Expert Witness Corner: Maximising Quantum – A Physiotherapist’s Role

Traditionally, personal injury cases involve a report from an orthopaedic consultant or general practitioner to help establish the nature of the medical condition and its causation and prognosis. An experienced clinical physiotherapist can offer a complete understanding of the whole process from first injury right the way through to recovery. Armed with this knowledge, a more thorough and wide-ranging report can be provided that will accurately reflect the extent and timing of patient recovery – essential when considering issues of quantum and future care costs.

Soft tissue injuries are injuries not involving bony damage such as fractures. They are often incurred as a result of whiplash or repetitive strain and, as the name implies, only involve damage to muscles, tendons, ligaments, fascia and nerves. The damage is usually invisible on x-rays and scans and can be detected only by skilled examination. Torn muscles, ligaments, nerves and cartilages may require a surgeon’s skills. But once this primary care has been administered, the client will invariably be referred to a physiotherapist. A physiotherapist can provide specific and individually tailored treatment aimed at assisting the body’s natural healing and restoring full function.

Examples of relevant soft tissue injuries include:

•Tendonitis
•Tenosynovitis
•Muscle strains
•Lifting injuries
•Lower back pain
•Epicondylitis
•Carpal tunnel syndrome
•Whiplash injuries
•Work-related upper limb disorders.

When examining issues of quantum and future costs, it is essential that a lawyer receives the whole picture: the exact nature of the injury, detail of treatment, likelihood of full recovery, timing of recovery, and an indication of future care costs, if any. An experienced physiotherapist in clinical practice has a wealth of relevant expertise.

A clinical physiotherapist is usually involved with a patient from presentation of the injury through to the end of rehabilitation. Treatment can be broadly divided into four stages:

1: Conducting a detailed specific examination to identify the body structures damaged and any loss of function.
2: Devising a treatment programme.
3: Implementing the treatment programme.
4: Seeing the patient through to the end of rehabilitation – hopefully back to ‘normality’.

The ‘hands-on’ nature of the patient–therapist relationship, plus the inevitably regular patient contact, give physiotherapists an enormous advantage when it comes to diagnosing and treating a complex soft tissue injury. In addition, the wealth of knowledge relating to rates of recovery from the various soft tissue injuries means that when it is applied to cases requiring an evaluation of quantum and likelihood of recovery, the lawyer receives an opinion from an expert with an understanding of the whole rehabilitation process.

Client history:

Any comprehensive account of the background to an injury (particularly where it is work-related) should include information about the claimant’s regular daily activities, whether in a work environment or home situation. A physiotherapist is accustomed to observing and assessing the impact of a client’s environment on his or her injury. This is an essential consideration when seeking to restore full function.

Case Example:

Mr T had been using an improvised workstation and subsequently incurred severe soft tissue injuries. The physiotherapist identified how the postural stresses on the body had resulted in the patient’s symptoms. Excruciating pain along the spine – relieved only by lying flat – and severe pain and tenderness of the forearms were the consequence of sitting for 3 months of intensive work on a laptop.

Client Examination:

Soft tissue injuries are difficult to assess accurately, with x-rays and scans rarely providing useful evidence. Even nerve conduction tests are of little value when assessing damage to nerves subjected to excessive stress. What is required is an evaluation of any adverse mechanical tension within the nervous system which may be restricting movement.
Physiotherapists are used to palpating and testing specific structures within the body to diagnose exactly what has been damaged, i.e. whether it is a tendon, a tendon sheath, muscle, fascia, a nerve or any combination of these. A physiotherapist can help in differentiating between whether the client’s condition is constitutional and has been aggravated by work or trauma, or is caused by work or trauma.

There is a growing acknowledgement of the need for a biopsychosocial assessment when examining people, and this is the approach traditionally taken by a physiotherapist. Social history and status, mental and emotional states, as well as working situation and lifestyle, can all contribute to how the patient reacts to and copes with symptoms.

There are many standard tests that can help with the assessment of the physical condition. One such example is the straight leg raise. The test involves the patient lying comfortably relaxed on his back. The examiner places one hand under the Achilles tendon and the other above the knee. The leg is lifted perpendicular to the bed, with the hand above the knee preventing any knee bend. The leg should be lifted as a solid lever moving at a fixed point in the hip joint.

This is a simple biomechanical test that has been recognised for hundreds of years as a way of identifying lumbar spine (lower back) problems. However, it is of limited value only. When the leg is lifted in the manner described, many structures move – the hamstring muscles, the lumbar spine, the hip and sacro-iliac joints and fascia, as well as the nerves. Pathology of any of these structures may affect the client’s reaction to the test.

An experienced physiotherapist will combine such tests with detailed palpation and observation of functional movements to arrive at the all-important specific diagnosis. In addition, the patient’s posture and manner of movement will be analysed and the results added to the overall assessment.

Case example:

Mrs B was secretly videoed by an insurance company while shopping. A physiotherapist was able to identify how the client had become so used to coping with her injuries that she avoided a lot of the normal, potentially painful, actions employed by other women shopping, e.g. standing upright with arms by her side most of the time, avoiding heavy or bulky items, loading carrier bags lightly, and using both hands to carry each bag.

Expert opinion:

An experienced clinical physiotherapist possesses an unrivalled knowledge and comprehension of how the body works under normal conditions and when coping with a disability or soft tissue injury. With regular and prolonged experience of treating soft tissue injuries, a physiotherapist can offer a valuable and meaningful opinion about all aspects of treatment and recovery.

Prognosis:

An essential component of any medico-legal report is a prediction of future developments on a balance of probabilities basis. A clinical physiotherapist sees large numbers of similar injuries from first contact through to recovery, and can thus give a reasoned prognosis based on experience. This should include the likelihood and anticipated timing of resolution, the need for further treatment and any possible long-term disability.

Conclusion:

When a lawyer is trying to find an expert witness that can help with soft issue PI cases it is worth considering an experienced physiotherapist can bring a unique and valuable perspective in any personal injury case involving a soft tissue injury. Experience of patients from first injury right through to recovery gives such specialists the widest professional knowledge when it comes to assessing future treatment and costs thereof, and arming the lawyer with the necessary detail to fully assess quantum.

Rosemary Quinn is an experienced physiotherapist based in the North West of England. You can view her profile and find an expert witness at X-Pro, the innovative expert witness directory.

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