Original article from the "Attorney at Law" can be viewed here.
The article in the last edition of Attorney at Law magazine raised some questions by a few curious attorneys who were not currently using digitized motion x-rays or stress xrays for the evaluation of AOMSI (Alteration of Motion Segment Integrity) in their cases. The concern I responded to the most was not the validation of AOMSI, as most of them did reference my resources and felt that the evidence would be supported legally in a trial, but their concern was would an insurance company accept this information in terms of an out of court settlement? While it is impossible to answer that question without taking several ill-advised liberties, I can share with all of you my experience as an independent examiner, peer reviewer, and treating physician. The goal of this article is to help you communicate these findings and why determining the cause of continued complaints are relevant.
Current Trends of File Reviews
Many of you are aware of and have had cases affected by the current trend of independent file reviews and examinations. The main issue that appears in the cases I have performed file peer reviews on is poor documentation, including lack of objective evidence supporting the patient’s complaints. It’s likely you have looked at records from some chiropractors and medical doctors and know there is a need for such review service.
Pending if you are representing the defendant or plaintiff your opinion of these records offers you a good option to support your case or you have been left utterly frustrated. The file reviewer who is performing the peer review is looking for the same thing you are. First, the treatment should be both supported by current evidence based guidelines and the proper diagnosis. Second, the documentation should have evidence to support the diagnosis or injury and should correlate to the mechanism of injury (MOI)1. Evaluation of AOMSI for ongoing neck pain, back pain, headaches, dizziness, and referred pain to the mid-back, arm or leg after a motor vehicle collision (MVC) would be medically necessary in many cases.
A doctor who has ordered this testing at the appropriate time and can explain the relatedness to the MOI is doing exactly what is expected. Certainly, if the diagnosis is not supported it will likely be held against the doctor, in fact if the doctor’s file is reviewed and there is lack of evidence to support the diagnosis then both treatment and the diagnosis may be subject to criticism. My question to plaintiff attorneys, is if your client’s physician’s records have been reviewed in a negative way, meaning the treatment and diagnosis was not supported; does that help or hurt your position later in negotiation or even at trial? To the attorneys that help protect the defendants, will knowing that AOMSI is not present, support the fact that long term and persistent symptoms are not probable based on a normal MRI and normal stress radiographs?
As a treating physician, if both of these studies are normal and the patient’s account of pain does not correlate to exam findings, then it is my obligation to tell the plaintiff ’s attorney and the insurance carrier of the inconsistency. In addition, my office policy is to dismiss the patient from treatment due to the fact I cannot offer probable cause of why the patient has ongoing complaints.
If your case does have proof of ligament laxity or AOMSI, then your client or policy holder does have a supported reason for chronic neck or back pain despite a normal MRI. Remember in my last article, in this publication, “ARE YOU UNDER VALUING YOUR CLIENT’S CASE?” I stated that AOMSI is an increased translation (hypermobility) or angular motion, or decreased motion as in a spinal fusion, as described in the Guides to the Evaluation of Permanent Impairment, 5th edition. 2 This means the condition is ratable, which cannot be rejected. If the MOI matches the injury and there is lack of a pre-existing injury, then it would be medically probable that AOMSI occurred as a result of the trauma. Likewise if you are representing the defendant and the injury is not supported by the MOI or objective findings, then there is no rationale to support ongoing treatment or pain as it would relate to the MVC.
But the report from the hospital stated everything was normal
I realize the tone of this article has been mainly to the plaintiff attorneys, but I have only been questioned by three insurance adjusters. All three had the same question regarding the digitized stress films. The question was, if the findings were abnormal, why did the radiologist at the hospital state in their report that everything was normal? My response to all three was the same, as I have questioned several radiologists on this subject. Can the radiologist make a decision that one vertebra has moved in translation of 3.0 mm verse 3.5 mm? All of the radiologist I have spoken to have said (I paraphrase here) that it would be unreasonable to expect that level of decision making without measurement and they do not measure the amount of translation. In addition, only one knew of AOMSI as it was referenced in the Guides to the Evaluation of Permanent Impairment, 5th edition.
I hope by addressing the questions asked by the few attorneys the last 6 weeks answers the questions wondered by the many. If you need further clarification or are facing other challenges in your cases call me. We all learn from each other and that allows all of us to provide the best service for those injured and those other policy holders we aim to protect from false claims. It is important to remember AOMSI is not a finding that can be faked by the patient, client, or policy holder.
Dr. Linton is recognized by the Kentucky Board of Chiropractic Examiners with a specialty in Chiropractic Orthopedics and Peer Review. He also has earned his Independent Chiropractic Examiners certification through the American Board of Independent Medical Examiners. He is certified in Guides to the Evaluation of Permanent Impairment using the 5th and 6th editions. Linton is a consultant to both insurance companies and plaintiff attorneys. Robert Linton, DC, FACO, CICE, CCIC Linton Spine & Joint Chiropractic Center Mount Sterling, KY 859-499-1009 firstname.lastname@example.org