Physiotherapy Expert Witness – practical strategies

Physiotherapy expert witness evidence was the topic of last week’s discussion and is the continuing theme today. As discussed the term “simple soft tissue injury” has become a catchall phrase within the legal system as well as primary care. I think it is a lazy expression because it avoids the onus of specific differential diagnosis and allows clinicians to hide behind a superficial examination (or screening radiology) without attempting to quantify the nature of the pathology, the extent of  tissues involved, the factors which are provoking symptoms and of course the appropriate treatment strategies.

From a physiotherapy perspective one simple strategy for identifying symptomatic tissue and recording in both  legal document and clinical report is to qualify the limiting factor when assessing range of motion. For example in the whiplash case we discussed if Cervical rotation is limited to 70° then a qualifying statement outlining the nature of symptoms produced and their location at the time of limitation provides more clinically useful information. For example the extract below demonstrates this for a Cervical & shoulder case on initial clinical examination.

Cervical Spine

Flexion                           -           ¾ range limited by pulling and discomfort in the right  neck and scapular area.

Extension                      -           Clear – No pain.

Right side flexion       –           80% (limited by right-sided discomfort).

Left side flexion          –          80% (limited by pulling and discomfort on

the right side).

Right rotation              –          80% (limited by strain and discomfort on the

right side).

Left rotation                 –         90% (limited by mild discomfort and pulling

on the right side).

Right Shoulder

Flexion                          -           full range           -           no pain.

Abduction                    -           full range           -           no pain.

Horizontal flexion     -           full range           -           no pain

Hand behind back     -           full range           -           no pain

These descriptors are particularly useful in establishing the likely tissue pathology but importantly also differentiating physiotherapy evidence from the routine evidence delivered from Orthopedic & Neurosurgeons – which in my experience never quantify the limiting factor other then stating  Ranges of motion (ROM).

Range of Motion – Revevance?

This issue is particularly relevant here because I was cross examined on this issue in the case we discussed last week.

The patient’s functional limitations where:

Sustained use of the arms particularly in overhead positions

Prolonged driving

Carrying

Sustained anti-gravity positions

The barrister enquired as to how the range of motion could be so good and yet she still described such functional limitations?

My reply was that it was like comparing apples and oranges. The functional limitations reported did not relate to movement deficits – they related to impaired tolerance for loading and sustain positions Therefore assessing range of motion was a somewhat irrelevant measure on from a clinical perspective. It shifted down the priority list (applied clinical reasoning) relative to the functional impairment.

Unfortunately this issue is rarely discussed in detail in a court of law because the surgeon’s evidence is often heavily weighted to range of motion findings and therefore these are considered to be important variables. I believe it is only when barristers are fully briefed on the pertinent aspects of clinical examination will the reliance on Radiology and ROM be surpassed. To achieve this there needs to be pre-court discussions analysing the clinical evidence and the line of question to be developed.

As clinicians we know that ROM is only one of a number of clinical variables and often has limited or no relevance in some clinical presentations. How many hypermobile patients with traumatic neck injuries have you seen where ROM has absolutely nothing to do with symptoms? How many fibromyalgia patients have restricted range of motion (greater than 20%?) and yet repeatedly describe a sense of tightness or muscle tension.

It is important that the role of ROM in a particular pathology be established in order to ascertain its relevance. This brings us nicely into another clinical marker which we as manual therapist use – Palpation.  Again I would consider this as a skill exclusive to physiotherapists and other allied health professionals and it’s an area where we have a proven to have particularly adept skills.  As clinicians when we palpate we are looking for a number of features related to tissue sensitivity.

Muscle spasm

Resistance to movement

Characteristic End-feel

Correlation with functional deficits

Correlation with primary areas of symptoms

These palpatory findings essentially form of an algorithm from which physiotherapists form a judgment – gaining a far deeper understanding of the tissue status.  The term muscle spasm is so frequently thrown around both clinically and legally without discussion of the underlying mechanisms and quantification of it’s relevance in the overall clinical context.

So, in conclusion, as we attempt to remedy the situation which will undoubtedly be an ongoing challenge, I encourage you to quantify the limiting factors in any clinical test procedure and take responsibility to define responsible structure s on the basis of examination findings. I think this will go some way to improving professional credibility- raising our perceived value not just within the legal profession but amongst our medical colleagues in musculoskeletal management.

Enjoy the clinical challenge

David

GHTime Code(s): f5ea6 

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