Academy of Chiropractic Personal Injury & Primary Spine Care Program
Quickie Consult 1083
Narratives 86 N
Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time. -Mark Studin 2006
"Static and Stable MMI"
Dr. Studin: what's your questions?
Guest Doctor: the question is between static and stable as to, with the consultation you sent out. we wouldn’t us want to use the stable instead of static as far as after MMI treatment?
Dr. Studin: Okay. So just to be clear, I want to make sure that we explain what static and stable means. Static means permanent and stationary it and they never getting better. Stable means there's still some ways to go. It could stabilize these stabilized, but along the way you're still making progression. Once you hit MMI okay. And that's the key. Once you ascertain MMI has been attained. Now let's talk about that because that's going to go into really answering the full context of the question. If you're doing it the old-fashioned way, muscle testing, range of motion, ADL’s, all of those things go into ascertaining a static or stable MMI and I always prefer using computerized versus manual because now you have at least the, you know, verification that the muscle testing and the range of emotions within 10% where he repeats, you know, and you're familiar with that. Yes?
Guest Doctor: Yes, Correct.
Dr. Studin: Okay, great. Now I prefer and when I practice, I did ASBE, Applaud Spinal by Mechanical Engineering from Arizona, which was incredible. And it was all about having the patient bend, look at the individual motor units to see if the Vertebra rotated, less than it was supposed to or the opposite direction to show if they've actually attained MMI, because you can actually see normal motor unit, you must understand it so far, don't have to explain any more of that.
Guest Doctor: No. Got It.
Dr. Studin: Now, that we have doctor weekends work and then Symvetra, which is the next generation which has been released now we could look at a simple fluxion extension or even the static view.
You're able to see that vertebra when it's really stabilized because you're going to re x-ray periodically knowing that the x-ray radiation is not going to do any harm the literature is clear about that we've discussed that. Now you've got a method to verify that they're still making progress or that they've stabilized. With that being said and having tools to use. Now you, when you obtain MMI, the patient is static and stationary, however they go back into their repetitive lifestyle. Okay. Bend and stretching, you know, lifting, carrying, pulling computers, you know, all of those things and the area and the joint can regress back to the area prior to MMI, they can regress. Now I'm not using the word destabilized cause I don't want to confuse that. Okay.
I think those are bad words because there's much too much confusion. But the words can be, the joint can regress back to a point prior to MMI. Now you've got to treat them again periodically to bring them back to that MMI point, but they're never going to get better beyond that MMI point. So, you're going to bring them back, but they're still static because it's never going to go beyond that point. So, you diagnose this is static at that MMI point. Now, that's your goalpost. Okay. Or your substandard where you need to be. And if they regressed beyond that, you've got to bring them back there. But you never going to get them beyond that because you've already deemed that static, permanent and stationary. Does that explain it or is it still a little confusing?
Guest Doctor: Yeah, that explains it. I was just, I've used doctor Schoenfeld’s narratives and then when he writes stable, he writes a state where little, if any immediate changes expected and further periodic care will be required to re-stabilize the injured joint preventing future worsening. So, I was a little confused between….
Dr. Studin: Dr. Schoenfeld and I had many conversations about that as recently as last week. Um, and he's cleaning that language up also. So, now understand something, this is more of a function of the insurance industry nomenclature of static and stable. Um, but we're trying to create a level of standardization within that and it's challenging because you've got, you know, um, what doctors use when insurance companies use what lawyers use and you're trying to create a consistent message that's clinically accurate and that's the most important thing. So, I would change that language in that report from Dr Shenfield saying the patient has the same static MMI or maximum medical improvement in parentheses, MMI. We never want to abbreviate.
However, the patient due to their repetitive lifestyle and occupational lifestyle, not sure not might, but oh, actually you could determine that based upon the connective tissue pathology as sequella too. You want to write this down because I'm never going to remember this.
Guest Doctor: I'm trying to,
Dr. Studin: Again, based upon the connective tissue pathology, when these things come out of my mouth was like God talks to me. It's not me talking. I have no idea where it comes from. Okay. Based upon the connective tissue pathology as sequella too, the bodily injuries from the accident on January 1st you know, whatever the date is, the ability for the joint to permanently hold in a normal biomechanical scenario has been compromised.
The patient will need periodic rehabilitative care to bring back joint back to their static MMI point to prevent advancing quickening. So, I put advanced degeneration quickening of premature MMI. It's not premature. What we're doing. It is premature, but it's going to happen anyhow, but we're just delaying it. So, what word should I use?
Guest Doctor: Uh, prevent future worsening. Prevent Future.
Dr. Studin: You are not preventing it. It's going to happen to delay premature degeneration. Because once the ligament has gone and collagen in the last 10 or replaced only with Collagen, now there's internal adhesions there. Even like gristle and steak, it's never going to get better. So, what's going to happen is when you go back in your repetitive lifestyle motion, that joints can be constantly malposition then based upon Wolff's law and the PA's of electric effect, the bones going to remodel.
It's not even a question not putting that shit might not end well, and by the way, Julius Wolff has become my favorite dude in this whole conversation, and he has been for the past, because we know a bone out of position that someone’s going to Remodel. And the reason that remodels is the PSO electric effect, and to stabilize the body wants to create an electrolyte homeostasis. So, we know that that's going to happen. That's going to suck calcium from the bone. It's going to lead to you and it's going can change the morphology of the bone and then that person, there's going to prematurely degenerate. So, we, you know, all of those things, okay, we know that's going to happen. So, when they regress back from that aesthetic MMI, that's static MMI point is going to cause premature degeneration.
We know that, but when they regressed, it's going to advance that and create pain and other issues because now remember the little clique and the facets with the no susceptive being activated, when the presets approximate or rub, we know it's going to fire and then it's going to go up to the brain. Currently it's going to go back out to despair, muscles for the body to pull in different places to try to create a homeostatic human being. You know that plum line front and sides you, so it's going to pull left, right, left, right to the spine. You know, front and back sides the side to create homeostasis, Biomechanically. When it does that, then all of a sudden, the body's going to start to remodel, but if you don't fix that periodically, that muscle patterns is going to remain static.
That little body, you'll change it a little bit, but it's going to remain static because it's static around that, that biomechanical failure. Then it's going to hit Tetris because the muscles are eventually going to hit Tetris, once it hits Tetris, you're screwed unless you break that type of stuff, which is challenging. But once you hit it, then that bone will lock in that wrong position and now that cascade continues, and once that bone remodels your patient has gone from corrective care to management, you'll never fix them like high blood pressure, diabetes, you never fixing them. They're just managing them. There's no solution. But if that bone remodel, there's not a chance in hell that you can plumb that spine because the foundation is crooked there. Now you understand. I mean, I just want, and I know you've been through the training, you understand that, but just think of where we started from static MMI.
Now all of a sudden your patient's permanently, you know, screwed up and they've got to manage them. Boy, I wish I recorded what I just said, but guess what we did.
Guest Doctor: Yeah, you did. That was the best part of that.
Dr. Studin: Well, I got to tell you, I've learned that there's so much that I say and I just like, what the hell did I just say? But is there anything I left out that you'd want to add that you'd want anyone else to know that are listening to this? this is a critical topic.
Guest Doctor: Yeah, that clarifies that. So, I just got to change that wording in there and that, that makes complete sense.
Dr. Studin: Okay. Please do me a favor. Change the wording, email to doctor Schoenfeld and email it to me. Cc Michael and say, is this the wording you want me to use? Send it to Michael and myself this way we'll create some synergy. And Mike is Mike, he's just incredible proofer and he understands it, so he'll be able to polish it up maybe a little more. Okay?
Guest Doctor: Thank you.