Fundamentals

Fundamentals

Medical causality is imputed when the association between a medical condition and a given exposure (physical, biologic, or chemical) is such as to lead one to believe that the condition would not have occurred in the absence of the exposure. The temporal relationship between the exposure or injury and the medical condition (or symptoms suggestive of the condition) is the first factor that must be assessed. The illness or disease should occur after the exposure (referred to as “temporal ordering”) and within a time period that is reasonable given the nature of the exposure (temporal contiguity). In certain situations (such as asbestos, lead, and benzene exposure) there is a long latency between the time of exposure and the appearance of disease. Hence, regardless of whether a temporal relationship appears to be present, determining causality also requires one to assess whether a causal relationship is biologically plausible.

               A causal relationship is biologically plausible when:

               1. The relationship between the medical condition and the exposure or injury can be explained anatomically or physiologically.

               2. The duration, intensity, or mechanism of exposure or injury was sufficient to cause the illness or injury in question.

               3. There is evidence suggesting that the exposure is consistently or reliably associated with the process under investigation in the population under investigation or in peer-reviewed literature.

               4. Cause and effect are contiguous--ie, there is a readily understandable relationship between the two, in which an increase in the magnitude of the exposure reliably leads to an increase in the severity of its alleged effect upon the injured or exposed person, and vice versa.

               5. There is literature providing biologic or statistical evidence indicating that the symptoms or disorder could develop as a result of the exposure (coherence).

               6. There is specificity of the association for the injury (ie, the absence of other factors, especially pre-existing disease, that could have caused or contributed to the problem).

               The independent examiner is obligated to evaluate the validity and strength of all postulated causal mechanism. Mechanisms that appear weak, or are clearly flawed, must be identified as such and accepted as likely only when at least two other criteria for biologic plausibility have been met. Optimally one would wish to satisfy all criteria. There are, however, circumstances when contiguity cannot be demonstrated, as some exposures lead to disease in a noncontiguous fashion. Specificity of association is also difficult to illustrate definitively given the multifactor nature of many disease processes. Literature supportive of causality is generally available, but must be closely scrutinized before relying upon it as it is often poor quality.

Causality

Causality

The independent medical examiner is expected to address causality unless it has already been accepted by the insurer, is presumptive (ie, automatically accepted based on case law or legislation), or has been established through litigation. Causality always must be addressed when the referral source has significant doubts regarding the legitimacy of a claimant’s complaints as related to the initial injury (or alleged injury). Even in the presence of a clear causal relationship between an accident and subsequent physical pathology, one may need to state whether an exacerbation, recurrence, or aggravation of a prior condition occurred and apportion liability accordingly.

               

When examining a claimant who seems credible and insists that one or several medical problems were caused by a given event or exposure, many physicians accept this as fact, even though a careful analysis of the situation would clearly indicate otherwise. The independent examiner is hired to evaluate the claimant objectively, and is expected to base determinations of causality upon commonly accepted physiologic, epidemiologic, and statistical principles, rather than make decisions empirically or based solely on the claimant’s history and the apparent believability thereof. Multiple definitions of causation and their application are discussed in the AMA Guides fifth, and in greater detail in the Guides companion, Master the Guides Fifth. 

Brain Principles Pt.3

 Brain Principles

PRINCIPLE #3

When your brain is troubled, you have trouble in your life.

A troubled brain leads to trouble in your life. It is harder for you to be your best self or to achieve what you want out of life. Plus, you often act outside your own values, morals, and desires. Making poor choices and engaging in unhealthy behaviors are more common when your brain is not working at its best. With a troubled brain, it is much more challenging to follow a treatment plan, and even if you do manage to break free from your addictions, you are far more likely to relapse.

Brain Principles Pt.2

 BRAIN PRINCIPLES

PRINCIPLE #2

When your brain works

   right, you work right.

It has become clear that when your brain works right, you work right. A healthy brain makes it so much easier for you to be your best possible self, to be happier with your life, to be successful in your work, and to have loving relationships. When your brain is working at optimal levels, you are more likely to make good decisions, be reliable, and be an effective employee, friend, lover, parent, or child. Having a healthy brain also greatly increases your chances of sticking with a treatment program so you can overcome addiction.

Brain Principles Pt.1

Brain Principles

PRINCIPLE #1

  Your brain is involved in 

        everything you do.

Your brain controls how you think, feel, act, and interact. From the moment you wake up, it is your brain that plays the central role in your life. It is your brain that urges you to reach for that first morning cigarette or tells you to refrain from smoking. It is your brain that lets you stop drinking coffee after a single cup or pushes you to empty the whole pot.

          Your brain is involved in every decision you make. It also influences who you are and what you do: from social aptitude to athletic skills, parenting style to management approach at work, artistic talent to the type of music you like, Look at any aspect of behavior - from relationships, school, work, religion, and sports - and in the middle of all behavior is brain function. The impact of your brain affects your body too. Whether you live a long healthy life, suffer from a debilitating condition, or have your days cut short by a terrible disease, your brain is the center of it all.

Musculoskeletal Pain and Chiropractic Care

Musculoskeletal Pain and Chiropractic Care

This study evaluated chiropractic treatment and its cost effectiveness in caring for manual labor workers who complained of musculoskeletal problems. Of the 34 patients involved in the study, 13 complained of neck/arm pain and 19 of back/leg pain. 57% of the patients complained of symptoms lasting over 3 months. The subjects averaged 3.23 chiropractic treatments a month if they suffered from neck/arm symptoms, and 5.32 treatments a month if they reported back/leg symptoms. The course of treatment lasted six months. The researchers assessed the patient’s pain, functional outcomes, quality of life, perceived improvement, and employee satisfaction over 6 months. As well, they monitored the cost to the employer prior, during, and after the study period.
Throughout the study and its evaluations, back/leg patients displayed larger treatment benefits.
The Functional Outcome category, which is the patients’ ability to perform normal daily tasks, included the areas of mobility, body care, ambulation, house management, and work. Chiropractic modestly improved the subjects’ lives in body care, house management, and ambulation. The category Quality of Life, on the other hand, included social functioning, emotional disposition, general health, vitality, and body pain. The patient’s level of body pain, vitality, and emotional well being also improved with the treatments.
Patient satisfaction reports were very high. In both groups, those who did not feel “cured” at one month definitely did by six months. 84% of the back/leg patients found the treatment beneficial, and 77% of the neck/arm patients were pleased with their treatment outcomes.
In appraising the overall costs of treatments and sickness, the researchers reported that the employer’s overall costs fell by 30% in the first year of the arrangement and by a further 20% the following year. The extensive treatment costs, however, absorbed 40% and 82% of these savings.

Chiropractic Treatment of Disc Herniations

Chiropractic Treatment of Disc Herniations

This study examined 27 patients in a private chiropractic practice who presented with neck or back pain and who had MRI-documented cervical or lumbar disc herniations that corresponded with clinical findings.
“Patients were treated with a course of chiropractic care consisting of traction for the cervical spine or flexion distraction in the lumbar spine in the acute phase of care, in addition to interferential/ultrasound combination and cryotherapy. In the subacute phase, rotational manipulation was judiciously added, as were isometric and flexibility exercises. In the chronic stage of care, distraction manipulation and rehabilitative exercises were continually employed. Rehabilitative exercise included extension exercises in addition to pelvic tilts, lifts and knee flexion stretching.”
“Treatment frequency was typically four to five times/wk for weeks 1 and 2, then three times/wk with decreasing frequency as the patient progressed. Duration of active care varied from 6 wk to 6 months.”
“When patients reached the point at which their VAS [visual analog scale] score was ?2, their exam findings reversed and their extremity pain resolved, a repeat MRI was obtained. This scenario occurred as early as 6 wk after initiation of care.”
If the patients did not reach these milestones, follow-up MRI was performed 1 year after the initiation of care.
The study found that 22 of 27 (80%) had good clinical outcomes; 17 of the 22 (77%) “had not only good clinical outcome but also evidence of reduced or resolved disc herniation upon repeat MRI scanning.”
Five patients (18.5%) had a marginal or poor outcome, but none had worse clinical signs or pain ratings at the end of the study.
At the beginning of the study, all 27 patients had left work because of the severity of the pain; at follow-up, 21 (78%) were back to work in their former occupations.
VAS scores decreased from an average of 6.9 before treatment to 1.9 following treatment.
One important issue that the author addresses is the controversy of whether manipulation is contraindicated for disc herniation. After reviewing the literature, and from his clinical findings, he concludes that manipulation is indeed safe for disc herniation: “…in the cervical and lumbar spine, rotational manipulation most likely cannot be implicated in disc failure or exacerbation of a disc herniation, and for rotational forces from a manipulation to be involved in disc failure, facet fracture must occur first.” No complications occurred in this study.