What Is The Difference Between Exacerbation and Aggravation?
A CASE STUDY FOR LEARNING.
A 28 year old man injured his low back at work while doing repeated bending and lifting. He had a well documented pre-existing low back pain history with lumbar spine imaging that showed moderate to severe degenerative changes.
His base line back pain was 2/10 and occasional. His work injury increased his symptoms to 8/10 and constant. The claim was accepted.
Treatment consisted of anti-inflammatory medication and therapy. Repeat imaging confirmed his degenerative pre-existing low back pain condition.
He was found to be a non surgical candidate. He was referred for impairment rating with the claim being nearly three years old at referral. He remained on light duty these entire three years.
At impairment rating, he was obese, and his lumbar spine exam demonstrated no ratable findings (i.e. WPI =0%). It was discussed and agreed upon that the employee would perform a trial of full duty, although his pain was still above his pre-injury baseline.
The employee was opined to be at maximal medical improvement (MMI). He was provided a provisional opinion that his pre-existing low back condition had been “aggravated” on an industrial basis. Future care was outlined, and it was asked he follow up in three months for an update on his clinical status.
At four months, the carrier provided additional prior chart documentation for review, which contained no new contributory information.
A symptom review update was carried out the employee, and it was learned that he was tolerating work at full duty without problems, and his back pain had entirely returned to his pre-injury baseline without the need of increased supportive treatment (i.e. more pain medications or an “increased burden of treatment”).
A summary supplemental report was issued which documented the return of the employee to his pre-injury baseline. The opinion of causation was revised based on new and additional information which found the employee’s back pain to now be best described as an “exacerbation”.
No further future care was indicated, the impairment rating remained WPI =0%, and no further treatment on an industrial basis was recommended. The employee was discharged as cured.
There is often confusion about the terms “exacerbation” and “aggravation”. This case nicely demonstrates these “words of art” and how they apply to clinical situations.
The claim had been appropriately managed with conservative care, and the employee was a non surgical candidate. He had become MMI. He had not, however, been returned to a trial of full duty.
If this were the end of the story, his condition would be considered an industrial “aggravation” of his pre-existing low back pain.
The AMA Guides 5th Edition, Glossary, page 599, defines an “aggravation” as, “A factor(s) that adversely alters the course or progression of the medical impairment. Worsening of a preexisting medical condition or impairment”. More specifically, in clinical terms, a permanent “aggravation”.
There was a clinical opportunity here, however, because the employee was very motivated to return to work. He was assured that after a thorough examination and review of his imaging studies, his pain was “not dangerous” and he should consider a trial of regular work, given that his current restrictions were based only on tolerance of symptoms, and not risk or capacity loss.
He was furthermore reassured that if his symptoms worsened, he would simply return to clinic for replacement of his tolerance limitations. He agreed.
The story ends happily, as the employee not only successfully returned to his usual and customary work, but the pain also returned to pre-injury baseline.
An adequate trial of full duty for four months had been performed without “recurrence” of his low back symptoms. At this time, the opinion was revised to describe his condition as an “exacerbation” as that term is defined on Table 10-4, Chapter 10, Causation, of the AMA Disability, Second Edition, “Temporary worsening of a prior condition by an exposure/injury”.
Keys of Review:
• The AMA Guides 5th Edition, Glossary, page 599, defines an “aggravation” as, “A factor(s) that adversely alters the course or progression of the medical impairment. Worsening of a preexisting medical condition or impairment”.
• This condition is best defined as an “exacerbation” as that term is defined on Table 10-4, Chapter 10, Causation, of the AMA Disability, Second Edition, “Temporary worsening of a prior condition by a exposure/injury”.
• If the employee is motivated, and present restrictions are based only on tolerance, and not risk or capacity loss, consider a trial of full duty. Fear on behalf of the employee can be managed with adequate review of the physical exam findings and imaging if clinically appropriate. Agree on a clinical follow up plan to decide if future care management is still indicated in the claim, and further support your recommendations. This approach may minimize industrial morbidity and allow the employee to play a decisive role in the ultimate outcome of their injury.