Academy of Chiropractic Personal Injury & Primary Spine Care Program

Quickie Consult 1122
Lawyers and Medical 76 L

From the Desk of Dr. Mark Studin
Academy of Chiropractic

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

"Explaining Ligament Laxity-AOMSI to Lawyers"


Dr Studin: So the question is how do I explain to the lawyer why x-ray digitizing is important? and then from there, how to get them to realize it's in our mutual benefits even though the first consideration is the patient because it's going to change the diagnosis, prognosis and or treatment plan, but we just have to continue to identify and put out there that's the only reason to do this test and any tests because it changes your diagnosis, prognosis and treatment plan. Now that we've got that on the table and out of the way, let's talk about it purely from the lawyers perspective, you have a patient that comes in and by the way, we recommend a company called Symvetra. we've taken Dr’s work and we've modernized it. The engineering models updated it and they could do a lot more than just look for laxity of ligament or alteration of motion, segment integrity, but there are other platforms that do that. We just have to think this is the best in the industry that your patient comes in. Give me a setup for your patient. What's the clinical presentation?

Guest Doctor: so the patient comes in after a traumatic injury. In this case, let's just say it happened, could be a motor vehicle accident and they have pain in their cervical spine, shoulder pain, headache. the patient comes in and on exam there's no obvious neurological deficits they have decreased range of motion, a lot of muscle spasms, the patient really is not responding to care. Maybe I'm rehabilitation is making them a little bit worse, we have x rays on the patient. And what's important to discuss this, that we have what are called stress views on accent. So it's not just simply the patient standing in that static or stationary position. We actually have them bummed their neck while we're doing yesterday. And that's to give more of a functional sort of look at how the spine works when the patients during their normal daily activities. But it also gives us a window into the connections of the bones, which are the ligaments. Now in a lot of cases, those patients that aren't responding also, whether it's through maybe my office or a Michael Specialty Office, I also have an MRI and particularly of interest is one that MRI come back from a medical legal perspective, there's nothing really demonstrable on that MRI that links their pain syndrome, their injury to something structurally that is entered like say at this clinic. So in these cases we want to really look at alternative wasting demonstrating that injury.

Dr Studin: I practice a little different than you, first of all, the distress x-rays, basically a date series is what you're talking about, it is my protocol in every trauma case to series on the cervical spine. Because I need to look to see if there's ligaments involvement and bio mechanical failure as well as osseous involvement and get my listings. Then in the low back, I do AP lateral two old leaks cause I got to see if there's a license, and they'll do fluxion extension again because I'm looking at biomechanical failure. when the patient comes in from me and I see pain, muscle spasm, range of motion, I'm or automatically doing biomechanical stress studies. But that's my care-path. I will do a baseline in the beginning of care and that tells me what's going on with that patient for a biomechanical failure. Now it might be muscle spasticity holding the vertebra, it might be ligament issues, but if there's ligament issues, that's going to move too much, not too little, but then when I get the MMI then I'm going to do a follow up to see what residuals are there and I'll know how to order my treatment plan, for the patient for the future to treat them palliatively. what we're doing in the flection extension x-ray specifically, we're looking, and here's the what we explained to the attorney and according to doctor, who's been doing this for 30 something years, And this is not published in the literature, this is his experience. Approximately 70% of all whiplash patients, a flexion extension cracks in the patients have ligament damage in their spot and the majority of them are relatable. With that being said, what we do is we measure bone moving forward and backwards, one at each motor unit and combined, if it's greater than three and a half millimeters in the cervical spine and four and a half millimeters in the thoracic or Lumbar, it's a ratable injury. You could do that pretty much off the X-ray with a ruler. Here's what you can see, it’s angular deviation. If there's greater than 11 degrees angular deviation looking from the ADP model for the Vertebra above the vertebral below that is unreadable. and that's the part that's missed for most doctors. Now, from memorial's perspective, we know and it goes back to the former superintendent or state farm of who said there's a $60,000 case reserve if there is lax of the ligament diagnosis, we also know that you can rate that and that's rated at the 25% whole person impairment to actually take 25 to 28% whole person impairment. which seems a lot to a lot of lawyers, but it's right out of the guides. However, here's the issue if you don't have an impairment rating, and this is what you need to explain to the lawyer, there are four quadrants of Colossus. Number one is pain, neurological issues. That's MRI, EMG, SSEP, X-ray a and Ortho, neuro, Chiro, etc. All your medical findings are with 25% settlement value to the attorney. Now you have an impairment rating that's worth 25% then duties under the rest of the loss of enjoyment of life duties under duress means that I can still do, but to a lesser degree, and it's impaired my ability to function at my job, I was promotional prospects, etc. And the last quadrant is what I can no longer do a called code loss of enjoyment of life. What I can no longer do after a reasonable course of care is concluded. That's your last 25% quadrant. However, the Colossus Algorithm is written on purpose, because they know that the medical providers are not giving impairment ratings without an impairment rating. It doesn't consider duties under duress of loss of enjoyment of life. So the impairment rating really is valued at the 75% of your settlement offer, assuming you have the rest of the information in there. So you need to explain to the attorney, and according to case reserves is signed to lax of the ligament, they start with $60,000 top number. Each carrier does it differently and the carriers are getting wise to it and they're changing their algorithms as you speak, but the carry your stolen don't want you to have all this information and the attorneys are going to say: “oh, I'm not a lawyer, I'm going to work as comp lawyer, I don't do that.” And you say to the lawyers, listen, I work with a loss. Here's what I said to one lawyer just yesterday. I worked with a lot of lawyers, not you, but a lot. This was in Texas. and some lawyers just don't want to put an apparent rating. it's not what they're used to. It's not your talk, because that's about courtroom stuff. That's your thought. But this is settled which is 99% of your income. It's worth 75% of your settlement value. And that's what I said to this lawyer and he says, well, I don't really need it. I said to myself, this guy like the dinosaurs, you don't want to change, because they have their business models upside down. So basically I told the lawyer I was talking about someone else, but really I was talking to him directly because they need to understand that they don't have to like it, not like it, agree with it, disagree with it's real, and I know that factually because some insides and speaking to the attorneys and the adjusters, I'm on most every insurance company in the nation. I think that pretty much explains how you need to do with the attorneys and how to explain it to them. Is there anything we missed?

Guest Doctor: No, but I wouldn't like to just take like two seconds to summarize it. And this is again, probably for the attorney to listen to. When you're looking at ligament laxity, and you had mentioned it perfectly that the AMA guides to the evaluation of permanent impairment give an impairment rating of 25% for the whole body for the ligament injured. And I would say that 90% of traumatic injuries that do not have the monitorable bodily injury on MRI, we'll have these types of injuries, but the attorney needs to think of it from an alteration of motion segment integrity That's what the MSI stands for. Now, if a patient or a client walks into a lawyer's office and they say, Hey, I was in a motor vehicle accident and I had a fusion surgery done, so maybe I had some six years, that is one book end of alteration of motion segment integrity. The surgeon uses it, those two vertebrae become one and that motion in that segment is permanently altered it surgery and everybody understands that surgery is a big deal. Those are easy, but the other book end of that’s segment is not moving because it's fused and the ligament laxity side, that's the opposite of that level of injury, it's moving too much. So those are equivalent injuries in the eyes of the guy, but I think a lot of attorneys don't realize that, and a lot of doctors don't measure it. That's the number one reason to measure that because you're finding underlying injuries that really have permanent toxic effects for the patient. 

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