Causation. Dual Challenge for Clinicians. Gary J. Levine, Esq. Attorney at Law 369 South Main St Providence RI 02903 401.521.3100 email@example.com. Steven G. McCloy, MD. Axiom Occupational Health, LLC 100 Smithfield Avenue Pawtucket, RI 02860 401.312.0545
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Dual Challenge for Clinicians
Axiom Occupational Health, LLC
100 Smithfield Avenue
Pawtucket, RI 02860
Clinical Assistant Professor of Medicine,
I/we have no financial interests relative to this presentation.
Patient developed knee pain while walking back to the cash register. Causality: work-related.
CLAIMANT'S KNEE STRAIN IS IPSO FACTO AN ON-THE-JOBINJURY. EMPLOYER FAILED TO REFUTE THE CAUSAL NEXUS,ESTABLISHED BY CLAIMANT'S EVIDENCE, THAT HER INJURY WAS NOT THE RESULT OF AN IDIOPATHIC EPISODE.
Bill of particulars
Per se doctrine
prima facie case
PAULS VALLEY TRAVEL CENTER v. BOUCHER2005 OK 30 112 P.3d 1175 Case Number: 100169 Decided: 05/03/2005THE SUPREME COURT OF THE STATE OF OKLAHOMA
Medical Causation is physical or biological in nature.
The legal definition may vary from state to state and between states and the Federal law.
Legal Causation has two components:
Cause in fact: the occurrence of an event brings about a result
Proximate cause: relates to the predictability or remoteness of an event.
Pain and Swelling (first time),
Second injury, giving way
MRI for medial meniscal tear
What about prior abnormal anatomy?
Cause in fact?
Arising out of and in the course of his or her employment?
Connected and referable to the employment?
The Leaky Secretary
[We should all groan at this point because low back pain is so common, so difficult and so important.]
NIOSH process for determining work relatedness
What is the disease? How certain are you? What evidence supports/does not support the diagnosis?
What is the epidemiologic evidence for that condition? Is there support for a relationship to work?
Is there evidence that exposure was of frequency, intensity and duration to support work-relatedness?
What other factors are present in this case?
Is there information to suggest that the history, etc. are inaccurate? Is there corroboration?
Source: Glass, p. 60.
Is there evidence of disease?
Is “degenerative disk disease” a “disease,” or is it a factor of normal aging processes in the spine?
Studies of normal people with NO history of back pain lasting more than 24 hours show that one-third of people under age 39 have DDD. In those aged 40-59, 59% have DDD. Over age 60 shows DDD in 93% of MRIs. (Boden, SD, Davis DO, Dina TS et al. 1990. Abnormal MRIs of the lumbar spine in asymptomatic subjects. J Bone Joint Surgery 72A:403-8.
Is there epidemiologic evidence to support this diagnosis?
Is there evidence of exposure?
Are there other relevant factors that might affect causality?
Prior injury? Prior back pain?
Age and gender
Other spine disease
Low education and income levels
Elevated Score of Scale 3 of MMPI
Small JW and CM Kalina. Facilitating return to work: Transitional duty and case management. In, Derebery J and JR Anderson. Low Back Pain. 2002 OEM Press.
Hall, H, et al. Spontaneous onset of back pain. Clin J Pain 1995;14(2):129-133.