 Phone: (709) Fax: (709) Pager: (709)
12 Curriculum Vitae EDUCATION University: Memorial University of Nfld. Medical School, St. John s M.D. (September 1982-May 1986) Memorial University of Nfld., St. John s B. Sc. In Biology (Three Years Completed) September 1971-August 1973 (Full-Time) January 1976-April 1982 (Part-Time) Technical: High School: College of Trades and Technology, St. John s Diploma of Medical Laboratory Technology, R.T. (May 1974-December 1975) Queen Elizabeth Regional High School Foxtrap, Newfoundland Grade XI Honors Diploma (June 1971) CERTIFICATIONS Sept Certified Independent Medical Examiner (American Board of Independent Medical Examiners) June CCFP May LMCC May MD Oct B. Med. Sci. EMPLOYMENT EXPERIENCE Sept 2003-Present Occupational Physician, Private Practice Medical Consultant (Part-Time) - Workplace Health, Safety & Compensation Commission Medical Consultant Rehabplus/Fitnessplus Aug 1998-Aug 2003 Occupational Physician, Atlantic Offshore Medical Services, St. John s, Nfld.
13 Medical Officer (Part-Time), Workplace Health, Safety & Compensation Commission Jan 1995-Mar 2000 Family Practice, 193 LeMarchant Road. St. John s, Nfld. July 1988-Jan 1995 June 1986-June 1988 Dec Dec June 1983-Aug Dec 1975-July 1982 Jan Apr Sept Dec Aug May 1974 May 1972-Aug Campbell Medical Group-General Practice & Maternity Family Practice Residency Program, Memorial University of Newfoundland Student Operator in Telemedicine, Memorial University of Newfoundland Medical School, St. John s (Part-Time) Summer Studentship, Memorial University of Newfoundland Medical School, St. John s Research Assistant II in Experimental Surgery, Memorial University of Newfoundland, St. John s Student Demonstrator in Microbiology, Memorial University of Newfoundland, St. John s (Part-time) Science Technician in Biology, Memorial University of Newfoundland, St. John s (Part-Time) Science Technician in Biology, Memorial University of Newfoundland, St. John s Student Assistant, Land Classification, Canadian Forestry Service, St. John s APPOINTMENTS AND SOCIETIES Civil Aviation Medical Examiner Designated Seafarers Examiner Associate Staff, Health Science Corporation Newfoundland & Labrador Medical Association Canadian Medical Association Canadian College of Family Physicians Occupational and Environmental Association of Canada American College of Occupational & Environmental Medicine Editorial Advisory Council, Physicians Computing Chronicle
14 Member, Board of Directors St Luke s Homes Member, Professionals Assistance Committee Past Member - Physical Medicine Research Foundation Past Member, Medical Advisory Committee, Berlex Canada Past Member, Board of Directors, Newfoundland & Labrador Medical Association Past Member, Medical Advisory Committee, St. Clare s Mercy Hospital CONGRESSES/COURSES Completion of ACOEM Basic Curriculum in Occupational Medicine; May, Basic Curriculum in Occupational Medicine: A Survey of the Essentials Segment 3, Kansas City; April 30-May 1, Basic Curriculum in Occupational Medicine: A Survey of the Essentials - Segment 1, Chicago; April 12-13,2002. Basic Curriculum in Occupational Medicine: A Survey of the Essentials - Segment 2, Seattle; Oct27-28, Advanced Topics in Impairment and Disability Evaluation: Critical Knowledge and Skills, Chicago; Sept. 9-10, Evaluating Impairment - Use of the AMA Guide: A Case Study Approach, Chicago; Sept. 7-8, World Congress: Whiplash - Associated Disorders, Vancouver, Canada; February 7-11, PUBLICATIONS, ABSTRACTS, EXHIBTS 1. Rideout-Vivian, Susan. Review Article: A Tool Designed to Improve Auscultation Skills. Physician s Computing Chronicle, Oct, Rideout-Vivian, Susan and Huckell, Victor D. Module 11. Cardiovascular Disease, Advancing Women s Health Program. 3. Rideout-Vivian, Susan and Belisle, Serge. Module 5. Premenstrual Syndrome, Advancing Women s Health Program. 4. LeGal, Y.M. and Rideout, S.C.: Reduction of Myocardial Infarct Size: A Comparison of the Effectiveness of Intra-aortic Balloon Pumping and Transapical Left Ventricular Bypass. Trans.Am. Aoc. Artif. Intern. Organz. 29: , 1983.
15 5. LeGal, Y.M., Bartlett, R.B., Couves, C.M., Jewer, D., Torraville, D., Cant, E., Noel, F. and Rideout, S.C.: Phosphokinase (CPK) and CPK-MB Iso-enzyme Levels Following Operative Procedures Involving the Heart Artif. Organs. 3:297, LeGal, Y.M., Bartlett, R.B., Couves, C.M., Jewer, D., Torraville, D., Cant, E., Noel, F. and Rideout, S.C.: Significance of Plasma Creatine Phosphokinase (CPK)-MB Iso-enzyme Activity Procedures Involving the Heart Proc. Can. Fed. Biol. Soc. 23: LeGal Y.M., Couves, C.M. Rideout, S.C., Ash, K.M., Squires, D.S., Collins, D.J and Wright, E.S.: The Role of Methylprednisolone as Adjunctive Therapy to Cardiac Assist Devices. Artif.Organs, s-43, LeGal, Y.M. and Rideout, S.C.: Reduction of Myocardial Infarct Size: A Comparison of the Effectiveness of Intra-aortic Balloon Pumping and Transapical Left Ventricular Bypass. Am. Soc. Artif. Intern. Organ, 12:7, Couves, C.M., LeGal, Y.M. and Rideout, S.C.: Cardiac Assist Devices. Exhibit Royal College of Physicians and Surgeons of Canada, Ottawa, June
17 Injury Type: 32-1 Deceased 32-2 QUADRIPLEGIA, COMPLETE OR INCOMPLETE This includes complete and incomplete. Incomplete refers to partial motor and sensory loss. Complete refers to full motor and sensory loss PARAPLEGIA OR HEMIPLEGIA, COMPLETE OR INCOMPLETE Paraplegia refers to paralysis of the legs and lower part of the body. Hemiplegia refers to paralysis of one side of the body. CASE Mr C.M. is a 23 year old man who was driving a 1994 Ford Mustang that hydroplaned on a wet road and rolled three times. There was extensive damage to the vehicle. Mr M. lost consciousness. In the emergency room he was oriented to person, but not to time, place or situation. He had little movement of his left arm or leg. An X-ray showed a fracture of the right temporal bone A CT scan showed a mass. Mr M had surgery for the removal of an acute subdural hematoma. Post-op Mr M regained the ability to speak, but continued to have problems with pronunciation. He could not readily identify objects or relay his thoughts. He continued to experience urinary incontinence. His left hemiplegia gradually improved to a left hemiparesis. He was able to walk with the use of a long leg brace on the left and a 4-footed cane for stability. He was able to grasp, hold, push, and pull with his left arm, but he was incapable of small muscle control or dexterous use of the left hand. Two years later he needed help getting in and out of the bathtub and doing buttons on his shirt. He could not use a manual can opener; he could not drive a car. On exam reflexes were increased in the left arm and leg with an upgoing plantar response on the left. There was generalized weakness on the left side. Senation was normal. His gait was abnormal. He could not walk without his cane and brace PERMANENT BRAIN INJURY This condition occurs as the result of a head injury. It is the result of physical damage to the brain tissue. In this condition there is permanent impairment in the mental and emotional processes and their functioning. It imposes restrictions on the client s ability to carry out the activities of daily living AMPUTATION OF OR PERMANENT LOSS OF USE OF A MAJOR MEMBER (i.e. leg, foot, arm, hand) loss of limb or part of limb 32-6 AMPUTATION OF OR PERMANENT LOSS OF USE OF ANY OTHER BODY PART toes, fingers, etc
18 32-7 PERMANENT LOSS OF A SENSE - (e.g. sight, hearing, smell, taste, touch) 32-8 INTERNAL ORGAN INJURY e.g. lung, heart, reproductive organs, loss of spleen, gastrointestinal injury associated with loss of bowel, kidney damage 32-9 FRACTURE OF WEIGHT-BEARING BONE(S) A weight-bearing bone refers to those in the leg (i.e. the femur/tibia/fibula/heel/bones of foot) OTHER FRACTURE(S) PERMANENT DISFIGUREMENT OR SCARRING This may be caused by the injury itself or be the result of surgery SERIOUS LACERATION(S) This refers to a severe cut that may or may not result in disfigurement. There may be temporary or permanent nerve damage i.e. loss of sensation and/or function. Loss of sensation or function may be complete or incomplete SERIOUS BURN(S) A serious burn is one that usually requires admission to a medical treatment facility. It usually takes more than three weeks to heal spontaneously. It may result in permanent disfigurement or scarring NECK STRAIN OR SPRAIN This may be referred to using the following terms: whiplash, whiplash associated disorder (WAD), a cervical strain, soft tissue injury (STI), etc. Neck strains/sprains will be further broken down into three categories dependent on the severity of the symptoms and signs. NECK STRAIN OR SPRAIN - MILD - This includes WAD(Whiplash Associated Disorder) I and II. Neck symptoms only (WAD I) - Symptoms may include complaints of pain in the neck (one or both sides), stiffness, and tenderness. There are no physical signs. Symptoms may be delayed hours or to the next day. Resolution is expected to start in days. Recovery to usual activities is usually in six weeks or less. Neck symptoms and musculoskeletal signs (WADII) - Symptoms usually include pain in the neck, one or both sides, and there may be pain in the arms. These start within minutes to a few hours. Signs include muscle spasm and /or decreased range of motion. X-rays may show spasm. Resolution may linger for months, but most resolve in ninety days. CASE Ms J.S. is a 25 year old teacher who was driving a 1999 Volvo that was rearended by a 2002 Nissan Pathfinder. At the time, she was stopped at a traffic light and was aware of the impending crash. Her seatbelt was on. Her car was pushed about 6 feet ahead. She had immediate soreness in her neck. After you got home her neck felt stiff and painful. Her right arm was aching. She
19 had no pins and needles and no loss of sensation in her arms. Her family doctor treated her with a soft cervical collar, gave her anti-inflammatories, and referred her to physio. Her neck remained stiff and sore so her family doctor ordered an X-ray of her neck. This showed flattening of the normal lordosis thought to be due to muscle spasm. She did not find physio or the medications helpful so she stopped both after 2 months. Three months post-mva she still had stiffness and pain in her neck, but the ache in her right arm was almost gone. An MRI was done and was normal. Her family doctor advised her to continue walking and swimming. He told her she had a whiplash injury and she would probably be better in 6-12 months. At 12 months she only occasionally had stiffness in her neck. This was associated with being tired or after a hard day at school. It settled quickly with rest. On exam she had normal range of motion of her neck with no guarding or spasm. Power, sensation, and reflexes were all normal. There was no muscular atrophy in the arms NECK STRAIN OR SPRAIN - MODERATE - Neck complaints and neurological signs (WAD III) - These may include absent reflexes, weakness and sensory deficits. Symptoms usually start immediately. Radiating shoulder and arm symptoms soon follow. Neurological deficits are found on examination. These symptoms may linger for months and there may be recurrences or chronic symptoms. Medical aid treatment may be required for up to one year NECK STRAIN OR SPRAIN - SEVERE - Neck complaints and fracture or dislocation (WAD IV) - In this case there is a fracture without spinal cord injury. Symptoms can start instantly. Neck weakness can be found. Radiation of symptoms to shoulder and arms are variable. The eventual outcome is variable ranging from complete recovery to long-term complications. CASE Ms S is a 23 year old lady who was the front seat passenger in a Mini that was hit from behind by a Volkswagon Jetta going 90 kph. She had immediate onset of pain and an inability to move her arms or legs. X- ray revealed a 5mm subluxation of C6 on C7. A CT scan showed herniation of the disc at C6-7 compressing the spinal cord and the C7 nerve roots on either side. Ms S was put in cervical traction. She went on to have an anterior cervical discectomy and fusion at C6-7. Postop she was maintained in a halo brace for 3 months. She recovered some extremity function but her neurogenic bladder persisted. One year after her injury the fusion was solid on X-ray exam. Her reflexes were hyperactive with bilateral positive Babinski s sign (upgoing plantars). She had weak triceps muscles and weak wrist and hand muscles. She was weak in the lower extremities diffusely but showed no evidence of spasm. She was paraparetic, but able to walk short distances in bilateral above-knee orthoses. About half of her ambulation was in a wheelchair.
20 She was incontinent of urine requiring catheterization. She had some loss of sensation. The diagnosis in this case is vertebral body dislocation with cauda equina syndrome with bladder compromise BACK STRAIN OR SPRAIN This includes injuries to the thoracic spine (upper back) or to the lumbar spine (lower back). Common terms to describe these injuries include soft tissue injury (STI), mechanical back pain, musculoligamentous injury, etc. Again we further divide this group into three categories according to the severity of the injury. BACK STRAIN OR SPRAIN - MILD - Back symptoms with or without musculoskeletal signs - Symptoms include complaints of pain in the back (upper and/or lower) with or without stiffness or tenderness. There may be buttock and/or leg pain. Symptoms may start within minutes or be delayed for hours or even the next day. Physical exam may show decreased range of motion and spasm. Resolution may start within days with most returning to usual activities in 90 days BACK STRAIN OR SPRAIN - MODERATE Back complaints and neurological signs. This may include absent reflexes, weakness and/or sensory disturbances. Symptoms usually start immediately. Pain often radiates below the knee into the calf and/or foot. Symptoms may linger for months and there may be recurrences or chronic symptoms. Treatment may be required for up to a year. This will include disc injuries. Terms used in diagnoses include sciatica, nerve root impingement, disc prolapse, etc. CASE Ms C.J. is a 31 year old lady that was the driver of a Toyota Echo that was T-boned by a Dodge Ram. She described burning pain, diminished sensation, and tingling of her left lateral thigh, and medial calf. On exam there was diminished sensation of the left medial calf, decreased strength of the left anterior tibialis, an absent left knee jerk, and pain below the knee with SLR of 30 degrees. A lumbar MRI revealed a herniated nucleus pulposus at L-4 impinging on the left L4 nerve root. The diagnosis was lumbar radiculopathy. Ms J was given anti-inflammtories and treated with physiotherapy and conditioning. She was given modified work. Eight weeks after her injury she had mild residual back pain but no leg pain. She still had diminished sensation of her left medial calf, but her reflexes, power, and SLR was normal. She returned to work full time without restriction. One year after her injury she still had mild residual low back pain and diminished sensation of her medial left calf. She continued work without modification BACK STRAIN OR SPRAIN - SEVERE Back complaints and fracture or dislocation. - In this case there is a fracture without spinal cord injury.