by Dorothy C. Sims, Esq. Trauma, no matter how mild, has the potential of aggravating or worsening any pre-existing degenerative disease of the spine. Often the defense medical expert will claim all symptoms of a back injury are due to a prior degenerative disc disease.  This may be claimed in spite of the fact that either the patient was completely asymptomatic before the trauma or the symptoms worsened significantly immediately after a trauma. References.

 “It has been reported that pre-existing degenerative changes, “no matter how slight,” adversely affect the prognosis.”    SOURCE:  Norris SH, Watt I. The prognosis of neck injuries resulting from rear-end vehicle collisions. J Bone Joint Surg. 1983; 65B: 608-611

“Chronic neurological sequelae develop after a single acute or multiple chronic traumatic episodes to the cervical spine and spinal cord.” SOURCE: Richard C. Schneider and Robert Knighton . Chronic Neurological Sequelae of Acute Trauma to the Spine and Spinal Cord: Part III The Syndrome of Chronic Injury to the Cervical Spinal Cord in the Region of the Central Canal. J. Bone Joint Surg. 1959; 41:905-919

“The high incidence of cervical osteoarthritis and spondylosis observed in those presenting years after acceleration/deceleration injuries suggests a very strong causal relationship, especially when the disease is localized to one or two levels”. SOURCE: Foreman Stephen M., Croft Arthur C. Whiplash Injuries: The Cervical Acceleration/Deceleration Syndrome. 2nd edn. Philadelphia, Lippincott Williams and Wilkins, 1995 p-340

Although we suggest that mechanical loading precipitates degeneration, the most important cause of degeneration could be the various processes that weaken a disc before disruption, or that impair its healing response. The combined effects of an unfavorable inheritance, middle age, inadequate metabolite transport, and loading history appear to weaken some discs to such an extent that physical disruption follows some minor incident. A common example is that of disc herniation following a cough or sneeze. It could be argued that such a weakened disc should be considered degenerated, even if it remains structurally sound. However, a disc is unlikely to become painful until it becomes disrupted, so there is little to be gained by anticipating future events and applying the term “degeneration” before this crucial nonreversible event actually occurs. As suggested previously, accelerated biochemical or cellular events in a structurally sound disc could be designated “early degenerative changes” to distinguish them from changes that are entirely typical of the disc’s age. The multifactorial nature of disc weakening suggests that, from a medicolegal standpoint, all discs are “vulnerable” to a greater or lesser extent, and the vulnerability can only be gauged from the violence, or otherwise, required to disrupt the disc and initiate degeneration.

The underlying cause of disc degeneration is tissue weakening occurring primarily from genetic inheritance, aging, nutritional compromise, and loading history. The precipitating cause is structural disruption occurring from injury or fatigue failure.

Adams MA, Roughley PJ. What is intervertebral disc degeneration, and what causes it?

Spine. 2006 Aug 15;31(18):2151-61. Review.

“When symptoms are more severe or progressive despite the use of a collar and when they occur in younger patients, operative treatment may be necessary”.  SOURCE: Way Lawrence W, Doherty Gerard M. Current Surgical Diagnosis and Treatment. McGraw Hill 11th edn 2003, New York, p- 1209 }

Consider the following in attempting to save money on prescriptions:

Ø      l. Check out www.needymeds.com, a nonprofit web site devoted to assisting financially needy individuals in obtaining medications.

Ø      2. Always ask for generic if your physician says it’s ok.

Ø      3. Buy more.  You can save money if you purchase a 90 day mail order rather than a 30 day.

Ø      4. Ask your doctor for free samples.

Ø      5. Ask your doctor if he can double your dose so you can save money by splitting your pills in half (check with your doctor first as some are time release and this can be very dangerous).

Ø      6. Consider major discount pharmacies for the best deals such as Costco and Target.  You can get many generic drugs for $l0.00 for a 3 month supply.

Ø      7. Check out www.pparx.org to see if you qualify for free or inexpensive medications from  the “partnership for prescription assistance” program.

Ø      8. More excellent sites:  www.rxassist.org ,  www.freemedicinerevolution.com and www.freemedicinefoundation.com

As such, the ethical standards do mention the fact that the orthopedic surgeon should review medical records to give his opinion. This information is provided in the Code of Ethics published by American Academy of Orthopedic Surgeons.

In the Code of Ethics and Professionalism for Orthopedic Surgeons published on website http://www.aaos.org/about/papers/ethics/code.asp  it is mentioned that:

                  “In providing testimony, the orthopedic surgeon should ensure that the testimony provided is non-partisan, scientifically correct, and clinically accurate”.

Dorothy Clay Sims, Esq. ~ Sims, Stakenborg & Henry, PA. 

• Offices in Ocala, Marion County, Florida and Gainesville, Alachua County, Florida. We provide service to the surrounding areas. Our telephone number is: 352-629-0480. Please visit our website at: www.ocalaw.com
• Giving the Attorney the Competitive Edge……….Check out www.mdinabox.com

Post-Traumatic Stress Disorder/anxiety based disorders – How to Test for It.  How to prove it. 

First, remember that you do not have to prove you have PTSD to be entitled to disability  benefits.  There are other psychiatric disorders that can be caused by stress that may not rise to the level of PTSD, but still be related to incidents that occur overseas. 

Proving Post-Traumatic Stress Disorder can be quite difficult. Not because it doesn’t exist or may be even clearly identifiable by the treating doctor but because of the prejudices juries, judges, and administrative law judges may have regarding the disease. Defense experts frequently claim that particular symptoms or particular timing of a symptom is proof that if the patient does not have PTSD.  This is contrary to the American Psychiatric Association’s definition of criterion for this disorder[1]. The treating doctor is urged to go the Diagnostic and Statistical Manual as well as other protocols published by the Veterans’ Administration, the American Psychiatric Association which set forth the criteria for diagnosing Post-Traumatic Stress Disorder. The defense medical expert may very well claim certain criteria exist but when forced to produce science to support that conclusion rarely are there any peer reviewed journal or publication that supports his/her method.

Since there appears to be a prejudice on the part of many judges and many jurors in regard to PTSD (it’s not real, too easily faked, etc.) the treating doctor  is urged to consider  the possibility of objective measures such as considering the following:

1.      Treating doctors may rarely provide any kind of Post-Traumatic Stress Disorder test or screening scale. Therefore, the treating doctor may consider the possibility of actually administering Post-Traumatic Stress Disorder tests to determine the specific symptoms of the disorder.

2.      Research reveals that individuals with Post-Traumatic Stress Disorder actually have, contrary to what one might expect, lower than normal decreased basal Cortisol levels and increased glucocorticoid receptors.[2] Therefore, if the doctor conducts blood work would be another recommendation to determine whether or not the blood level reveals the patient are out of the normal reference range.  This can then be used as objective piece of evidence by which the doctor may rely fitting the puzzle together to determine the ultimate diagnosis.  The blood work also may show findings consistent with PTSD by showing suppression on DST (Dexamethasone suppression test) and negative feedback inhibition.  In chronic PTSD patients, “Chronic CRF release “leads to an altered responsiveness of the pituitary gland as it is true in anxiety disorders.”[3]  In fact, if you have an MRI which shows lower than normal hippocampal volume, that can be related to PTSD as well.[4]

3.      This next suggestion may be extremely uncomfortable and the patient definitely   needs clearance from the family doctor and the psychiatrist. The doctor can monitor your patient’s heart rate while having your patient re-experience the trauma and/or showing him pictures or sounds of the event that resulted in the post-traumatic disorder and can objectively show any increase in his heart rate. Again, document his reaction.  Again, the APA indicates that chronic PTSD” may measured through studies of autonomic functioning (eg heart rate, electromyography, sweat gland activity)” [5]

Exposure to simulated trauma can cause increased sweating, rapid heart rate, etc.

4.      Research reveals that individuals with anxiety disorder have certain patterns on PET scans.  Sending your patient out for a PET scan under the circumstances, especially if he has been exposed to a blast injury may not be a bad idea either. Unfortunately, it is expensive and you really need somebody quite good at comparing your patient’s PET scan to individuals with anxiety disorders and a normal sample in order to draw a conclusion. But again, it can be an objective piece of evidence.

5.      The next piece of evidence is a well kept diary from the claimant as well as his family. Very often people don’t realize when their own behavior is bizarre or unusual and while the family may recognize it at the time they must document it clearly in a diary then there are explanations as to how the claimant or plaintiff as changed, become quite vague and somewhat useless. Our firm has a diary online and we urge patients and their lawyer to download the diary and give it to their family members and tell them to keep a daily diary of behavior; morning, noon, and evenings, for 14 consecutive days. This has proven to be invaluable in many cases and it is also helpful to the treating doctor to understand the severity to the patient’s condition and thus how to treat the PTSD.

6.      Consider that the patient may not actually have PTSD,  but may have some other diagnosis such as adjustment disorder secondary to the trauma which is not required the same level of trauma as does PTSD but still can be compensable. 

7.      Watch for defense doctors who give the MMPI, then ignore it.  An elevated PK scale can indicate the presences of PTSD.[6] 

8.      Watch for doctors who administer an abbreviated or shortened version of the MMPI because the shortened version won’t show the PK scale. That may be why doctors may intentionally give the shortened version – so they don’t have to admit their own test shows evidence of PTSD. 

[1] American Psychological Association Diagnostic and Statistical Manual, 4^th ed. TR, APA,  2000,  page 463

[2] Yehuda, Rachel “Biology of Posttraumatic Stress Disorder”, Journal of Clinical Psychiatry, Vol. 65,                (supplement 1), 2004, pp. 42.

[3] Id at 45

[4] Id.

[5] American Psychological Association Diagnostic and Statistical Manual, 4^th ed. TR, APA,  2000,  page

   465.

[6] Butcher, J., and Williams, C., The Essentials of MMPI2 and MMPIA Interpretation, 2^nd ed., 2000, University of Minnesota Press, pp. 170.

[1] Id at 45

[1] Id.

[1] American Psychological Association Diagnostic and Statistical Manual, 4^th ed. TR, APA,  2000,  page

   465.

[1] Butcher, J., and Williams, C., The Essentials of MMPI2 and MMPIA Interpretation, 2^nd ed., 2000, University of Minnesota Press, pp. 170.

Dorothy Clay Sims, Esq. ~ Sims, Stakenborg & Henry, PA.

 Offices in Ocala, Marion County, Florida and Gainesville, Alachua County, Florida. We provide service to the surrounding areas. Our telephone number is: 352-629-0480. Please visit our website at: www.ocalaw.com

• Giving the Attorney the Competitive Edge……….Check out www.mdinabox.com

By T. Christian Miller
June 17, 2007

Samuel Walker saw combat in Iraq firsthand: He was splattered with human flesh and shrapnel in a dining hall when a suicide bomber blew himself up just a few feet away.

When Walker got back to the U.S., he brought some of the battlefield home with him. He heard phantom screams in broad daylight, smelled gunpowder that wasn’t there. A loud noise would send him into a defensive crouch. He’d been eating French fries in the mess hall at the time of the blast, and the sight of a McDonald’s restaurant now brought back violent memories.

Two doctors diagnosed Walker with post-traumatic stress disorder, or PTSD, directly related to his close encounters with violence in Iraq.

But Walker was not a combat soldier. He was a civilian recreation supervisor for KBR, the largest contractor in Iraq. And instead of getting the medical and counseling help he sought, Walker, a U.S. Army veteran, found himself caught in a morass of red tape and rejected insurance claims.

A Times investigation of a taxpayer-financed insurance system, based on reviews of scores of cases, has found a pattern of repeatedly blocked claims for treatment of psychological injuries sustained by civilian workers in Iraq and Afghanistan.

Some seriously afflicted contract workers have been dumped into indigent medical care programs, according to court records. Many have had to wage lengthy legal battles to win payments for psychological treatment. At least four have committed suicide after returning home from Iraq, according to court records and interviews with attorneys and family members.

Although insurance companies have paid for counseling for many workers, they also have fought claims for psychological treatment more than for other types of injuries, according to data compiled by The Times from Department of Labor records.

Though contractors claiming psychological problems made up about 4% of nearly 1,400 serious reported injuries from 2003 to 2005, such workers accounted for 13% of the cases fought out in courtrooms.

In fighting claims, the insurance companies have relied on doctors with questionable expertise, according to court records and claimants’ attorneys.

Read the rest of story here.

Dorothy Clay Sims, Esq. ~ Sims, Stakenborg & Henry, PA.

Offices in Ocala, Marion County, Florida and Gainesville, Alachua County, Florida. We provide service to the surrounding areas. Our telephone number is: 352-629-0480. Please visit our website at: www.ocalaw.com  

• Giving the Attorney the Competitive Edge……….Check out www.mdinabox.com