Showing posts with label Personal Injury. Show all posts
Showing posts with label Personal Injury. Show all posts

Friday, January 25, 2013

Expert Witness from the perspective of the judge, TLABC Medical Legal Conference, Mexico, 2013


The following is from the rough notes I took at the Trial Lawyers of British Columbia Medical Legal Conference in Playa Del Carmen, Mexico, 2012.  The Hon. Marion Allen, having served 24 years as a judge was obviously an expert herself on expert testimony.  Even by Mohan standards she was well qualified to be the keynote speaker at this conference. What was immediately obvious was her intimate knowledge of the English language and the way she chose her words, conveying maximum meaning with minimum waste. She was also very amusing, sharing anecdotes about her own career with honest humility.  Hon. Marion Allen is a marvellous presenter.  


Experts are expected to be experts in their area of expertise, she said. The expert must understand that he has a duty to assist the court - rule 11 6.
She clarified the "Expert's duty of neutrality", going on to say, experts will be considered more neutral if they work both for defendants and plaintiffs.
Family doctors are more often subjective and objective and the judges will sometimes make allowances for the fact they are the family doctor.  It is understood this is different from a doctor doing an IME.


The expert's has a duty of full disclosure
- there is no room in court for any dishonesty or lack of full disclosure

She went on to describe the  test for science versus junk science
-discussion of 'motion capture' technique tool admissability - judicial level of reliability - and opposing views presented and discussed . This case was chosen because it was so 'close to the line'.

To this end, she recommended strongly that lawyers reread Mohan when considering introduction of leading edge technology.

She then went on to discuss at length what she called were  "really, really" bad reports quoting a fellow judge who'd described  one such engineering 'expert'  report as  'so foggy to confuse gobblygoop"

One medical report, she described  contained no statement of qualification. In another report the medical expert said a woman couldn't return to work because of an injury  she suffered  at work but knew nothing about the MVA that was subject of the trial, 
She said that the lawyer had  screwed up that badly, letting that get to the court.

Another Medical expert  had simply catalogued the complaints but offered no opinion

Her recommendations to the expert were as follows:
- don't be arrogant 
- cross examination is adversarial - remain objective and don't be offended - expect to be vigorously cross examined.  
- doctors insist on professional independence - resist pressure to make statements with which you are uncomfortable - lawyers are advocates for their clients - an expert must stand firm giving a neutral position on the facts
- make sure you know where the trial will be held
- I realize that doctors are busy but it's recommended that a doctor pop into a public trial and hear a portion of a personal injury trial if they have been retained and are going to be an expert witness for the first time
- speak slowly so the judge can write. It is up to counsel also to keep an eye on judge to ensure the expert isn't speaking too quickly.
-speak up, the acoustics of courts in BC are not that could be desired.
-for lawyers - call the plaintiff first unless there is a good reason not to- the plaintiff's version serves as  the skeleton for the judge in hearing the rest of the trial.
- get expert reports before the courts
- ensure judge or jury understands the expert's reports



Expert Opinion or Advocacy, TLABC Medical-Legal Conference, Mexico, 2013

These are my rough notes from the Trial Lawyers Association of British Columbia Medical Legal Conference. Hopefully they give an idea of the presentation which I suspect could be accessed in fuller detail from the presenter or the TLABC itself.  Obviously, if one is interested they should seriously consider attending a future TLABC conference.  I've found them extremely informative and likely to help me serve my patients whose illness involves them legal dispute. Lesra Martin was a naturally talented teacher and made lucid what at first appeared obtuse and obscure. I'm sorry my notes don't do justice to his wonderful presentation.


Invisible Line in the Sand: Expert Opinion or Advocacy
Lesra N Martin, Martin and Martin Lawyers, Kamloops, BC
Graduated University of Toronto, and Law Degree from Dalhousie University
Was Crown Prosecutor in Kamloops, BC now practices primarily personal injury

TLABC Medical-Legal Conference, Mexico , 2013

Last week attended conference by Dr. O Shaughnassey, Psychiatric and Psychological Aspects, then Hon. Peter Wilson, presented 
- I thought they'd leaked my talk to them but instead I will summarize what they said and add to what I said, but this told me the role of the expert was a central issue

When I hired an expert I get reply
"dr x assumed the role of an advocate"
"Dr. X has provided opinions that go beyond the scope of his area of expertise"

"The report is speculative and argumentative"

When I talk to the family physician he responds "i'm an advocate for my client, and he is expected to be an advocate for his client". There is a clear difference between being an advocate for the client and having a report declared inadmissable 

Principles of law
Supreme Court of canada
- relevance
-necessity in assissting the trier of fact
-absence of any exclusionary rules
-a properly qualified expert
-RV Mohan 1994 
paragraph 16-8 issue of relevance is a qustion of law it is role of the trial judge to conduct a cost/benefit analysis.  
paragraph 19-22 - expert opinion must be necessary ---in regard to whether or not the information provided falls outside the knowledge and expertise of the jury.

Courts caution experts about dx of malingering 

Must be properly qualified expert

R.v Abbey 2009 ONCA
-refined Mohan criteria - in stage 1 , expert must be properly qualified
- trial judge is the gatekeeper - insure that the expert is relevant 'prior' to judge deciding jury may hear the expert




Expert opinion for his or her opinion
Description of any research done to perform their opinion
List of documents that formed opinion 

2010 Mazur
expert is required to state facts and assumptions
rule 11-6  expands under old rule  - know the basis of decision

Avoiding common pitfalls
- They must not become advocates , but express their opinion in objective and impartial way and not present argument
-
It's not the experts role to look for collaborating evidence in the documents.  it is not the role of expert to draw inference and making editorial comments

Medical Experts should be abreast of current academic literature and maintain certification.  
Encouraged lawyers to seek experts who are leaders in the field not just available


Exclusionary rules - Mohan - 
-expert has met all the requirements set out under Mohan
- it may not be that 'credentials' are sufficient, must also have specific expertise



Saturday, March 31, 2012

Chronic Pain and Temporal Mandibular Dysfunction

When people get whiplashes their jaw can be involved. This can lead to chronic pain in face and neck or complicate whiplash pain. Dentists and othodontists have noted this.  Today at the Trial Lawyer's Association of BC Essential Soft Tissue Injury conference a physiotherapist presented on this covering the topic neatly and succinctly with relevant and useful slides.  These are the notes I took and of course they don't cover all the material. The conference offered a CD with the various lecturers notes on that my own notes tend to remind me of what I thought was useful clinically and give a glimpse of what kind of information this conference covered clinically.
Essential Soft Tissue Injury Conference
March 31, 2012
Physical Therapy Treatments for TMD: Giving Hope to your Patients and Clients, Angelica Reeve, MSc,PT, BSc PT MACP
19th Street Physiotherapy Clinica
TMD - Temporalmandibular Dysfunction
TMJ is the jaw joint
connect mandible to temporal bone of skull by articular disc
Opening mouth requires mandible to slide forward and rotate - makes the disc very vulnerable
Muscles of mastication
masseter
temporalis - one of the reasons people complain of headaches
lateral and medial pterygoid
Temporal mandibular dysfunction
-collective term
-muscular
  • intra-articular (inside joint)
  • Combination
5 categories of very minimal to very severe
Causes
trauma -direct trauma, derangement, adhesions
micro trauma -indirect blow, whiplash, bruxism, adhesion
Mechanical dysfunction - trauma, bruxism, muscle imbalance, posture
Osteoarthritis - any of the above
Signs and symptons
loss of range of movement or locking
joint noises
pain - tmj, fascial,earache
pain ful neck
sudden change in bite
decreased hearing, blocked ear
Whiplash - hyperextension and hyperflexion
High incidence of TMD with cervical spine disorders
Five times more likely to develop TMD
20% of recorded cases TMD main complaint
Deep cervical spine muscles can be involved  in whiplash and contribute type i fibers versus type ii more common in superficial muscles
Muscle imbalance
-loss of spatial awareness
posture changes
forward head posture has been found to be correlated to TMD
Treatment
involves positive retraining
deep neck re posturing
Need to taught how to sit upright
Chronic pain
-provides more of a challenge
-change in hard wiring of brain
-increased sensitization
-anxiety and depression
Homunculus in Somatosensory Cortex
Homuncular Man = more face and hand
Chronic TMJ Pain can be associated with problems
  • fascial expression recognition
-two point discrimination
-loss of expression
______________________________________________________

Personal Injury and Myofascial Pain

Dr. Mark K. Frobb is a pain management physician with a special focus on Orthopedic Medicine Rehabilitation. He was also the co chair of this Essential Soft Tissue Injury Conference put on March 30 -31 at the Vancouver Convention Centre by the Trial Lawyers Association of British Columbia in association with the Family Medicine of BC.  His presentation was one of the most informed and extensive addressing controversies and certainties alike.  His slides were excellent. Talking with him between sessions he was jovial and down to earth with a quick wit and astute ability to key into questions being asked him. He was a superb communicator. He is an executive member of the Medicolegal Society of British Columbia and President elect of the the Canadian Association of Orthopedic Medicine.
My notes do not do justice to his presentation. I was busy reading the slides and listening with rapt attention to his fascinating insights rather than taking notes. Therefore, they're really just a few things captured here and there.  The Trial Lawyers Association of BC provided a CD with the notes and other information relevant to the conference. Having attended another one of these conferences a few years ago I needed a wagon to carry home the vast collection of notes that different speakers had provided. I thought the CD was considerate given that some of us older sorts had had personal injuries and could well carry home a cd easier than all the binders of previous years.
Myofascial Pain: Relationship between Pain, Impairment and Function
Dr. Mark K. Frob
The Essential Soft Tissue Conference, March 30, 2012
Myofascial pain syndromes are characterized by regional muscular pain patterns typically involving groups of muscles which functionally control complex movements in a specific anatomical area.
14.4% of general population suffer from chronic musculoskeletal pain
myofascial pain syndromes in variaous studies account for 21 % to 93% of pain
History: Myofascial Pain Syndrome
-Dr. Janet Travel and Dr. David Simons 1977
  • Dr. Janet Travel served Dr. J. F . Kennedy
  • Dr. Janet Travel Clinical Professor of Medicine wrote on trigger points in 80 and 90
-Dr. David Simons - aerospace - work on weightlessness in space
Aerospace medicine
Together two of them - produced what remains the bible of myofascial pain
Myofascial Trigger Points (MTrPs)
taut muscle bands t latnt MTrp to active Mtrp
stress
24 to 54% of asymptomatic individuals have latent trigger points
MTrPs - palpable taut bands, equisitely tender, range of motion of taut muscle limitted
#1 cause - axial skeletal asymmetry
Poor Posture
-fatigue
-sleep deprivation
depression
otherwise radiculopathy, deficiency diseases, hypothyroid,
It presents with a story
Localized muscle tenderness
regionally referred pain
stiffness and limitation of range of motion
sensory distrubance - paresthesia
autonomic phenomena - sweating or decrease, temp changes
recognisable localized knot
‘jump sign’ - patient jumps when you touch
‘twitch response’  - muscle twitches when you touch it
muscle weakness without atrophy
Clinical investigation remarkable by it’s absence
No specific lab tests
infrared or liquid crystal thermography can show increased blood flow at trigger site
Electrical studies may show abn
But we don’t use them in clinical investigation - done as research
Treatment
Needling
drying needling - intramuscular stimulation
trigger point injections - local anesthetics, saline, sterile water, botulinum toxin, corticosteroids
neural acupuncture - injection at the acupuncture points - xylocaine
  • if it’s going to work its going to work as first treatment
Massage
Stretching
electrical stimulation
TENS
EMG
etc
Has a rule - if you see benefit but it doesn’t keep getting better after three visits benefit may have peak
Medications
non steroidial anti inflammatory medication and cream
tricyclic antidepressants
Nociceptive VS
Central Pain ()Neuropathic)
20-30% of patients with chronic myofascial pain will have concurnet or comorbid central pain characterics
ie hyperalgeisa
Central Pain Characteristics and comorbidities as described by Dr. Gouw
Pharmacology of Neuropathic Pain
a variety of meds , including cannabinoids
Disability and Impairment
AMA Guides to the Evaluation of Permanent Impairment 5th edition
Activities of Daily Living
self care
communication
physical activitiy
sensory function
non-specialized hand activeity
travel
sexual function
Impairment
= loss of use oor derangement of any body part or organ system or organ function
only those impairments interfering with ADLS
not all impairments interfere with ADL
Disability
=alteratioon of an individual capacity to meet personal social or occupational demands statutory or otherwise
PAIN
-pain is subjective
-pain can exist without tissue damage and tissue damage can exist without pain
a patient can have a well established pain syndrome without identifiable organ deficit
eg migraine
Need to assess credibility and pain behaivour
Need to balance indivdiual self reports and clinical judgement of examiners
Pain Behaviours - non verbal behaviour
  • primarily observed
  • congruent with established conditions
  • consistent over time and situation
  • consistent with normal anatomy and physiology
  • we’d like to find agreement among caregivers
CHRONIC PAIN DISORDER
-pain exists in more than one anatomic area and warrant clinical attent
-exists past expected treatment
-ccuases clinical distress and or impairment
-psychological factors
-symptons not intentially produced or feigned as in factitious disorder or malingering)
not better accounted by a mood, anxiety or psychotic disorder
Testing Instruments
clearly document history
use of pain related impairment worksheets (PRI’s)
Functional Capacity Evaluation -work simulations

Personal Injury, Chronic Pain and Comorbidities

Dr. Daniel Gouws completed his medical degree at University of Stellenbosch before emigrating to work in Southland, New Zealand, and Saskatchewan before coming to British Columbia. He passed his Master of Sciences at McGill University in Occupational Health Sciences before becoming a board member of the Occupational and Environmental Medical Association of Canada. He is an extremely intelligent, lucid presenter whose clinical experience is obvious from his revealing insights into the care of patients.  His talk, "Comorbidities and Timelines - What to watch when for when your injured patient or client isn't getting better" was a most informative.
The objective was to identify the factors that could contribute to a poor outcome in patients with soft tissue injuries.
The Trial Lawyers Association of British Columbia, Essential Soft Tissue Injury Conference provided a CD with the notes of speakers and other relevant information. I made some notes during the presentation relevant to my own personal interest. It doesn't do true justice to the wealth and breadth of information that Dr. Gouws presented or give you the slides both medical and humorous that accompanied his presentation.  It does give a glimpse and for that reason alone I think it's worth including them here.
Soft Tissue Injury Conference, TSABC, Vancouver Convention Centre
March3012
Comorbidities and Timelines, What to watch for when your injured patient or client isn’t getting better
Dr. Daniel Gouws,
South Africa
Occupational Health McGill
Mechanism of Injury
  • whiplash injuries occur when head accelerates relative to the body, excessive torgue and shear...damage through compression and distraction
Forces involved are considerable, at an imact speed of 20mph (32 km/hr) the human head reachs a peak acceleration of 12 g during extension
If the individual head is in slight rotation, a rear end impact will force the head further into rotation before extension occurs.
In addition to neck pain
-headache
visual disturbances
dizzines
weakness
parasthesiae
cognitive deficits
TMJ
They can often be presenting also with symptons of concussion
Clinical course
Majority of patients improve spontaneously over the first three months
don’t know which go sour
Medical Model
Diagnois
  • History (subjective)
  • Exam (objective)
  • Ass
  • Plan
Differences
Acute pain versus chronic pain
  • chronic pain doesn’t get better
Role of patient with pain is different for acute versus chronic
Acute - follow treatment advice
Chronic pain - ‘partner’ relationship in care , patient responsible for daily management, very different from treatment of appendicitis
Chronic Pain
-lasts more than 3-6 months
varies in intensity from mild to excruciating
one area or multiple areas
emegence of complications
  • increased sensitivity to pain
  • emotional and cognitive distress
  • non restorative sleep
  • fatigue
What is happening in backgrown
  • dogs in background of slides
Chronic Pain
  • chronic co morbidities
Patients get frustrated with us
We get frustrated with them
Blame game
-There is no exact relationship among - degree of pain, extent of pathological change and extent of impairment
-We do not prove or disprove pain with special investigations.  Special investigatiosn are only considered to be appropriate if they will change the management of the patient
-It is inappropriate to request special investigaton in the abscenede of clinical findings such as nerve root entrapment or potentially surgically correctable lesions.
Comorbidities
  • psychosocial
  • what is the effect of the injury and comorbidities
  • deconditioning
  • post traumatic stress
  • substance abuse
  • Depression and anxiety
  • Chronic pain patients who are depressed are 9x more likely to be disabled
  • Untreated psychopathology is greatest likelihood for poor outcome
Loss of Control
  • Regression
  • Isolation
All my friends are dead
Diagnostic Dilemna
  • extensive assessment by multiple physicians
  • numerous investigations (included repeated diagnostic studies) without any real improvement or resolution of symptons
Drugs
  • chronic pain is not an emergency, should get appropriate appointments at appropriate times
  • beware of opiates
  • Canada has distinction of being one of the top prescribers of opiates in the world
Cognitive Distortions
  • unconscious complications of chronic pain
  • non uncommon - we are all prone to cognitive distortions - ex ‘the little engine that couldn’t because he was a worthless bum like your father’
  • emotional reasonling
  • mind reading
  • entitlement
  • ‘la belle indifference’  - patient smiling while saying her pain is 9/10
  • hopelessness
Kinesiophobia
limits activity
limits treatment compliance
becomes self perpetuating - less action - less activity - more pain
Catastrophizing
  • research shows relationship between catastrophising and heightened pain intensity -
Relationship problems
-less interest in sex
Procrastination
-once pain is under control I’ll do more
-I have to wait for my MRI because I can do anything (like take out garbage)
Loss of control
  • fundamental to ability to cope
  • learned helplessness
  • the ability to gain a sesnse of control is fundamental to the ability to cope - self control likened to an energy source and fatigue
  • once you become disabled a lot of that which was taken for granted becomes a bid decision
Workplace Factors
  • adverse outcomes in pain study
  • 1)do you enjoy your job
  • 2) do you get along with your supervisor
Workplace autonomy
  • a factor - disability of chronic pain - less work autonomy - more pain disability
After 6 months chance of return to work drop
Discuss return to work considerations
What can be done?
-individual cognitive behavioural psychotherapy
-exercise
-work conditioning/work hardening
-ergonomic modifications
-modalities used in conjunction with active exercise
  • pain self-management programs
  • PDP, PGAP programs
Elements
-set personal goals
  • improve sleep
  • -increase physical activity
  • manage stress
  • etc
Loss of control
Goal therapy can be effective in helping patients regain control
Chronic Pain Self Management Program
www.selfmanagementbc.ca