Quality care for accident injuries. Our goal is to provide the best pain management and injury recovery treatment possible with a focus on biomechanics. Our staff has completed specialized training in biomechanics, which allows them to accurately diagnose injury and design an individualized treatment plan that best meets the individual patient’s needs. We understand and manage the underlying medical and psychosocial conditions that are often ignored but have a massive impact on outcomes.

Car Accidents

In 2020, around 4.8 million people were seriously injured in motor vehicle accidents. (National Transportation Safety Administration)  with an estimated cost exceeding $474 billion. (NSC) In 2021, close to 43,000 people died in automobile accidents, a 10.5% increase over 2020. (Administrative Agency for Highway Safety)

The average economic cost of a fatal auto accident (including wage losses, hospital fees, administrative expenses, motor vehicle damage, and employers’ uninsured costs) in 2020 was $1,750,000, while the average economic cost of a debilitating injury was $101,000. (NSC). In 2020, occupants of passenger cars accounted for 62% of crash fatalities, compared to 17% of pedestrians, 14% of motorcyclists, 2% of cyclists, and 2% of occupants of large trucks. Insurance Institute for Highway Safety.

The fatality rate per 100,000 kilometers driven increased by 21% between 2019 and 2020, marking the highest significant annual increase since records began in 1975.

Biomechanics

Biomechanics is how human body components interact with mechanical forces during an accident to cause injury. It examines how external and internal stresses affect the human body, creating movement or distortion. Muscles, tendons, ligaments, joints, soft tissues, and bones are studied in biomechanics. The Insurance Research Council (IRC) analyzes more than 70,000 motor vehicle collision injury claims from 32 insurance firms.

-56-66% of diagnoses are neck strains/sprains

-49-56% back strains/sprains, 10-14% shoulder problems

-8-9% knee disorders

The biomechanics of automobile accident injuries can be intricate and diverse. Understanding these systems can aid in the improvement of vehicle safety measures and the comprehension and treatment of injuries incurred in automobile collisions.

In automobile collisions, persons may be exposed to various forces that might result in severe injuries. These forces may comprise uniaxial loading and multiaxial loading. – Consequently, incidents that occur at slow speeds, often less than 20 km/h can nevertheless result in severe injuries despite the lesser forces involved.

Common injuries resulting from automobile collisions include: 

Whiplash is a common injury that can result from a low-speed collision. It is caused by the fast movement of the head and neck back and forth, which can strain or tear the neck’s muscles and ligaments.  Even low-velocity collisions can also result in head injuries, including concussions and skull fractures.

Accidents at low speeds can cause chest injuries, including shattered ribs and internal hemorrhage. Abdominal injuries: Abdominal injuries, such as organ rupture and internal hemorrhage, are also possible in low-speed collisions. Back and spinal injuries: Low-velocity collisions can cause back and spinal injuries, including sprains, strains, and fractures.

Whiplash is defined as “an acceleration–­deceleration process of energy transfer to the neck that may result from rear-­end or side contact, most commonly in motor vehicle accidents, and other mishaps.” The energy transfer may cause bone or soft tissue damage (whiplash injury), which may lead to a wide range of clinical symptoms (whiplash-associated illnesses) (Cassidy et al. 1995, p. 22).

Within 75 ms of impact, simultaneous upper cervical flexion and lower cervical extension produce an S-­shaped neck curvature (figure 8.17), which ultimately gives way to a C-­shaped hyperextension curvature (Grauer et al. 1997). ­ These movements put the lower and higher cervical spines at danger of injury from the rear-impact mechanism (Panjabi, Pearson et al. 2004).

The hyperextension model is insufficient in capturing the complicated motion of the cervical spine during whiplash, as it is overly simplified. Modern study on whiplash has revealed that it is not a cantilever movement, i.e., an extension–flexion movement of the head, as was popularly assumed in the past. Less than 150 milliseconds after impact, the cervical spine is compressed. During this time, the cervical spine buckles; the upper cervical segments flex and the lower cervical segments lengthen around improperly positioned axes of rotation (Bogduk and Yoganandan 2001, p. 272).

Whiplash may appear to be a straightforward harm mechanism. However, “in a particular accident there is likely to be a complex interaction between different forces depending on the speed and direction of the impact and the head and neck position” (Barnsley et al. 1994, p. 288). In addition to the cervical musculature, spinous ligaments, intervertebral discs, vertebral bodies, and facet (zygapophyseal) joints, the brain and temporomandibular joint may also be involved (e.g., Davis 2000; Ito et al. 2004; Panjabi, Ito et al. 2004; Pearson et al. 2004). In figure 8.18, many mechanisms and potential damage sites are depicted. Clinical and psychosocial symptoms can be connected with whiplash-­related illnesses (Eck et al. 2001).

 

Potential mechanisms and injury sites for whiplash-­related injuries. Shear forces affecting a spinal motion segment.

(a) Translation of the superior vertebral body anteriorly relative to the inferior body, which stresses the articular surfaces of the zygapophyseal joint (A), the anterior annulus fibrosus (B), and the zygapophyseal joint capsule (C).

“(b) Translation of the superior vertebral body posteriorly relative to the inferior body, which stresses the intervertebral disc (D) and the zygapophyseal joint capsules (E).” (“Whiplash-related injuries – Human Kinetics Canada”)

(c) Common lesions affecting the cervical spine following whiplash injury. A, articular pillar fracture; B, hemarthrosis (hemorrhage into a joint) of the zygapophyseal joint; C, rupture or tear of the zygapophyseal joint capsule; D, fracture of the subchondral plate; E, contusion of the intra-­articular meniscus of the zygapophyseal joint; F, fracture involving the articular surface; G, tear of the annulus fibrosus; H, tear of the anterior longitudinal ligament; I, end-­plate avulsion fracture; J, vertebral body fracture.

“Whiplash is categorized into five grades (Pastakia and Kumar 2011):” (“Whiplash-related injuries – Human Kinetics”)

• No neck pain, stiffness, or physical signs
• Complaints of neck pain with stiffness or tenderness but no physical signs noted
• Neck pain and stiffness complaints with decreased range of motion and point tenderness
• Neck pain and stiffness complaints with neurological signs
• Neck pain and stiffness complaints with fracture, dislocation, or spinal cord injury

Rear-end crashes are distinctive. 

Most neck injuries occur at modest speeds, decreasing over 20 km/h. Injury is caused by seatback and differential motion. Recent research shows that facet joints clash as the neck bends and expands. Biphasic motion, when the normal spinal curves flatten as the torso sinks into the seat cushion, is associated to lumbar and thoracic spine problems. (“Biomechanics: a primer for motor vehicle collision injuries”) The dorsolumbar spine elongates early in collision.

Frontal crashes: features

In frontal collisions, the occupant slides forward with the car (inertia). Many injuries involve the car’s interior, seatbelts, airbags, and steering wheel. Higher-speed crashes frequently cause contusions, lacerations, abrasions, fractures, and organ damage. Spine and limb strains are still prevalent but require bigger delta-Vs than rear or side strikes. Airbags can cause cuts, burns, and fractures. Steering wheels in cars without airbags can cause chest and abdominal injuries.

Side crashes 

Direct bullet contact and loading can result from lateral strikes. Only 10-12 inches separate a person’s torso from the bullet car’s door and front. Head, shoulder, extremity, torso, and pelvic injuries can result from door intrusion or bullet car strikes. Side airbags help decrease significant injuries for adults, but children may suffer more severe injuries depending on their sitting posture and physical features.

Impacts

When an initial motor vehicle incident is followed by a second collision with another vehicle or structure, the occupant may be in a less-than-optimal seating position. After a rear-end collision, the occupant’s head is near the airbag ejection port when it deploys. Airbag deployment near the port may cause severe injuries.

Occupant issues

Personal preferences and physical attributes determine how drivers and passengers situate themselves in the car. Some choose a forward, backward, vertical, or horizontal seat to alter body-to-vehicle distance. Some sit with their legs crossed, forward, or apart, varying their proximity to side and front vehicle structures.  Nobody’s seatbelt fits properly. Minor occupants’ shoulder harnesses may be positioned toward the neck, causing cervical spine loading. Arm positions on and off the wheel and in various postures can cause arm and shoulder injuries and more severe injuries with airbag deployments. Reaching for something in the backseat can cause shoulder injury. High-heeled shoes lower the ankle, causing foot injuries.

Out-of-position occupants may suffer more serious injuries. If a driver has their head inclined to the left to see incoming traffic and is rear-ended, the neck ligaments will be pre-tensed, causing cervical spine strain. If an occupant leans forward, there will be a larger gap behind their back, resulting in higher acceleration levels in rear accidents. In frontal crashes, the person’s head may be next to the dash, increasing the risk of head damage.  Variable collision tolerance is documented. Age, stature, weight, and health affect injury risk and severity. Degenerative musculoskeletal diseases, autoimmune disorders, past injuries, prior surgeries, diabetes, and other factors lower the damage threshold and may hinder healing.

Vehicle motion determines occupant movements biomechanically. Police report, if possible. If the incident is recent, take photos of the scene and affected automobiles. Suppose mid-1990s Fords and Chevrolets are involved. The attorney may be able to retrieve data from the “Black Box” to assess impact speeds and length. If the automobile crashes again or if the download is delayed while driving, the data may be lost.  In an ideal situation, objective injury-proof requires photographing a patients abrasion, lacerations, swelling, and bruises before they dissipate. Focus is generally on what happened during and after the incident, occupant placement, airbag deployments, contact areas, and bruising, discoloration, and lacerations. This data and biomechanical expertise determine occupant kinematics, contact points, acceleration levels, and loading forces.

Many biomechanical tolerance tests were performed before MRI scans and improved imaging technology were available, with many reference sources relying on outdated human tolerance thresholds for bodily parts, such as 1986’s SAE J885.  Soft tissue and brain injuries may require extra testing consistent with current available technologies and enhanced understanding of pain generators and comorbidities which maintain pain.  In addition to the immediate injuries that can result from a car collision, there can also be long-term health effects. These can include persistent pain, psychological side effects, disability, and a decline in life quality.

Even if they do not believe they have received major injuries, persons who have been involved in an automobile accident must seek medical assistance immediately. Some injuries, such as head trauma and internal bleeding, may not be immediately visible, but if left untreated, they can be fatal.

For more detailed information on multiaxial loading and its effects: (see “Whiplash-related injuries – Human Kinetics”)

Multiaxial loading uses the same stress and strain concepts just discussed and extends them into two-­ and three-­dimensional space. Although the biaxial and triaxial responses are illustrated for tensile loading only, the concepts are equally applicable to compressive loading and to force vectors with reversed orientation. The following formulations are for linearly elastic materials.

material biaxially. (b) Elongation caused by Fx and the resulting perpendicular contraction in the Y and Z directions. Dashed lines indicate conformation prior to loading. Solid lines indicate conformation while loaded. Biaxial (Two-­Dimensional) Loading Responses Consider a three-­dimensional body (figure 3.29) with sides of length X′, Y′, and Z′ that is subjected to axial forces Fx and Fy. The stresses produced in the X and Y directions are as follows:

The X-­direction stress (σx) ­will, according to Poisson’s effect, cause deformation in all three directions. Elongation in the X direction and contraction in the Y and Z directions are shown in figure 3.29b. By applying equations 3.34 and 3.35, we obtain X-­ and Y-­direction strains attributable to σx:

We similarly obtain Y-­ and X-­direction strains attributable to σy:

To obtain the combined effect of σx and σy, we add the strain effects just calculated. The net strains in the X and Y directions are then

We have presented two normal stresses, σx and σy. As previously described, a tangential, or shear, stress (τ) is also created. In the case of biaxial loading, shear stress (τxy) is created as shown in figure 3.30a.

FIGURE 3.30 Shear stresses in response to biaxial and triaxial loading. (a) Shear stress (τxy) created by biaxial loading. ­Because of equilibrium conditions, τxy = τyx. (b) Triaxial tensile stresses (σx, σy, σz), shown as solid vectors, result in shear stresses (τxy, τyz, τzx), depicted as broken-­line vectors. Equilibrium constraints dictate that τxy = τyx, τyz = τzy, and τzx = τxz.

FIGURE 3.31 Triaxial loading. Applied forces in the X, Y, and Z directions (Fx, Fy, and Fz, respectively) load the material triaxially.

Triaxial (Three-­Dimensional) Loading Res­ponses The addition of a third axial force in the Z direction complicates the conceptual model only slightly, whereas the mathematical aspects of the model become quite involved. Focusing on the conceptual application (figure 3.31), we now have

• Fx, which creates σx = Fx/(y′ · z′) and produces elongation in the X direction and contraction in the Y and Z directions
• Fy, which creates σy = Fy/(x′ · z′) and produces elongation in the Y direction and contraction in the X and Z directions
• Fz, which creates σz = Fz/(x′ · y′) and produces elongation in the Z direction and contraction in the X and Y directions

The equations for resultant strains seen in triaxial loading are

 

The shear stresses (τxy, τyz, τzx) produced in triaxial loading are shown in figure 3.30b.

My insurance said a procedure is investigational, but my doctor says its standard of care?

As a physician, I am frequently asked by my patient why a procedure that is considered standard medical treatment might be denied as investigational. Even more intriguing is why some private insurance companies will approve a particular procedure under one plan, and will disapprove the procedure as investigational under a different plan, although both are administered and owned by the same company.

The reality is that health care dollars are limited and insurance companies apply a cost benefit analysis to their coverage decisions, tempered against a possible public relations backlash, and the frictional hassle of dealing with the State insurance Board appeal and scrutiny. Always confer with your physicians office, and your insurance carrier. Your appeal rights are time limited, so pay close attention to any requests for information. Unless you have signed an ABN [Advanced Beneficiary Notice], you may not have to pay a bill that the insurance company denies as investigational.

Following a car accident, your nagging neck pain may not be just “soft tissue.”

Neck pain is one of the most common chronic pain conditions in modern medicine and can lead to depression, sleep disturbance, and inability to work.  Even though there may be minimal damage to your car, you can still sustain significant whiplash.  In fact, even at low speeds, occupants can experience severe whiplash, even a 5 mph collision.

The term “soft tissue” is frequently tossed around as if it is an insignificant injury; this could not be farther from reality, as even the brain, liver, and heart are soft tissue, and it doubtful you could survive long with any of these structures damaged.  Soft tissue includes

• Muscles
• Tendons
• Ligaments
• Nerves
• Discs
• Micro fractures
• Facet subluxation
• Hemorrhage or edema of the periarticular tissues (facet joints)

Correctly diagnosing the cause of neck pain is fundamental in correctly treating the symptoms and relieving the pain and improving function.

Mistakes often made by pain patients applying for private disability benefits.

1. Blindly attending an Independent Medical Exam
2. Failing to consult with a disability insurance lawyer
3. Misunderstanding the definitions of “disability” and “occupation”
4. Inadequate documentation of the claim review process
5. Believing all mental conditions are excluded or subject to limitations
6. Inadequate communication with a treating physician
7. Quantifying your time
8. Ignoring the possibility of surveillance
9. Blindly accepting that subjectively diagnosed conditions are not covered
10. Tossing out the disability insurance application, policy, and claims documents
11. Assuming that you have enough evidence for your claim if your employer says you are too sick to work.
12. Relying solely on the advice of your human resources department.
13. Documenting your disability claim using only the forms provided by the insurance company.
14. Accepting a psychiatric determination instead of a physical disability.
15. Accepting a residual claim instead of total disability
16. Not realizing the effects of social media
17. Waiting too long to seek a diagnosis and file a claim
18. Trusting the insurance company to be fair and do the right thing
19. Prescription drug abuse and the effect on disability claims

Blindly attending an Independent Medical Exam

After submitting your claim, you may be asked to submit to an “independent” medical examination by someone chosen and paid for by your insurance carrier.  Before submitting to an “independent” medical exam or any other exam, you must first ensure that your carrier has a right to conduct the exam per the policy language.  For example, a psychologist, not a physician, conducts a neuropsychological exam over several days and the carrier to deny benefits often uses the subjective findings from such an exam.  If your policy requires that you submit only to “medical exams” or exams “conducted by a physician,” there is certainly an argument that you need not submit to neuropsychological testing.  Further, you may wish to be accompanied by an attorney or other legal or medical representatives who can monitor your “independent” medical exam.

Failing to consult with a disability insurance lawyer

Patients who are considering filing a claim for disability insurance benefits are advised to meet with an attorney experienced in the area before submitting a claim.  Claim departments of insurance companies have one goal:  to pay only those claims they absolutely have to pay.  And unfortunately, some companies even take that one step further by designing their claims process to elicit information from insured’s that is then misconstrued and used to close the claim.  Their friendliness is specifically designed to give you a false sense of security so you will share more information than you might otherwise, and their helpfulness is designed to get you to trust them so you won’t question the documentation they demand, all while studying you and your claim to figure out how best to reduce or close your claim as soon as possible.  Claims examiners are on the payroll of the insurance company, meaning their employer’s instructions come first and foremost.  All of the information you submit plus the additional information they’re able to obtain is examined and reviewed with their one goal in mind.

Misunderstanding the definitions of “disability” and “occupation”

There is no such thing as a “standard” disability insurance policy, and the definition of “disability” can significantly vary.

Inadequate documentation of the claim review process

When submitting a claim and speaking with their carrier, it is important to take notes to assist them in remembering what was said in the event that their claim is denied. Patients should keep notes of all telephone conversations (including the date and time of the call, and what was said) and identify the person with whom they were speaking. Every conversation with the carrier should be confirmed in a letter sent by certified mail so that there are no misunderstandings. The “paper trail” may later be used as evidence to establish unreasonable treatment during the claim administration process.

Believing all mental conditions are excluded or subject to limitations

Most disability insurance contracts differentiate between mental and physical disabilities.  More recent policies cut off benefits for psychiatric conditions after two or three years.  Insured’s often blindly accept their carrier’s decision to deny or limit benefits based on these conditions without considering numerous relevant factors, including whether there are any physical aspects to the mental condition, whether the mental condition has a biological/organic cause, or whether another, covered condition was the legal cause of the disability.

Inadequate communication with a treating physician

Insured’s should not discuss their claim or that they are considering filing for disability insurance benefits with their treatment provider until after you have had several visits.  Physicians are often reluctant to support claims for benefits if they question the patients’ motivations.  A physician who has treated you without success will likely be more willing to cooperate.  It is also important that you communicate your symptoms and limitations to your treating physician in an organized and detailed manner so that all relevant information is recorded in your medical records, which your insurer will ultimately request. When finally speaking to your treating physician about your claim, you should ensure that your treating physician understands the definition of “disability” under the terms of the insurance policy, which can often be different than the definition as that word is normally used, so that he or she can accurately opine as to your ability to work.

Quantifying your time

You should be wary of insurance companies asking you to compartmentalize in percentages what your activities you engaged in pre- and post-disability.  To the extent that there is any crossover, companies will often deny benefits or provide benefits for merely a residual disability.  It is important that you broadly describe your important duties – rather than your incidental duties – so that your carrier has a clear understanding of the thrust of your occupation.

Ignoring the possibility of surveillance

Insurers are likely to videotape or photograph patients who have filed for disability insurance benefits; the insurance company will be watching your activities. If you do things your doctor said you shouldn’t do, it might look like you are trying to cheat the insurer.

• If the insurance company sends you an activity log to complete, that only confirms that you are being watched. Follow your doctor’s instructions carefully. Patients who engage in any activities that they claimed they could not perform and are caught on tape are likely to have their benefits denied and the contract could be terminated.
• Also, the total value of your benefit payments plays a major role in the likelihood of surveillance.  The amount of reserves set for a claimant’s disability benefits must justify the cost of the surveillance.  The cost of each surveillance operation varies, but surveillance costs usually range from $2,000 – $5,000.  This means that relatively high-value claims are more likely to be subject to surveillance than low-value claims.
• Anytime claimants meet with or talk to a claims examiner or field rep, they’re essentially under surveillance.  If a claims examiner asks to meet in your home, they are trained (and expected) to inspect the surroundings to see if there are any inconsistencies from the story of your claim.  Insurance companies hire experienced investigators and train them further on how to write reports to be used in disability claims.  For example, if you have a bad back and had to fire your housekeeper due to financial concerns, the investigator will make sure to note the immaculate condition of the exterior and interior of your house in his or her report, which can then become the basis of assumptions – that you must be able to clean and repair your home.  Or, if you sit for an extended period of time to talk with the field rep in spite of being in pain, the field report will include such observations that you are able to sit and work for extended periods of time despite whatever documentation was already provided.

Blindly accepting that subjectively diagnosed conditions are not covered

Disability insurers often deny benefits by insisting that the insured’s subjective symptoms do not provide objective, verifiable evidence of disability. In many cases, there is no provision or contractual requirement mandating that the insured submit objective evidence of disability. Therefore, the insured may be able to secure benefits with ample evidence bearing on the extent and severity of his or her limitations, which is far more important than providing a definitive diagnosis.

Tossing out the disability insurance application, policy, and claims documents

From the time of application forward, patients should keep copies of everything (including notes from meetings with the insurer’s sales representative or agent, the policy application and the policy itself). If the sales representative provided a letter or a verbal representation that the patient jotted down, those notes can go a long way if the insurer says that the policy says something different.

Assuming that you have enough evidence for your claim if your employer says you are too sick to work

The insurance company, not your employer, will be paying your long-term disability benefits. Assuming that your employer’s opinion regarding your ability to work is sufficient to qualify for benefits is a big mistake. The insurer will decide when you meet the legal definition of disability under the terms of the policy.

Relying solely on the advice of your human resources department

While human resources personnel might mean well when giving you advice, they are not trained in interpreting insurance policies, and they have no influence over the insurers for the most part. Taking action to obtain long-term disability benefits will be up to you.

Documenting your disability claim using only the forms provided by the insurance company

Your doctor must answer certain questions on the insurance company forms. But don’t leave it at that — you may need further explanation or information to prove your disability. Sit down with your physician and explain the terms of your disability insurance policy. Request that your doctor complete a report that fully explains how your sickness or condition is preventing you from performing the substantial and material duties of your occupation. Even if your doctor charges you for such a report, it is well worth the money.

Accepting a psychiatric determination instead of a physical disability

Most newer disability policies have a 12 or 24-month cap on benefits from mental and nervous conditions. Insurance companies are looking to reclassify claims because of this limitation. By reclassifying claims that may have started out a physical disability to a mental and nervous disability claim the insurance companies are able to reduce their liability. This issue relates to the last point: your doctor must be very specific in describing your symptoms and functional capacity. Many people try and work with chronic pain from back problems, but this pain may become unbearable and cause them to become depressed. If an insured files a disability claim in this scenario, the claim should be pursued for the back problems and chronic pain condition, which may not have a benefit limitation, in addition to the depression.

Accepting a residual claim instead of total disability

Most disability policies have clauses that differentiates between total and residual disability. Without going into too much detail in this overview, a disability claim is usually considered a total disability if the insured is unable to perform material and substantial duties. The claim is considered a residual (or partial) disability if the insured is able to perform some of their material and substantial duties. Insurance companies like to look past the required duties and jump to the income of the insured in order to back into a residual claim, when the job duties almost always guide this decision. No matter your current income level, if you cannot perform the material and substantial job duties, you are considered to be totally disabled in most policies.

Not realizing the effects of social media

Social media has become such an important factor in claim investigations and many people like to portray a “second” life on social media networks with their friends. These sites are the only places many disabled insured’s can feel normal and like a regular part of society. However, insurance companies may not look at it this way. If you are active in groups or forums that support activities that your restrictions and limitations indicate that you can’t do, the insurance company may try and use this against your claim. It’s important to remember that insurance company investigators can find everything about you on the Internet, and it’s next to impossible to completely remove something once it’s out on the Web.

Waiting too long to seek a diagnosis and file a claim

Successful people are rightfully proud of their career achievements and enjoy what they do for a living, so it makes sense that they wouldn’t want to stop working. In the long run, this decision can end up hurting a disability claim. Many policies require an insured to be under the regular care of a physician and have reduced or stopped working to qualify as the date of disability, not necessarily when the insured began to suffer from his or her restrictions and limitations. If you have been reducing your job responsibilities prior to filing a claim, your material and substantial duties at the time of disability may have been simplified and reduced, making your disability claim that much more difficult to prove. Likewise, if you’ve become disabled and don’t file your claim, there may be restrictions and deadlines that hurt your claim. It is important to seek medical care as soon as you are suffering work restrictions and limitations and to prudently decide when and how to file your disability claim.

Trusting the insurance company to be fair and do the right thing

Insurance companies will tout how quick and easy their claims process is when you are purchasing a policy from them or even when you request claim forms. But this process becomes anything but quick and easy as the claim process unfolds. Under the guise of trying to prevent fraud and maintain “integrity,” insurance companies teach their claims examiners to behave like your friend and convince you that they are on your side, when these statements are carefully scripted to gain your trust and make you slip up into saying something they can use against you and your disability claim. Claims examiners and their managers earn bonuses based on achieving certain claim ratios, so it is misleading to say they aren’t biased when their compensation depends on how many claims are paid or denied. It’s important to have an expert help you with your claim, someone you know is on your side and help you every step along the claim review process.

Prescription drug abuse and the effect on disability claims

Medications have been responsible for the improved the quality of life for many sick and disabled individuals, many of whom receive disability benefits from both the Social Security administration and private disability insurers.  Some patients may develop life-long dependencies to many of these drugs.  When claimants become addicted to the medications they’re using to control their disability or disease, their claims for disability benefits can become much more difficult and challenging, subject to multiple delays or denials.  Insurance companies often defend against disability claims involving drug dependence in two ways: asserting that the disability is only a “legal disability” or that the disability is intentionally self-inflicted.  These are both causes of disability that have been increasingly excluded from insurance coverage.  Legal disability can loosely be defined as an inability to work in an occupation due to legal or license restrictions, rather than a factual disability.

Chronic pain sufferers might be required to undergo “residual functional capacity,” or “RFC,” assessment.

In an RFC assessment, disability claims examiners assess your physical and mental limitations to determine whether your disability limits you so much that you can’t work full-time. Unfortunately, the claims examiners at Disability Determination Services often give short shrift to pain. One reason for this is that a disability applicant’s complaints of pain are subjective and hard to prove. And doctors who actually treat disability applicants (the “treating physicians”) commonly do a poor job of referencing their patients’ levels of pain in their treatment notes and inferring what the resulting effects might be on the patient’s ability to engage in normal daily activities. It doesn’t help matters that Social Security medical consultants, who work in conjunction with disability examiners to make initial determinations on claims, never meet the disability claimants whose medical records they read and evaluate.

However, federal court cases have held that Social Security must evaluate the intensity, persistence, and limiting effects of your pain symptoms on your ability to do basic work activities. The following factors should be considered:

• the location, duration, frequency, and intensity of your pain
• how pain affects your daily activities
• factors that precipitate and aggravate your pain
• the type, dosage, effectiveness, and side effects of medication taken to alleviate pain
• other treatments used to relieve symptoms, such as acupunture or physical therapy
• other ways you relieve pain, such as lying down or applying ice.

Your doctor should include information on the above factors in his notes so that they appear in your medical record. In addition, Social Security will want to know your doctor’s opinion on the functional limitations you have that are caused by your pain and how long your chronic pain is expected to limit your ability to function.

How Functional Limitations Limit the Type of Work You Can Do

Determining how your chronic pain limits you physically can be tricky. You may be able to stand or walk for an hour without resting, but only by gritting your teeth against the pain. Or perhaps a long walk feels fine at the time, but you pay for it later with sore muscles or exhaustion. When applying, you need to be realistic about how your pain would limit you in full-time employment. If you can only stand or walk an hour at a time by ignoring a great deal of pain, you probably cannot stand or walk an hour at a time every day to do a job. (This would mean that you are limited to doing sedentary work, or even “less than sedentary” work.)

And don’t forget to write down all the things you do to relieve your pain throughout the day. Do you have to put your feet up periodically? Do you need to lie down or nap every day? Is it important that you are able to stand up and stretch your legs when whenever you want? Do you have to apply heat or cold packs throughout the day? These are physical limitations that affect your ability to work some full-time jobs, so you need to include them in your application. Remember, if you (and your doctor) don’t write it down, Social Security won’t know all the ways your pain limits you. (For more information, see our article on why your doctor needs to document your functional limitations.)

In general, pain is not something that can be established by objective testing or observation. Only you can know whether and how much it hurts. For this reason, your credibility is very important to establish disability based on chronic pain. This is why it’s important not to exaggerate your symptoms. However, if Social Security denies you benefits because it doesn’t believe your symptoms are as bad as you say they are, the agency must have clear and convincing reasons to reject the claims in your application or your testimony.

How Activities of Daily Living Affect Your Credibility

The most important thing that Social Security considers to evaluate your credibility is your activities of daily living (ADLs). In the application process, you will provide information about what you are able to do despite your disability. For example, are you able to cook, clean, do yard work, shop, and care for children? Social Security may also send you an ADL questionnaire to fill out or make an ADL call to your friends and relatives to ask whether you can do certain activities.

Be sure to consider how your chronic pain makes everyday life difficult. For example, you may be able to do the same household chores you always did, but perhaps they take three times as long because you have to stop and rest so much. When you go shopping, do you have to have someone come along to carry the bags? What about your social life – do you still go out to see friends, or has it been months since you left your house except to see the doctor? It is important to be honest with yourself about how limited your life has become. If your activities of daily living appear normal, Social Security will find it hard to believe that your chronic pain is disabling.

How Medical Treatment Affects Your Credibility

Receiving continuous medical treatment is also very important to establish your credibility. Social Security will doubt that you have really been in severe pain if you have not sought treatment for your pain on an ongoing and continuous basis. Treatment may include non-medical or non-traditional methods such as acupuncture, massage, physical therapy, exercise, yoga, meditation, and herbal supplements. Be sure to document everything you do to relieve your pain in your application for disability benefits. If you haven’t been able to afford to see a doctor, see our article on applying for disability without regular doctor visits.

How the Mental Effects of Chronic Pain Limit Your Ability to Work

Don’t forget to consider the mental and emotional effects of chronic pain. Including information about how your pain affects your mental capabilities may be very important to establish disability through the RFC assessment. (If Social Security finds that the physical effects of your pain limit you to sedentary work, there will still be plenty of jobs you can do unless you can show that you don’t have the mental capacity for sedentary work.)

Mental effects of chronic pain often include difficulties with concentration and memory. It can be hard to learn and retain new information when you are distracted by pain. Chronic pain may also make you impatient and irritable, making it difficult to get along with supervisors and coworkers. Because chronic pain can be very difficult to live with, the emotional effects of your pain should also be considered. Living with chronic pain may cause depression and anxiety. Psychological stress may cause increased pain. If your medical providers have ever suggested that you seek therapy or a psychological evaluation, be sure to follow up. Include any diagnoses or treatment for mental illness in your disability application.

How Social Security Uses the RFC Assessment to Determine Disability

After doing a physical and mental RFC assessment on you, Social Security applies a formula that includes your age, education, and job skills to determine whether you qualify for disability. For more information, see our section about how Social Security uses your RFC to determine disability.

Questions about social security disability.

 

Many of our patient’s have suffered significant injuries which lead to chronic pain, which may preclude them from gainful employment, and I am often asked questions regarding the process of applying for disability.  This blog is intended to provide general guidance, but should not be considered legal or medical advice.

Chronic pain affects an estimated 116 million American adults—more than the total affected by heart disease, cancer and diabetes combined, according to a recent Institute of Medicine report.  Disability is more common than many people realize. According to the Social Security Administration, a 20-year-old worker has a three in 10 chance of becoming disabled before reaching retirement age.

SSDI is a payroll tax-funded, federal insurance program established in 1954.  It provides a monthly benefit for people who have worked in the past, paid Social Security taxes and are unable to work for a year or more because of their disability.

Applying for Social Security disability benefits can be difficult, due to how long a claim may take and the high chance of being denied, and many patient’s are improperly denied disability, because of documentation errors.

It is also my personal opinion that some individuals are granted SSDI inappropriately, and are in fact quite capable of gainful employment. Disability insurance takes too many workers out of the job market prematurely, reducing their lifetime income and slows American economic growth.  Keep in mind that disability insurance payments, which account for almost $1 out of every $5 spent by Social Security, are growing about 5.6 percent a year after inflation in the last two decades, compared with just 2.2 percent for other Social Security spending.  The government made $128.9 billion in insurance payments to 10.6 million disabled workers and their family members in 2011, 25 percent more than it received from payroll taxes.

There are five significant steps in determining if a patient with chronic pain qualifies for SSDI:

 

Step 1.  Is the individual presently “working (engaging in substantial gainful activity)” according to the SSA definition. Earning more than $1,010 a month as an employee is enough to be disqualified from receiving Social Security disability benefits.

Step 2.  Conclude the chronic pain disability must be severe enough to significantly limit one’s ability to perform basic work activities needed to do most jobs. For example:

• Walking, standing, sitting, lifting, pushing, pulling, reaching, carrying or handling
• Seeing, hearing and speaking
• Understanding/carrying out and remembering simple instructions
• Responding appropriately to supervision, co-workers and usual work situations
• Dealing with changes in a routine work setting

Step 3.  The Social Security Administration is required to consider pain and the limitations imposed by pain in the adjudication of a disability claim. However, before pain may be considered, a medically determinable severe impairment must be established by medically acceptable clinical and laboratory diagnostic techniques.

Because chronic pain is not a directly listed impairment in Social Security’s blue book, another medically determinable severe impairment must be established first, (which are related to chronic pain), examples include:

• inflammatory arthritis
• neurological disorders
• somatoform disorders
• back injury
• chronic renal disease
• inflammatory bowel disease

Once a medically determinable severe impairment is established, then the established impairment must reasonably be expected to produce the pain.

The Social Security Administration is required to evaluate the intensity, persistence and functionally limiting effects of the pain, i.e., how does the pain affect the individual’s ability to do basic work activities. Because symptoms, such as pain, sometime suggest a greater severity of impairment than can be shown by objective medical evidence alone, the adjudicator is required to carefully consider the individual’s statements about his/her pain with the rest of the relevant evidence in the case record. An individual’s statement about the intensity and persistence of pain or about the effect the pain has on his/her ability to work may not be disregarded solely because they are not substantiated by objective medical evidence.

The following factors are to be considered by the Social Security Administration in the assessment of pain:

The individual’s daily activities:

• The location, duration, frequency and intensity of the individual’s pain (or other symptoms)
• Factors that precipitate and aggravate the symptoms
• The type, dosage, effectiveness and side effects of any medication the individual takes or has taken to alleviate pain (or other symptoms)
• Treatment, other than medication, the individual receives or has received for relief of pain (or other symptoms)
• Any measures, other than treatment, the individual uses or has used to relieve pain (or other symptoms) (e.g., lying flat on his/her back, standing for 15 to 20 minutes every hour or sleeping on a board)
• Any other factors concerning the individual’s functional limitations and restrictions due to pain (or other symptoms)

Pain, if present, is a symptom that must be addressed in the adjudication of all disability claims.

Step 4.  The ability of an individual to perform work they have done in the past despite their chronic pain is next evaluated. If the SSA finds that a person can do his past work, benefits are denied. If the person cannot, then the process proceeds to the fifth and final step.

Step 5.  Review age, education, work experience and physical/mental condition to determine what other work, if any, the person can perform. To determine chronic pain disability, the SSA enlists medical-vocational rules, which vary according to age.

Other key elements include:

Additionally, quality for Social Security disability benefits, you must have worked for:

• 1.5 years if you are younger than age 28
• 4 years if you are age 38
• 6.5 years if you are age 48
• 9 years if you are age 58
• 9.5 years if you are age 60

Social Security pays disability benefits if your doctor expects your medical condition to last at least one year, or if your condition is terminal, as with some cancers. If your condition might not last a full year, you can look into other programs for short-term help, such as workers’ compensation or your own disability insurance. The time period that a person is eligible for benefits differs among various types of policies; it can range from a few months to a lifetime.

I Am Being Told That My Pain Is Subjective, That It Is Unprovable, And Therefore I Cannot Be Compensated. If This Is So Subjective And Mild, Why Can’t I Function?

 

I have been asked the above question hundreds of times, in one form or another, by patients, attorneys, or insurers. The reality is that pain symptoms are by definition subjective. They are after all symptoms, akin to the symptoms that one might experience after having a stroke. To document objective evidence of pain requires expensive testing of the central nervous system, which is not the standard of care, and in a non research setting would be considered medically unnecessary. However, the research has already been done and is readily available.

Chronic back pain is one of the most frequent reasons for permanent impairment in people under age 65, and yet is considered a subjective symptom and often denigrated as unprovable by third party insurers, who seek “objective” evidence of disability. The reality is that chronic pain is associated with reduced brain gray matter and impaired cognitive ability, which is reversible with appropriate and adequate treatment.

Evidence suggests that the mechanisms of chronification of pain are related to cortical reorganization, an objective functional neuroplasticity change. Brain neuro-imaging with structural MRI in patient’s experiencing chronic low back pain documents a significant decrease of gray matter in the brainstem and the somatosensory cortex which correlates with increasing intensity of pain. Interestingly an increase in gray matter bilaterally in the basal ganglia and the left thalamus, the pain transmission centers, also correlates with increasing intensity of pain. These data support the hypothesis that ongoing nociception is associated with cortical and subcortical reorganization on a structural level, which may play an important role in the process of the chronification of pain, and that the thalamic pain processing center increases in size and functionality.

Appropriate and adequate treatment of chronic pain reverses many of these functional and structural brain abnormalities, and restores gray matter in the brainstem and the somatosensory cortex.

For additional information:

http://www.painjournalonline.com/article/S0304-3959(06)00255-7/abstract
Affective components and intensity of pain correlate with structural differences in gray matter in chronic back pain patients, T. Schmidt-Wilcke, et al. May; PAIN Volume 125, Issue 1 , Pages 89-97, November 2006

http://www.jneurosci.org/content/31/20/7540.abstract
Effective Treatment of Chronic Low Back Pain in Humans Reverses Abnormal Brain Anatomy and Function
David A. Seminowicz, et al. The Journal of Neuroscience, 18 May 2011, 31(20): 7540-7550; doi: 10.1523/​JNEUROSCI.5280-10.2011

An electromyelogram (EMG) is a test that is used to record the electrical activity of muscles.

When muscles are active, they produce an electrical current. Typically, an EMG is given at the same time as a nerve conduction study (NCS). These tests are used to diagnose nerve injuries and muscle damage and are referred to as elctrodiagnostic testing (EDX). Very often they will be given to individuals who have suffered low back injuries or neck injuries to diagnose nerve damage which may be causing symptoms in the upper or lower extremities (arms or legs).

The EMG measures the electrical integrity of the spinal cord to the muscle, and is frequently normal at first even with severe spinal cord injury.

The NCV will measure how quickly and completely a person’s arm or leg nerve transfers “information”, or how quickly and completely they respond. If nerve damage has occurred very often the response will be delayed or incomplete. NCS will show conduction changes in carpal tunnel and tarsal tunnel syndromes. It is very important to note that most EMG/NCV tests are not 100% accurate, and have at least a 10-30% margin of error. Very often individuals with nerve damage will have normal EMG/NCV tests even though they are experiencing severe nerve damage. One of the critical elements in utilizing an EMG /NCS is the timing of the study in comparison to the onset of the injury.

Electrodiagnostic studies (EMG and NCS) examination may be most helpful when performed several weeks after the injury has occurred. However, NCSs are often useful acutely after nerve injury, for example, if there is concern that a nerve has been severed. In fact, if studies are delayed, the opportunity to precisely identify the region of injury or to intervene may be lost. In some cases, even needle EMG testing performed immediately after a nerve injury may demonstrate abnormal motor unit action potential (MUAP) recruitment and/or provide baseline information that can be helpful to document preexisting conditions, date the injury, or serve as a baseline for comparison with later studies.

For more detailed information go to painmd.tv