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Permanent impairment case study - endocrine system

The following case studies relate to injuries to the Endocrine System.

More detailed information regarding the assessment of injuries to the endocrine system may be found at Chapter 8 of the permanent impairment guidelines and Chapter 12 of the AMA4 Guidelines.

We make no warranties or representation about the accuracy or completeness of the information contained in these Case Studies. It should be noted that the information contained herein is not provided as a substitute for legal advice.

Case Study # Brief Description Primary Body System Secondary Body System
E1 Aggravation of diabetes Endocrine  
E2 Type 2 diabetes mellitus Endocrine  

Injuries

Diabetes- aggravation due to weight gain and inability to exercise

Date of Birth: 7 March 1948

Date of Motor Accident: 4 September 2007

The claimant was injured when an oncoming car crossed into his lane. The claimant swerved to the right to try and miss the vehicle, but his car was hit on the passenger side, causing it to skid and he ended up facing in the opposite direction.

He was diagnosed with Type 2 diabetes in 1995 ie. 12 years pre-accident, after presenting with classical symptoms of hyperglycaemia. He was commenced on a diet and exercise and Diabex tablets. His diabetes control can be assessed by measurements of a glycated haemoglobin test which gives an indirect measure of the average blood glucose level over the preceding 2-3 months. The non-diabetic range is 4.0-6.0% and good diabetes control is considered to be the situation when the value is <7.0%. I have details provided to me since 2002 and in November 2002 the value was 6.7%, June 2003 7.0%, February 2004 6.7%, November 2004 9.0%, February 2005 6.5%, August 2005 7.4%, February 2006 8.3%, May 2006 8.1%, August 2006 8.2%, April 2007 8.4%, and August 2007, just prior to the accident, 8.1%. It can be seen that his diabetes control had progressively deteriorated over those 5 years and had not been ideal particularly from February 2006. Records of his weight were also provided to me and in August 2007, he was 117.6kg. He states that he had regular eye checks for diabetic retinopathy and that there were mild changes present but he never required laser therapy.

The claimant was known to have coronary artery disease having had a myocardial infarct in 1993 and he had suffered from hypertension since 1975. He was also diagnosed with primary hyperparathyroidism in 1999. He had suffered from angina since 2000 along with sleep apnoea, was diagnosed with post traumatic stress disorder in 1968 and was also diagnosed with Alcohol Dependence from his time in the Armed Forces from 1965 to 1974.

Clinical examination

The claimant weighed 119.7kg and was 165.5cm tall. This gives a Body Mass Index of 43.8 (normal 20-25), indicating significant obesity. The ideal body weight for a man of his size is 56-70kg. There was no obvious diabetic retinopathy, there were reduced pulses in his feet but there was no objective evidence of peripheral neuropathy with his ankle jerks, vibration sensation and monofilament sensation being normal. His BP was raised at 140/90. In addition he was somewhat restricted in his gait.

Diagnosis and causation

The claimant states that prior to the accident he was on an exercise program to assist weight reduction, paid for by the Dept Veterans’ Affairs. He states that he attended the gym for 1 hour twice per week where he worked on weights, a treadmill for 20 minutes and performed aqua aerobics in a swimming pool. He states that he also exercised in a pool on occasions and walked on an oval for up to 1 hour per day. Since the motor vehicle accident, he states that he is unable to exercise significantly as he gets pains in his feet and legs (mainly calves and knees) after walking 30-40 metres and the symptoms take 20-30 minutes to subside. In addition, he does get angina with exertion and this on occasions would limit his exercising ability but there was no evidence that this has been worse since the accident. As far as his weight is concerned, there clearly has not been any weight gain since the accident.

Consequently, there is no evidence that weight gain can be implicated with respect to aggravation of his diabetes but there is evidence that his ability to exercise has been impeded since the accident. I do not have details regarding his diabetes control since the accident (such as glycated haemoglobin values) but Type 2 diabetes is known to be a progressive disorder whereby the pancreas produces less insulin with time and consequently it would be expected that his glucose levels would increase as time goes by and thus it would not be surprising, in the absence of any additional therapy for the diabetes (until recently) that the glycated haemoglobin would increase. Despite that, regular exercise reduces insulin resistance and can reduce the rate at which blood glucose levels increase over a period of time and the inability to exercise since the accident therefore potentially would have had a detrimental effect on his diabetes. My view is that, particularly taking into consideration his long standing obesity and his poor diabetes control prior to the accident, is that the inability to significantly exercise since the accident would only have had a very small impact upon his overall diabetes.

Impairment evaluation

  Body Part or System AMA Guides/ MAA Guidelines References (chapter/ page/table) Permanent (YES/NO) Current %WPI* %WPI* from pre-existing OR subsequent causes %WPI* due to motor accident
1. Endocrine Chapter 12, page 271- 272 YES 7% 4% 3%

* %WPI = percentage whole person impairment

The total degree of permanent impairment of those injuries caused by the motor accident which I have assessed is 3%.

Injuries:

Type 2 Diabetes Mellitus

Date of Birth: 2 November 1949

Date of Accident: 21 May 2004

Clinical Examination

Impairment Evaluation

Any queries in respect of the methodology used in assessing permanent impairment may be directed to the WPI e-mail enquiry service at wpienquiry@maa.nsw.gov.au. This service is operated by the Injury Management Branch of the MAA who are responsible for the content and publication of the MAA Permanent Impairment Guidelines.