As a guy who will be completing his 74th trip around the sun in a few weeks, I have accumulated a predictable set of degenerative changes in my lumbar spine. I have abused and repetitively traumatized certain aspects of my person, resulting in significant degenerative changes. On occasion, I have acutely injured certain aspects of my person. Given my current job is behind a desk, there is not a compensable injury noted. However, had I continued my career as a Physician Associate working in orthopedic surgery, perhaps the lower back pain could be a cumulative disorder?
By definition, cumulative trauma is explained as repetitive micro-stress over time that exceeds the body’s ability to recover. Standing over an operating room table for hours at a time really does stress the lower lumbar region. In my situation the calendar would be considered a comorbidity, tempered by the piano I carry around. In addition, I have a greater than 50-year history of lumbar injury secondary to participating in military activities across the pond.
Recently I underwent enhanced imaging studies of the lumbar spine to address some of these low back complaints. A buddy, who was an exceptional orthopedic surgeon, saw the films and texted back “dude really”. In short, there were significant degenerative changes from a variety of sources. Thus, the question becomes are the current complaints a function of the ordinary activities of my occupation (if I was still working as a Physician associate) doing orthopedic surgery?
The Rise of Cumulative Trauma Claims in an Aging Workforce
I mention this secondary to several articles I have recently reviewed. The rate for cumulative trauma claims in California has risen by approximately 50% since 2008. Approximately 70% of those claims are orthopedically related. At the same time, a report from the Bureau of Labor Statistics indicated a nearly doubling of workers aged 75 and older in the last decade. Add to that, the workforce being 55 and older is already a substantial share of the active labor force.
If my claim landed on your desk, what must you, as the claim file handler do? The first step is to credibly establish the exact mechanism of injury. A credible injury requires a plausible biomechanical explanation. The second step is to clarify any particular red flags. When job duties do not align with the identified findings on diagnostic imaging studies, causation has to be questioned. And it is not the pathology noted on MRI studies or other diagnostic imaging evaluations that will help you with the causation opinion.
An MRI describes anatomy/pathology. And not how it got there. Are the findings noted as a function of the identified event or are they related to 50 years of ordinary disease of life wear and tear?
This is where a detailed history, a comprehensive review of systems, a thorough physical examination, and a clear comparison between the clinical data and the proposed compensable diagnosis must come from the treating provider. Every provider, including myself, was taught not to worry about insurance, treat the patient. However, when noting each of the above factors, it is clear that the pathology being addressed as a function of the reported mechanism of injury must be objectively associated. This is not to say there are not unrelated comorbidities, only they are not to be treated as part of the identified injury.
Why Clinical Findings Must Support the Diagnosis
This lack of clarity often shows up in how diagnoses are assigned. There are many what I call “garbage can” diagnoses that are assigned without appropriate clinical information to support that assessment. A sprain/strain is not the same thing, as two different structures (ligament = sprain, muscle = strain) are compromised with each diagnosis. Radiculopathy is simply not complaints of leg pain; this diagnosis is to be associated with very detailed specific physical findings.
The evaluating provider needs to acknowledge that both factors can exist. As noted in my case, there was significant compromise to any number of structures within the lumbar spine. Not all them are a function of the compensable injury that occurred eight days ago. To assign all that pathology to the compensable injury is a disservice to all parties concerned.
To be clear, if the identified event aggravated pre-existing pathology, that aggravation can be compensable. It still requires specific, competent, objective, and independently confirmable medical evidence. The narrative report should reflect that specific information.
Building Claims Decisions on Objective Evidence
As a claim file handler, I would encourage you not to rely on imaging reports, for the purpose of accepting pathology as a function of the reported mechanism of injury without detailed scrutiny. And the concept of “I did not have pain before and I have pain now” means that all the pathology identified is related is not to be accepted. Do not ignore baseline function, prior clinical history, and the exact findings noted that do not support an acute event.
In summary, cumulative trauma does occur. However, prior to accepting requires a disciplined analysis. When factors such as the calendar and other degenerative processes are identified, this notation then requires additional scrutiny.
The mechanism of injury must make sense. The objective clinical findings must correlate and support this. And then the imaging studies must match both. Any claims decision must be built on objective clinical evidence consistent with the reported mechanism of injury and to a reasonable medical probability. If all these factors are present, then so be it. However, as an example, the current state of my spine is simply not a function of any specific recent occupational event.
