Academy of Chiropractic’s Doctors PI Program

Narratives 64

From the Desk of :


One of the most common requests in the medical-legal community is to apportion injuries in patients/clients with multiple accidents. It is always (yes an absolute) a requirement to determine what bodily injuries are attributed to what trauma, which clearly defines the word causality. The #1 cause of attorneys losing cases is for lack of causality and in cases with multiple traumas the opposing side tries to assign the cause of the injury away from their clients (insurance company) responsibility.

Personally, I do not care who is responsible as my job is to treat my patient and get them well. However, I have a responsibility to my patient and the truth to be able to assign causality to the best of my ability in an ethical manner. The following tutorial is designed to make the entire process both easy and demonstrable. Please understand that the word “demonstrable” is required in a legal proceeding and where you must defend yourself in most cases. Therefore, it is important you understand the full process and memorialize how you arrived at your opinion (show your work just like in grammar school math) because you will often have to defend your opinion years after you arrived at it.

The most obvious place to start is an extremely detailed history of each accident and in this scenario complaints per body part is critical. In addition, you then look at clinical findings (examination findings and often IME reports are quite detailed in a full recounting of the history. They do have some positive value!) and then test results such as imaging or electrodiagnostics. Once you have these three pieces of the puzzle, you then need to create a simple sheet of paper that is divided. In this tutorial, we are going to consider a patient with three accidents.

As you can see below, I created 3 columns, a simple hand-written piece of paper with lines will suffice. This way, you will have a visual (demonstrative) representation of each injury. Next, you need to assign what each column is for. 

From here, you start to build your data and in the end, becomes a process of elimination. You need to add findings from all 3 accidents in each column. I will create each column separately as an example.

As you can see, I have posted the symptoms from each accident. Next, we need to build the clinical findings and then assign what accident is responsible for what symptom. It is here that can get a bit confusing as I am ONLY going to consider “relatable” and significant examination findings. As I am looking at today and must consider causality, the previous clinical findings are not the primary arbiter; only today is. Also, please understand this is NOT an exact science, it is OPNION… Yours and you get to be right, but again it must be demonstrable at best and clinically accurate at worst if there is no demonstrable proof.

The next step is to document the clinical findings:  

Now the fun starts!!!!  You must start cross-linking what symptom matches what the original “causal date” is. You need the original date because it will help you understand what is an exacerbation, what is an aggravation and what is new. 

Definitions: Causal Relationship – Exacerbation – Aggravation


Although you must always apply the definitions, interpretations and standards of the jurisdiction in which the case is filed or to be heard, the most commonly referenced resources for determining cause and causal relationship are the Federal Employees Compensation Act (FECA) and the Guides to the Evaluation of Permanent Impairment (4th and 5th editions, published by the American Medical Association). Many states have their own variations of these definitions and standards. Direct Causation: This term refers to situations where the injury or factors of employment result in the condition claimed, through a natural and unbroken sequence. Aggravation: If a pre-existing condition is worsened, either temporarily or permanently, by a work-related injury or car accident, that condition is said to be aggravated. Therefore, an aggravation of a pre-existing condition must include a stimulus that worsens the status quo of a susceptible condition. Temporary aggravation implies that the "aggravation" is temporary or self-limited, causing only a transient increase in symptoms, without persistent effect. This is sometimes referred to as an "exacerbation" and usually involves a limited period of impairment and/or medical treatment, after which the worker returns to his or her previous medical status. Permanent aggravation occurs when an "aggravation" causes permanent changes in the natural course of an ongoing condition. A permanent aggravation alters the natural course of the preexisting condition, accelerating or worsening that condition, such that it will never return to the pre-injury state.

The next step is to assign the first accident clinical findings followed by the test results. I usually do everything in 1 step to make this a time-efficient process, but for the sake of teaching, I will break it down in many steps. 

Now add the test results from accident #1 and link them. You can now assign causality to the herniated discs on the January 2015 and the entire incident is in black lines. 

Next is to look at 2016 and determine what is causally related as either 1) new 2) exacerbation or 3) aggravation. I am also going to cross-link both clinical and test findings in the next step. 

The light blue solid line represents the causally related findings from 2016. You will notice the “Cervical Pain Left” a black line. That is because I have assigned causality of the 2016 cervical pain to the 2015 accident. This is the first sign of an apportionment of a second trauma to a different accident and will factor into the end equation. 

Now we are going to add the third accident and assign once again, both the symptoms and test findings. 

Here is the REALLY, REAALY FUN PART… WE put it all together where the following step is the finalize the apportionment.

You need to follow the 3 threads:

Accident #1: Black

Accident #2: Blue

Accident #3: Red

Everything caused from accident # 1 is in black with a dotted line from accident #3 showing in this case, it is an aggravation from accident #1. This pictorial representation (demonstrable explanation) also CLEARLY shows the bodily injuries and the verification. There are many cases where it is not as clear-cut as the sample I created. Many will have EMG’s, CT scans, etc., while others will have ZERO test results. This is where your experience must prevail. 

NOTE: Before I conclude the consultation, which is coming shortly, the rule of this consultation is that you must figure this out independently before I work with you to explain how to do it. Therefore, you must read this 5 times or more and then create a sample to “play with.” If you call me, you must use the password “Leave me alone” for me to help you. This will signify that I know you have at least read the entire consultation. Too many are lazy and want me to teach them individually and this takes a lot of time. That is something I don’t have, which is why I took the time (15 hours) to create this tutorial for you. This is also something I have been working on for years to be able to get this in a digestible format. 

When you look at the last chart, it is purely “connect a dot” where you get to see where everything is coming from. Now you can apportion causality. 

NOTE: I suggest you print out the last chart and place it next to the computer so you can play “connect a dot” in following my logic.

Accident #1

Cervical Pain – HNP C4-5, C5-6        100%

Accident #2

Cervical Pain – Exacerbation with causality 100% from accident #1

Right Knee Pain – Partial Tear Anterior Cruciate 100%

Accident #3

Cervical Pain

HNP C6-7: 100% accident #3 (and right hand numbness)

Aggravation HNP C4-5, C5-6: 70% accident #1, 30% accident #3 (because the pain scales increased while also acknowledging there is a new herniation)

Right Knee Pain: 100% accident #2

Lumbar Pain 

HNP L4-5, L5-S1: 100% accident #3 (no radicular symptoms prior) 

Sleep Loss: Accident #3

Headaches: 100% Accident #3 verified by DTI 

CASE #2: The entire case is in the graph and it is usually this easy