Table 16: Differentiators
DIFFERENTIATORS - When there is disagreement about categories, a series of more objective medically available DIFFERENTIATORS are offered. The more objective DIFFERENTIATORS have an asterisk (*) and when DIFFERENTIATORS information is deemed insufficient evidence, the lower DRE rules.
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The basis for these categories relies upon the interpretation of:
1. Historical or observed injury claim related paravertebral muscle guarding (synonymous with objective muscle guarding, non-uniform loss of range-of-motion, and dysmetria) or appropriate non-verifiable radicular complaints.
2. Spine injury claim related focal loss of ankle and knee reflexes (verifiable by #4).
3. Spine injury claim related circumferential measurements loss of girth > 2cm above or below the knee that cannot be explained by non-spine problems or hypertrophy, e.g. dominance, activity (verifiable as related by #4).
4. * Unequivocal Electromyography (
EMG) findings of nerve root compromise in the extremities (multiple positive sharp waves or fibrillation potentials or slowed h-reflex (S1 only) related to spine injury acutely or if studied late, appropriate polyphasic waves more accountable to the incident in question than other insults).
5. * Lateral lumbosacral motion x-rays hyper-flexion/ hyper-extension comparison views exhibiting significant injury related translation/angular motion, e.g. significant = >5mm of translation anterior to posterior or, 11o more rotator motion than at adjacent motion segments by comparing the position of vertebral bodies on lateral hyper-flexion radiograph relative to the hyper-extension radiographs (see
figures 13 and 14).
6. Rectal examination indicating loss of anal tone or sensation of bladder control due to spinal injury.
7. * Cystometrogram (CMG) studies indicate of unequivocal neurological compromise with incontinence related to spinal injury.
The present percentages of total body impairment are derived arbitrarily as depicted in tables 17, 18, 19, 20.
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Table 17. Arbitrary percentages of the spine for Impairment rating.
Table 18. Lumbar (L-S) DRE categories of Impairment
Table 19. Cervical (C-T) DRE categories of Impairment
Table 20. The Thoracic (T-L) DRE categories of Impairment
The ABC Long tract impairments (AMA guide DREs VI, VII, VIII) are added to the DRE I-V categories relative to the amount of spinal cord injury involved in the changes in the cervico-thoracic and thoraco-lumbar regions when related to lower extremity dysfunction.
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There are different guides for providing opinions about impairment and you should use the one that you can best justify. Thus, it is important to differentiate between a guideline and a rule. The difference between a guideline and a rule is well depicted in the movie Ghostbusters where Bill Murray’s character responds to seduction by Sigourney Weaver’s, “As a rule I don’t sleep with people who are possessed.” But as she continues her amorous advances he adds, “But, that’s more a guideline than a rule.” Similarly the AMA Guides to impairment is, as titled, a guide and not a rule. Guidelines are intended to help, not limit, a clinician’s professional contribution of some reliable science to arbitrary administrative codes.
In 2001, the importance of differentiating guidelines from rules comes to the forefront in the arena of workers compensation. The US Supreme Court advises judges since the 1993 Daubert v. Merrell Dow decision, to concentrate on the data behind the expert’s opinion rather than relying on subjective experience. These rules of evidence require judges to allow only opinions supported by scientific evidence beyond hypothesis. The US Supreme Court’s 1993 change in the Federal Rules of Evidence (F.R.E) is redefining the playing field even for workers compensation. F.R.E. explicitly demanded peer-reviewed published data that results from research based upon accepted scientific methods that must include both hypothesis testing and an error rate. F.R.E. further require the data be formulated indepen
dent of the proceedings for which it is presented. Since 1993, what is known as the Daubert Decision has been upheld and strengthened by General Electric v. Joiner, Kuhmo Tire v. Carmichael, Weisgram v. Marley and Black & Decker v. JL Nord cases at the US Supreme Court level and in district court of appeals with decisions like the Nat’l Bank of Com. Vs. Dow Chemical and the Black Vs. Food Lion that applied to medical testimony. The new F.R.E. gradually creeps into the different corners of our legal institutions with decisions on record in Arkansas and Tennessee workers compensation cases in 2001, then Texas 2002, Oklahoma and New Mexico 2003.
Thus evidence based on hypothesis testing could soon supersede whatever administrative guidelines we now use. Daubert F.R.E. will obviously challenge the foundation of current medical and legal practices the many jurisdictions. Clinicians soon may have to defend the scientific basis behind opinions. The Spine Injury Model thus provides a firmer scientific basis to administrate expert opinions than either range of motion or imaging models of impairment rating.
Always remember that the court requests your opinion. As professionals our opinion for patients is hopefully based upon more scientifically sound foundation than can be obtained from his or her grandmother. Judges are beginning to demand we scientifically justify our opinion. We will no longer be able to hide behind the books we use for guidance. In some instances we may be forced to vary significantly from indefensible guides too weakly based on science. To be fair, professional and acceptable as an expert, clinician will need to use evidence based on a firmer scientific foundation beyond "experience" and "conventional wisdom".
In summary, try to keep in mind the potential impact of what you recommend on both the physical and non-physical elements of the problem.
-Remember the Groucho Marx joke:
"Doctor, Doctor! After surgery will I be able to play the violin?"
" I would hope so."
"Great? Cause I could never play it before."
Surgery, medications, physical methods & rest do not train you to play violin, work hard or return to Normal Activity after a long rest. Only physical conditioning, not rest, begets comfortable activity tolerance.
-Also realize that only the computer on the patient's shoulders can weigh the different (non-physical) pressures, fears and understanding needed to make a reasonable choice of options.
As clinicians we can help patients physically and emotionally with difficult decisions. Encouraging activity and the accumulation of sufficient information can help patients understand some options. Nowhere in the literature have both elements of acute care been better illustrated than the work of
Malmivaara et al, '95 and the others [
236b,
236c,
236d,
236e,
236f] who treat the reduced activity tolerance rather than just the pain. Non-physical issues were addressed with strong assurance of "no hint of anything serious to stand in the way" of the most important physical treatment is to "avoid the debilitation of inactivity by pursuing normal activity as soon as possible." As a friend, we can provide an opportunity to for our patients to face serious decisions in a more informed and less emotional fashion. We can support the collection of needed information for making those decisions while avoiding harsh judgment when behavior varies in the emotional battle for survival and avoidance of facing failure.
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