Post hoc ergo propter hoc is alive and well and living in our courthouses.
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Post-traumatic causation must take into account both previous patterns of illness and the incidence of unprovoked symptoms |
Since Socrates around 400 BCE boldly enunciated human cause-and-effect in defiance of the gods of Mount Olympus, man has struggled to understand the antecedents of unexpected experiences. Personal injury lawyers make it a career path.
Whether promoting or refuting injury as a cause of Low Back Pain (LBP), litigators need to consider the "spontaneous" incidence, prevalence and natural history of this most common symptom.
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"Spontaneous" onset Low Back Pain is so common that post-traumatic proximate causation is frequently suspect |
During any given month, about one third of the adult community will have LBP1. The main predictors of a new episode in current non-sufferers include not only a previous episode of LBP, but also current existence of musculoskeletal pain elsewhere2.
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90% of sufferers from a new episode of Low Back Pain stop consulting by 3 months, but the majority still have pain at a year |
As previously noted, the causes of most new episodes of Low Back Pain are unknown2. Although evidence of degenerative disc disease is common in sufferers, it occurs with increasing frequency and severity with age alone, irrespective of the presence of pain.
Until recently, the natural history of such episodes of pain was uncertain. From studies of subsequent consultations and work records, it was believed that 90% recovered within a couple of weeks and only 1 in 50 went on to chronic pain3.
A recent British community study4 confirmed relatively low repeat consultation rates within 3 months of the new episode, but found that the majority still had troublesome LBP after a year.
US investigators5 had asked general practice back pain patients how they would feel if they had the current severity of symptoms for the rest of their lives. At 7 weeks, and even at 1 year after an episode, only about 2 in 3 reported a good outcome. Depression and younger age were indicators of poor outcome at 7 weeks, and pain below the knee also portended a worse prognosis longer-term.
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Predictors
of poor outcome: |
An earlier study6 at a different US centre had identified major predictors of poor outcome as LBP-related disability, numbers of days in pain, lower levels of education, and female gender.
For a significant proportion of the adult community, troublesome low back pain is a recurrent experience, and medical records document only the tip of the iceberg. Establishing proximate causation by compensable injury requires more than proximity in time and the client’s attribution.
Because clinicians commonly have little training or interest in medical causation, attending physicians and plaintiff medical experts may be vulnerable to challenge on the causal connection.
Copyright © 2008 Electronic Handbook of Legal Medicine