Chiropractic Medical-legal Narrative Report

DrBackman.com Chiropractic & Massage; lawrence dieter, d.c.
1171c Toro St. San Luis Obispo, CA 93401
(805)544-0237

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Lawrence Dieter D.C., Chiropractic
"people do not care how much you know until they know how much you care."
www.drbackman.com   email:

February 09,1998  

TO: Todd Porter
Attorney at Law
1026 Palm Street, Suite 214 San Luis Obispo, CA 93401
(805)541-4847 FAX..541-4855

RE: Xxxx Xxxxx
Date of injury: 05-08-97

NARRATIVE REPORT

INTRODUCTION
Mr. Xxxxx presented as an intelligent, well-adjusted, 34 year old male, non- smoker with a mesomorph body type (preponderance of muscle). The patient is employed at Lindamood-Bell Learning Processes Inc. as a computer software/hardware technician.

HISTORY
Mr. Xxxxx was driving his vehicle, with his seat belt on, when the accident occurred. While traveling south on Madonna Road, a vehicle in front of him stopped abruptly. Mr. Xxxxx was able to bring his auto to a complete stop, which was followed by being impacted from the rear by a second vehicle, which in turn forced him into the car to the front. His wife was the only other passenger in the car.

The metal attachments of both the driver and passenger's seat belts were dislodged from the floor as a result of the impact. In addition, the automobile frame was visibly compressed.

(Xxxx Xxxxx and his wife Xxxx Xxxx provided this account of the auto accident).


PAGE 2 of 9
RE: xxxxx xxxxx
DOI: 05-08-97

PAST HISTORY
Mr. Xxxxx first presented at this office on 10-17-90 with a chief compliant of back pain and secondarily, neck pain after being injured at work. At the time, he was employed as a dry wall taper. A MRI of the lumbar spine was performed on 11-02-90 and reveled a mild to moderate (2-3mm) disk bulge at LS-S1 and a 1-2mm disk bulge at L4-LS. At the end of that treatment, he was rated as having a 17% whole body impairment. Treatments for low back pain and associated signs and symptoms prior to the 05-08-97 auto accident are as follows: 1996, three office visits; 1995, one; 1994, one; 1993, three.

Definition of Pain Terminology:-*

Frequency:
* occasional -1 - 25 % of the time.
* intermittent - 26 - 50 %
* frequent    51 - 75 %
* constant   76 - 100%

Severity:
* Minimal pain constitutes an annoyance but no handicap.
* Slight pain can be tolerated but would cause some handicap.
* Moderate pain can be tolerated but would cause marked
                 handicap in activity being attempted.
* Severe pain would preclude the activity that causes pain

*AMA Guides to the Evaluation of Permanent impairment, Forth Edition, 1993, page 316

CHIEF SUBJECTIVE COMPLAINTS
Prior to the 05-08-97 auto accident:

Mr. Xxxxx reports that usual level of low back discomfort prior to 05-08-97 consisted of occasional, minimal to sight pain (low back pain once per week and shooting pains into legs once every two months).

05-13-97: Mr. Xxxxx experienced renewed and additional signs and symptoms immediately after the auto accident. Moderate to severe low back pain radiating pins and needles into both legs, slight right knee pain.


PAGE 3 of 9
RE: Xxxx Xxxxx
D.O.I. 05-08-97

SUBJECTIVE COMPLAINTS CONT.
05-13-97 cont. (the patient noted that his pants, at both knees were marked black after the accident) loss of sleep, nervousness, tension, moderately altered sex life, slight depression, slight loss of memory, difficulty concentrating moderate pain caused by activities of daily living and fatigue. Constant slight cervical pain began at the time of the accident, which developed into moderate constant pain over the following week.

02-03-98: The patient is no longer able to pick up his children, participate in sports and most recreational activities. In addition to this, his sex life has undergone moderate levels of accommodation.

Mr. Xxxxx's low back pain precludes him from climbing any number of steps, (by definition, severe) or lifting 20 lbs. more than once. The following activities cause moderate pain developing into severe pain after the noted elapsed time: bending at the waist, 10 min; walking more than 100 yards; sitting, 60 min.; standing 30 min.; descending stairs, 3 flights; climbing stairs, 4 flights; reaching over head, 4 min.; changing position from supine to sitting or visa versa and from sitting to standing or visa versa, 2 immediate repetitions.

Lost Hours From Work:
Mr. Xxxxx lost 3.5 hours of work (~$11.55/hr.) as a result of the accident.

Days Working in Pain:
The patient has continued to work in constant moderate pain and with
minimal to moderate levels of accommodation.

PHYSICAL EXAMINATION
05-13-97 Blood pressure was measured at 112/70 mm hg.

The physical exam revealed moderate cervical muscle spasm, swelling, loss of range of motion accompanied with a minimal loss in hand grip strength (the latter was noted retroactively). The dorso-lumbar spine also exhibited muscle guarding, swelling and spasm. The cervical and dorso-lumbar spine range of motions were limited and positive orthopedic tests were found, as noted below.


PAGE 4 of 9
RE: Xxxx Xxxxx
DO1.' 05-08-97

CIRCUMFERENTIAL MEASUREMENTS OF LIMBS:
            left      right
biceps -  32.5 cm. 32 cm.
forearm- 31.5     31.0
thigh   57.0     53.5* [minimal atrophic change]
calf   40.0     41.0
neck - 42.0 cm.

ORTHOPEDIC EXAMINATION
Orthopedic Tests:

Cervical Spine:
Positive cervical compression test exacerbated upper,

mid. and low neck pain. Positive soto hall test for vertebral bony injury or disease especially those of compression (the x-rays did not visualized any fractures, compression or otherwise). Positive cervical spine distraction test providing sight transient relief of neck and upper extremities; significance: nerve root compression and that the weight of the head is a liability.

Dorso-Lumbar Spine: Positive right and left and double straight leg raise test were positive exacerbating low back pain and shooting pains radiating into both legs..

[significance: (1.) indicates radiculopathy if pain is elicits sciatic nerve pain when the foot is dorsi-flexed; (2.) at 150 to 300, indicates spasm; (3.) at 350 to 700 the sciatic nerve roots tense over the intervertebral disk and intervertebral disk pathology is suspect; (4.)at 700-900, the Ls nerve root is at maximal traction and may indicate an L4-s disk herniation, ligamentous and other connective tissue damage].

Kemps test indicates a disk protrusion or prolapse of the disk nuclear material.

Jump Sign, grade 4 (severe tenderness, withdraws immediately in response to pressure and is unable to sustain pressure) was elicited initially in the cervical, lumbar (lt.>rt.) and gluteal (rt.>lt.) regions and while it resolved in the cervical spine, it remained in the lumbar and gluteal muscle groups.


PAGE 5 of 9
RE: Xxxx Xxxxx
DO1.' 05-08-97

Orthopedic Tests Dates:

                          05-13-97           02-05-98
Cervical:
Compression     positive             positive
Distraction        positive             positive
Soto Hall           positive             positive

Dorso-Lumbar

Left Straight leg raise   positive @ 400          positive @ 300
Right Straight leg raise positive @ 400          positive @ 650
Double Straight leg    positive @900           positive @350

Left Kemps         negative                negative
Right Kemps          positive                positive

Range of Motion -- Cervical Spine

DATE:              05-13-97                  02-03-98
            {% of Normal Range of Motion}
Flexion:                  64%                      100%
Extension:              67%                      100%
Rt. Rotation:        100 %                     100%
Lt. Rotation:        100 %                      100%
Rt. Lat. Flexion:    87 %                        75%
Lt. Lat. Flexion:  100 %                       100%

Range of Motion -- Dorso-Lumbar Spine

DATE:              05-13-97            02-03-98
            {% of Normal Range of Motion}
Flexion:               67 % *               78 % *
Extension:             0 % *               17 % *
Rt. Rotation:       67 % *               83 %
Lt. Rotation:        83% *                83 %
Rt. Lat. Flexion:  83 % *             100 %
Lt. Lat. Flexion:  83 % *               83 % *

*exacerbated lumbar pain at end-range.


PAGE 6 of 9
RE: Xxxx Xxxxx
DOI 05-08-97

Hand Grip Strength: (Jamar Dynamometer)
05-15-97               02-0J-98
Left Right             Left Right
150 lbs. 130 lbs.        145 lbs./ 160 lbs.
135 / 135                150/160
115 / 115                 145/ 155

MUSCLE TESTS

Motor function of the upper extremities were in tact, with the grip strength being above average. Heel and toe walk were unremarkable. Motor weakness was demonstrated in the Following muscle groups: Hip flexors: psoas muscle, left>right, grade 4 (motion against gravity with some resistance); Hip extensors, gluteal muscle group, grade 4.

X-RAYS
Series: Lumbar, AP, LA T
Date: 05-19-97
Location: A Back Alternative
San Luis Obispo, CA

Clinical Impression:
1. Minimal pelvic unleveling
2. 20-25% loss of disk height at L4-5(result of the 1990 injury)

NEUROLOGICAL EXAMINATION
The Valsalva Maneuver/test was positive for intervertebral nerve root compression by way of disk occlusion.
The Dermatomes were checked for sensory loss with a Warrenberg pinwheel. The C6-7 dermatomes of the left arm were Found to have a minimal loss of sensation. The patient's deep tendon reflexes at the levels were grade +1 (hypo-reflexia); C6, brachio-radialis; C7, triceps on the right; and C5,biceps L4, patellar; S1, Achilles were grade +2 (within normal limits). Babinski's sign was unremarkable for spinal cord (corticospinal/pyramidal tract disease and is absent in adults without said cord compression).


PAGE 7 of 9
RE: Xxxx Xxxxx
DOI 05-08-97

TREATMENT RENDERED
Treatment protocol [or Cervical acceleration-deceleration syndrome
includes initially ruling out any bony pathology cervical support as indicated, followed by addressing the soft tissue damage with physical therapy modalities, manual intermittent traction and at the appropriate time, specific chiropractic manipulation.

Mr. Xxxxx's aggravated lumbar disk bulges and lumbo sacral segmental dysfunction with associated sprain/strain were initially address with conservative physical therapy modalities followed by specific chiropractic manipulations above and below the level of disk injury.

This was followed with a two-month protocol (16 sessions) at the Low Back Clinic in San Luis Obispo, CA. This clinic uses the Med-X equipment and protocol. (This is the same equipment and protocol used to re-hab the Indy race car drivers.) You will find the computerized results graphed out in appendix A.

ACTIVITIES OF DAILY LIVING
The following is the American Medical Asso. outline of activities of daily living found in Guides to the Evaluation of Permanent Impairment, Forth Edition, 1993, page 317.:

          Description of Sensory Deficit or Pain
Grade                                     Percent Sensory Deficit

1. No loss of sensibility, abnormal sensation or pain.    Zero%
2. Decrease sensibility with or without abnormal            1-25%
    sensation or pain, which is forgotten during activity.
3. Decrease sensibility with or without abnormal          26-60 %
sensation or pain, which interferes with activity.
4. Decrease sensibility with or without abnormal          61-80 %
sensation or pain, which may prevent activity, and
or minor causalgia.
5. Decrease sensibility with abnormal sensation           81-100 %
and severe pain, which prevents activity, and
or major causalgia.


PAGE 8 of 9
RE: Xxxx Xxxxx
DO1.' 05-08-97

Marked in red are the activities, which have been negatively altered since the 05-08-97 auto accident for Mr. Xxxxx. For these activities, this patient has had to cease the activity, limit time spent and or accommodate. The number [showing the activity is the grade (1-5) as set forth by the AMA in Guides to the Evaluation of Permanent Impairment, page 48. (see the above table [or details).

ACTIVITY, GRADE
self-care, personal hygiene - bathing, 3; grooming, dressing, 4; eating, eliminating, 2
communication - hearing, speaking, reading, writing, using keyboard.
physical activity - intrinsic: standing, 4; sitting, 4; reclining, 3; walking, 4; stooping, 5; squatting, 3; kneeling, 2; reaching, bending, 4; twisting, 3; leaning, 5.
functional: carrying, 3; lifting, 4; pushing, 3; pulling, 3; climbing, 4; exercising, 5.
sensory function - hearing, seeing, tactile feeling, tasting, smelling.
hand function - grasping, holding, pinching, percussive movements, sensory discrimination.
travel - riding,4; driving, 4; traveling by airplane, 4; train, or car, 4.
sexual function - participating in desired sexual activity, 4
sleep - having a restful sleep pattern,2.
social and recreational - participating in individual or group activities, sports, hobbies, 5

APPORTIONMENT
Apportionment is to be a factor in this case. It is my estimation that the
patient has not reached within 3% of maximum medical improvement (MMI). But if Mr. Xxxxx were to be rated on the 02-03-98 exam, a reasonable calculation of whole body; partial permanent impairment (PPI) rating would be 40 to 50%. Subtracting, the 17 % rating from the 1990 injury would result in a net 23% to 33% PPI from this accident.

FUTURE MEDICAL/PERMANENT IMPAIRMENT DISCUSSION
Impairment is the loss of use of, or derangement of any body part,
system or function.
Permanent impairment is impairment that has become static or will stabilized with or without medical treatment and is not likely to reemit despite medical treatment. A permanent impairment is considered to be unlikely to change substantially and by more than 3% in the next year with or without medical treatment.


PAGE 9 of 9
RE: Xxxx Xxxxx
D.O.I. 05-08-97

FUTURE MEDICAL - DISCUSSION CONT.
This report has established the causation of Mr. Xxxxx's limitations as the result of 05-08-97 auto accident and now he is classified as being in "chronic pain," as defined by the AMA, Guides, page 312.

Noted under x-ray data, was the 20-25% loss of disk height as a result of the 1990 injury. Because of this auto accident, it is expect an additional 20-25% loss of disk height over the next 12 to 24 months. Essentially, in the near future the patient will be walking around with L4Ls and L4-S1 vertebral levels being 15 years older than if he accident had not happened.

DIAGNOSIS / CLINICAL IMPRESSION
L Cervical / Acceleration / Deceleration Syndrome.
2. Unstable Lumbar disk L4-5and L5-S1.
3. Lumbar Nerve roots L4-5 Radiculopathy with Motor Involvement.
4. Lumbar and Lumbo-Sacral Segmental Dysfunction.

DISCLOSURE
I certify by my signature below that the history and examination in this case were personally performed by myself. I typed and proofread this report. I further certify that this report is my work product and describes and expresses exclusively my professional findings, opinions and conclusions.

Sincerely

Lawrence A. Dieter D.C.
LAD/lad


Appendix A:
 Med-X Rehab. Graph

Blue lines: male norms
Red lines: before & after

LBCxxgraph.jpg (26468 bytes)

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