When Symptoms Begin to Outpace the Injury
At the time of the compensable event, a certain set of symptoms are reported. However, with time, the clinical presentation begins to expand beyond what was originally reported, the injury “worsens” and all of a sudden, we are finding all types of pathology not initially considered to be a function of the identified injury. It has been my experience that claims become expensive not because the injury worsens but rather because symptoms do not abate.
Symptoms Matter, But They Aren’t the Whole Story
There are no two ways about it, pain is real. I have provided continuing education lectures on the distinct types of pain, and those types of pain that should be a function of the identified event and those that are not. From an adjuster perspective, understanding pain and symptomology is crucial in maintaining costs in your claim file.
To be clear, from a clinical perspective, symptoms matter. This gives the provider guidelines of where to pursue the clinical investigation. An additional consideration is that two injured individuals can have the same injury, identical pain levels, however one returns to work in six weeks and the other is off work for 12 months. What is the difference? The difference is if the symptoms are supported by competent, objective, and independently confirmable medical evidence. As I write this blog, can you tell me if I have back pain or not? The key point here is that you, as the claim file handler, must understand the distinction between what the injured employee reports and what a clinician can objectify.
Understanding the Difference Between Symptoms and Objective Findings
Symptoms and objective findings are not the same thing. Symptoms start us on the path of clinical evaluation and cannot be objectified. However, objective findings such as loss of range of motion, weakness, neurologic changes, or other positive findings are just that, objective evidence. An acute fracture demonstrated on radiographic imaging provides objective evidence of a recent structural injury. Whereas degenerative changes speak against that particular parameter.
How Claim Creep Begins
What happens with this expanding symptomology is that there is extended therapy, repeated injections, referrals for chronic pain management, and other interventions are commonly employed. In some instances, this is where “claim creep” occurs. Additional diagnoses are added to the problem list, the result is that more treatment is reported, more medications are employed, and yet there is no change in the objective medical evidence being utilized.
Why Objective Medical Evidence Matters
There are several points worth remembering, pain is subjective, the actual injury sustained is our objective. At times, both of these may overlap but to be clear, they are not interchangeable. There are those who complain of severe symptoms with limited objective findings. And there are those who undergo multiple level lumbar fusion surgery and the pain and other symptoms have resolved within three days. It is your job as the claim file professional to look at each progress note and evaluate if the findings noted make clinical sense from an objective perspective or are they simply responding to subjective complaints.
Let Objective Findings Guide the Claim
The goal here is not to ignore symptoms. However, they are to be treated appropriately and at times no treatment is the best option. Each symptom needs to be placed in the proper clinical context. Additional treatment needs to be a function of objective findings and not disconnected from those findings. The parameters noted in several nationally published guidelines with respect to resolution of the pathology should be followed. If not, questions must be asked. The earlier objective findings drive the conversation, the more likely the claim is to stay clinically focused, medically defensible, and appropriately managed.
In any clinical endeavor, symptoms tell you where to look. Objective findings tell you if you have actually found something worth dealing with. If there is a question, ask to see the objective data that supports the basis for the determination.
