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Medico-Legal Issues Specific to Whiplash Induced TMJ Injuries

Dr. Steigerwald has produced a DVD that includes video demonstrations and accurate computer animations of a tmj whiplash injury, normal and damaged temporomandibular joint movement and more. This DVD has proven to be VERY useful for P.I. attorneys in establishing mechanism of injury/causation and has helped treating doctors to improve treatment results.
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INTRODUCTION

As trauma, especially the trauma of whiplash injury, has been identified as a precipitating factor for temporomandibular disorders, med-legal disputes frequently arise. This is specifically because casualty insurance, personal health insurance and dental insurance carriers do not want to be responsible for diagnostic and treatment costs. These companies then routinely deny coverage and compensation.

The general topic of temporomandibular disorders is a point of contention within the worlds of personal health and dental insurance because of the lack of specificity in identifying the signs and symptoms of TMD, a complete lack of standardization of protocol for diagnosing and treating them and the prevailing myth that TMD is a dental disorder. This allows any health insurance company to pass off diagnostic and treatment costs to the patients’ dental insurance. The dental insurance may well have a TMD exclusion (or not recognize TMD) and then the bills are then routinely denied.

The issue of traumatic causation is another issue. Casualty insurance carriers do not want to be responsible for TMD treatment delivered when causation is linked to trauma to persons insured by their companies. While coverage here is denied aggressively on the basis of causation, the same issues of diagnostic accuracy, need for treatment(s), acceptable treatment protocol(s) and prognosis are shared by all of these insurance entities.

Financial responsibility rests more heavily with the casualty insurance carriers however, as they do not have the same TMD exclusion clauses found in the health and dental insurance policies. Thus, for one reason or another, many TMD cases come to be litigated. This places a burden on all health professionals treating TMD and brings them into the world of lawyers and litigation. The good news is that examination, diagnosis and treatment of TMD is held to a higher standard. This is good for all concerned.

CAUSATION

The whiplash event has been implicated as a causation for temporomandibular disorders by epidemiologic studies of both whiplash patients and TMD patients. Imaging studies of post whiplash TMD patients have resulted in the same conclusions. Further, the proposed pathogenic pathway of whiplash induced TMD has been verified by computer model. In stark contrast to this, other proposed pathogenic pathways such as malocclusion and bruxism have failed epidemiological scrutiny and substantial statement has been made in the scientific community discounting the relationship between these factors and the development of temporomandibular disorders. This is not to say that these factors may not act as predisposing and perpetuating factors for a temporomandibular disorder, but the presence of these factors does not predict the eventuality of TMD and should not be used to discount the probability that a specific temporomandibular disorder onset following a traumatic event. Specific defense arguments against whiplash induced TMD claims from a causation perspective include:

  1. Pre-existing bruxism.
  2. Preexisting malocclusion.
  3. Preexisting clicking.
  4. No direct blow to the mandible.
  5. Prior injuries.
  6. Radiographic evidence of temporomandibular joint remodeling.

The key issue here is that a TMD exists only if there are symptoms. Treatment is not recommended for asymptomatic individuals even in the presence of signs indicating less than optimal jaw function. To date, there are no predictive signs for the eventual development of a TMD. This includes malocclusion, bruxism, temporomandibular joint clicking and temporomandibular joint remodeling. Patient history, including record review, stands as the key issue in developing a causation statement and may very well identify a precipitating event as causative and then identify other factors as perpetuating or even predisposing. The ability to accurately identify and then clearly demonstrate the precipitating event will determine the strength of the causation statement.

MECHANISM OF INJURY - WHIPLASH INDUCED TMD

It appears most probable that immediate damage to the temporomandibular joints themselves is produced by a combination of mechanical forces resulting from the vehicular collision and abnormal or accelerated muscular forces acting during joint movement produced by the collision. That is, abnormal muscular forces encountered during the collision are capable of producing injurious forces within the joint which may be disproportionate to the force of the impact of the collision. Certain predisposing factors such as pre-impact disc position may also effect the nature and degree of injury.

Normally, the mechanics of mouth opening occurs so as to protect the internal environment of the temporomandibular joint from undue compression during both rotation and translation.

The first movement which occurs during mouth opening is depression of the mandible secondary to relaxation of the elevator muscles and the effect of gravity. This allows for a minimum of joint compression during condyle rotation and translation thereby minimizing wear and tear on, or even frank injury to, the discal and cartilaginous components of the joint. Theoretically, if mouth opening, even partial opening, occurred without this decompression then forces would be placed on the components of the temporomandibular joint which could produce tissue damage in the joint. In point-of-fact, during the whiplash event it is quite possible that the elevator muscles contract as both rotational and translatory movements take place between the condyles and their respective mandibular fossae. This then would increase rather than decrease joint compression as the mandible and skull move relative to each other during the whiplash event. However, even if muscular tonicity was only maintained during joint movement, this would represent abnormal joint mechanics.

Furthermore, during the whiplash event, it is the 8 to 14 pound skull which moves relative to a less actively displaced 4 to 6 ounce mandible which is held in place by the hyoid muscles and other anchoring tissues. This is the reverse of the normal kinematics for the temporomandibular joint. Finally, these movements occur at an accelerated rate which adds to the stress on the region. The whiplash event then most probably produces frank tissue damage to the temporomandibular joints by:

  • Damaging certain aspects of the ligamentous support system of the temporomandibular joints during the reversal of normal skull-mandibular movement dynamics.

  • Disturbance of, or elimination of, normal protective muscular synergy by the reversal of these dynamics. As this affects the external pterygoid musculature it may produce injury to the disc complex. That is, the muscles which contract normally during mouth closure may contract reflexively while the mouth opens during whiplash.

  • Excessive Joint compression during joint movement secondary to maintenance of or increase in, rather than a decrease in, elevator muscle activity during joint motion. This may affect the disc proper and the joint surfaces as well as the retrodiscal tissue in those patients who possess pre-trauma anterior discs.

  • Accelerated condyle/disc/fossa dynamics during joint movement.

I would note here that the investigation into the mechanics of the mechanism of temporomandibular joint injury from whiplash is ongoing. Please note that in the UCLA computer model, while abnormal mechanics were noted which support the statement that abnormal temporomandibular joint mechanics were observed, questions concerning tissue tolerances remain. Once again, while the mechanics of the injury are interesting, the historical relationship of symptoms to event remains at the heart of the causation statement.

Frank tissue damage is not the only factor involved in the mechanism of injury for the temporomandibular joints however, although it is the most immediate. Other factors may subsequently act on the inflamed temporomandibular joint and perpetuate or even escalate what then becomes an inflammation/scarring process. Some of these factors are a result of the whiplash event e.g. cervical injury, and yet other influences may represent predisposing architectural, psychological, chemical and postural qualities possessed by the individual injured prior to the whiplash event. These predisposing and/or perpetuating factors frequently involve the very same patient profile pointed to by the defense as causative: malocclusion, bruxism, psychometric profile, tissue weakened by prior injury, arthritides, allergies and chronic pain issues. Care taken in identifying these factors will improve your treatment results and sustain your causation statement.

MECHANISM OF TMJ INJURY FROM A WHIPLASH EVENT SHOULD BE VIEWED AS A FUNCTION OF THE FOLLOWING FORMULA:

Frank tissue damage to TMJ apparatus affected by:

  1. Predisposing/perpetuating factors
  2. Influence of other injured areas, e.g. cervical spine
  3. Acquired parafunction, e.g. pain induced clenching and sleep disturbance

RADIOGRAPHIC IMAGING

Many medical/legal arguments concerning the proposed pathogenesis for a temporomandibular disorder center around radiography of the temporomandibular joints. Radiography (tomograms, transcranial views, panographic views, etc.) may provide useful information concerning fracture, tumor invasion and specific arthritides. Absent these factors x-rays should not be used to make a statement concerning the prior existence of, presence of or probable development of a temporomandibular disorder. While this is clearly referenced in the literature, x-rays are routinely used inappropriately to discount trauma as the causation in a temporomandibular disorder. Specific statements generally reference alterations in cortical bone shape of the mandibular fossa and condylar head despite the fact that longitudinal studies as well as electron microscopic studies of the temporomandibular joints have stated clearly that alteration in bone shape within the temporomandibular joints will occur within a normally functioning joint and that these joints are capable of extensive remodeling without pathologic process. Temporomandibular joint tomograms have demonstrated a statistically significant relationship between posterior condyle position in centric occlusion and anterior disc position. This has not however been linked to the symptom expression of TMD.

MECHANISM OF INJURY

One of the most frequent arguments made opposing the concept that whiplash precipitates TMD is that injury to the temporomandibular joints is impossible absent mandibular contact. A substantial body of literature stands in opposition to this perspective. In one review of 113 cases of temporomandibular disorders reported to arise from vehicular collisions only one person reported contact of the mandible within an interior structure of the car. In another study comparing whiplash victims without facial/head contact, whiplash victims with facial/head contact and overt facial/head trauma cases general symptom expression was seen to be similar, however, there were distinct differences noted concerning specific clinical findings. The proposed pathogenesis of temporomandibular joint injury from a whiplash event absent mandibular contact has been confirmed by computer study. Studies of whiplash patient populations and a population of temporomandibular joint surgical candidates supports this position.

TIMING OF ONSET OF THE DISORDER

Another issue frequently raised concerns the timing of the onset and/or identification of the temporomandibular disorder following the trauma in question. There are multiple issues involved here yet this point is frequently oversimplified with the statement made that if a temporomandibular injury was truly sustained as a result of a vehicular collision, the disorder would manifest immediately or at least within 24 hours of the trauma. In point of fact, this argument should be divided up into:

  • Onset of disorder
  • Patient recognition of disorder
  • Diagnosis of disorder

1. ONSET OF DISORDER

Under this heading one must consider the definition of a temporomandibular disorder and differentiate local symptom expression from peripheral symptom expression. The temporomandibular joint injury is a complex affair which may involve injury to support ligaments, articular tissue, synovial tissue, muscular and neurological elements of the temporomandibular apparatus. Injury to this region may well produce peripheral symptoms such as headache, neck and shoulder pain/spasm, ear symptoms and vertigo before producing local signs and symptoms of dysfunction. This is in large part due to the fact that the discs and articular surfaces of the temporomandibular joints have no nociceptive neurology. That is, while the internal environment of the temporomandibular joint is rich in proprioceptive neurology, local pain perception secondary to injury may be poor and further may be mediated by the central nervous system. Inflammation within the temporomandibular joint may well then irritate neurology which, while not producing local symptomatology, may well influence the brain stem and produce peripheral symptoms. These peripheral symptoms may well dominate the symptom picture until synovial tissue stimulated by the inflammatory process grows over the articular surfaces producing local pain. Local symptoms may also be delayed until scar tissue organizes to produce local destabilization of the joint. This may take weeks to months. The argument is frequently made that an injury to the temporomandibular joints would produce swelling within the joint that distends the pain sensitive capsule thus producing local symptoms. This level of injury would most certainly be considered severe and appears to be a phenomena limited to a minority of cases.

2. DELAY IN PATIENT RECOGNITION

Patients injured during a whiplash event are frequently subject to multiple sites of injury. These injuries produce a constellation of symptoms which can and frequently do mask the presence of a temporomandibular joint injury. Of particular note is the tendency for the symptoms expressed by cervical injury to overlap with those peripheral symptoms produced by a temporomandibular joint injury, e.g. headache, neck and shoulder muscle pain. This frequently leads to delay in patient awareness of jaw involvement in the symptom picture. Thus, the patient is frequently slow to report the involvement of the jaw to the treating or examining doctor. Complicating this issue is the fact that the relatively non-pain sensitive temporomandibular joint may produce local signs before local symptoms and those signs such as clicking, popping and intermittent/ partial locking of the temporomandibular joints may not be appreciated as signs of a substantial disorder by the patient. Thus, once again delaying report to the treating physician.

3. DIAGNOSIS OF DISORDER

As TMD has long been considered a subset of dental/chronic pain disorders and due to the focus on spinal, paraspinal and primary neurologic injury following the whiplash event the portal of entry physician frequently fails to examine the temporomandibular joints in the post trauma scenario. This includes failure to question the patient concerning this region and to perform the routine tests appropriate for evaluation of the region. This stands at the heart of many medical/legal issues and frequently leads to under appreciation of the whiplash event in question as the precipitating factor for TMD. This not only compromises the plaintiff's case on causation grounds but raises potential malpractice issues for the treating doctor on grounds of failure to examine and failure to diagnose. Doctors should be aware that within the scope of the paradigm shift toward rapid management of traumatically induced temporomandibular disorders these issues of standard of care responsibilities will be raised more frequently. The question of whether earlier identification of the temporomandibular disorder following trauma and the appropriate treatment and referral of the patient would have obviated the need for an eventual surgical resolution has been raised frequently over the past year. Questions of malpractice have arisen over this issue. Specific to the assignation of causation in an alleged temporomandibular joint injury, failure to identify the TMD component of symptom expression may well lead to claims being denied and appropriate compensation lost. This is a very difficult problem to overcome even with appropriate and accurate retrospective analysis. Portal of entry examination and re-examination during the first four months post trauma will serve to avoid this problem only if findings are documented. Undocumented suspicions are useless. Do not speculate, however, not every whiplash produces TMD and over-diagnosis is inappropriate. Diagnosis should proceed from history and findings and only a specific TMD diagnosis should lead to treatment, monitoring and/or referral. Support your findings.

OTHER IMPORTANT MEDICOLEGAL ISSUES

The treating and/or examining doctors are frequently asked to describe the effect of the trauma induced temporomandibular disorder on the lifestyle of the patient. It should be made clear that temporomandibular disorder patients, especially those who suffer from symptom expressive internal derangement, suffer and suffer greatly when the disorder is acute. The doctor should not be shy about expressing this both in reports and at trial. The doctor should accurately and fully describe the disorder and its effects during the time of treatment, but should not overstate future suffering in healed patients. Overstatements of future suffering serve to discredit the doctor and diminish the appreciation of the suffering that has occurred. Overstatement of future suffering and need for treatment may well also inappropriately color the record of the patient in the event of future trauma and/or other insurance related questions. The main issues to be addressed in expressing the effect on the patient's lifestyle include:

  1. Limitations in diet, this decreasing both the pleasure one associates with eating and the nutritional value gained from a full diet.

  2. Limitations in sexual expression and other expressions of affection which involve use of the mouth as well as the head and neck.

  3. Limitations in the capacity for full and expressive speech and laughter.

  4. Limitations in the capacity for free and unrestrained expression between the parent and children, especially as this involves holding a young child as the threat of unexpected forceful contact with the mandible of the patient is very real.

  5. Restriction of yawning which is a natural and universal act and which is very difficult to control.

  6. Pain and/or medication mediated marital, and/or social and occupational difficulties.

  7. Work, preclusions with associated loss of self esteem and/or loss of income.

In this last regard, disabilities and specific work preclusions occur as a result of temporomandibular joint injuries. This may involve restricted capacity to use the mandible or may be a result of peripheral symptoms of the TMD. These symptoms include: neck pain, upper extremity pain/paresthesia, dizziness, tinnitus, headache and/or fatigue. These symptoms may individually or jointly compromise the patient's work capacity. While each case must be considered individually, the occupations most affected are those that require repetitive mandibular use. These occupations as well as those that strain the cervical region threaten to perpetuate and even escalate the disorder. Specific work preclusions frequently include:

  1. Repetitive and/or expressive speech.
  2. Prolonged forward head and neck posturing.
  3. Repetitive/heavy lifting, pushing and pulling.
  4. Exposure to head and/or neck trauma.
  5. Exposure to loud noises and/or need for acute hearing.

Specific occupations which are affected most frequently by temporomandibular disorders include teachers, telephone operators, telemarketing personnel, sales persons and others who must speak repetitively and expressively as part of their job description. Issues of temporary and total disability will frequently be addressed and it is recommended that persons who fit this occupational profile should be put on temporary total disability or at least be reassigned with a job modification to eliminate the need for repetitive speech during the active treatment in the acute stage's of the symptom expressive internal derangement. Temporary total disability is generally extended to all patients during the first two to three weeks postoperatively. Issues of partial permanent disability and vocational rehabilitation are uncommon for TMD patients but do arise. Patients who require these more extreme ratings should be thoroughly examined to determine if an improved M.M.I. status can be reached.

SUMMARY

Temporomandibular disorders have historically been considered chronic pain presentations arising from malocclusion, bruxism and stress. This view of temporomandibular disorders prevails in our society and serves to discriminate against the patient who has developed a temporomandibular disorder secondary to trauma. Effective treatment of the trauma induced temporomandibular disorder requires a treatment protocol which stands separate from the treatment protocol for chronic pain disorders including insidious onset TMD. Effective medical/legal management of the trauma induced TMD requires an understanding of the literature which supports this position. The doctors involved in treating these disorders will facilitate the medical/legal process by:

  1. Providing timely and thorough examinations.

  2. Arriving at clear and scientifically accepted diagnoses.

  3. Making appropriate referrals on a timely basis.

  4. Communicating effectively with the doctors to whom they refer.

  5. Providing appropriate and accepted therapy including and beginning with home care.

  6. Thoroughly documenting all findings, diagnoses (including diagnostic updates), referrals and treatments.

  7. Limiting treatment to accepted time frames.

  8. Defining permanent and stationary goals within realistic expectations.

  9. Clearly outlining the need for any future care as well as explaining the lifestyle and disability impact on the patient's life without overstating anticipated future suffering of healed patients.

  10. Being prepared to defend decisions made concerning causation statements, referrals made and treatment delivered based on current literature.

Temporomandibular disorders are a serious health problem in the United States with billions of dollars spent every year treating the chronic expression of these disorders. With the evolving evidence that many of the more serious temporomandibular disorders begin following a traumatic event, including whiplash, identification of the trauma induced TMD becomes an important issue in our motorized society. In the adversarial environment within which these disorders are handled the medical/legal management of these disorders becomes equally important with the medical management of the disorder. Ineffective medical/legal management discourages doctors from actively treating these disorders and causes great hardship in the life of the injured person. This unfortunate situation need not exist and it is hoped that the guidelines established in this workbook will help to make this difficult problem more manageable.

MEDICOLEGAL CONSIDERATIONS AND TECHNIQUES

  1. Initial Intake Documentation
  2. Progressive Documentation
  3. Communications with the Attorney
  4. Deposition of Health Care Professionals and Medical Experts
  5. Trial Testimony of the Health Care Witness
  6. The Health Care Professional employed as an Expert


1. Initial Intake Documentation

A) History:

  1. Identify other health providers.
  2. Inquire as to past claims (workers compensation, personal injury: with or without lawsuit).
  3. Set forth the "what" "when" "where" "why" & "how" of the mechanics of the injury AND the symptoms and complaints. Read back what you record to the patient for acknowledgment of accuracy.

B) Preliminary Diagnosis:

  1. Identify intended treatment regimen to be applied both in your office and by the patient at home.
  2. Record expected nature and timing of improvement and/or referrals.
  3. Identify other treating doctors.
  4. Determine nature and timing of needed or possible referrals.
  5. Initiate and maintain TEAMWORK with other doctors providing patient care.

C) Obtain past films and/or take good quality films as needed

D) Obtain lien and authorization for information release:

  1. Have lien signed by patient and patient's attorney.

  2. Require prompt notification by patient and attorney if a new attorney is acquired.

  3. State that you are providing the lien as an accommodation to the patient to defer payment but that it should NOT be construed as an engagement of the attorney to collect money owed to you by the patient or a third party because you are not engaging the attorney in any capacity.

  4. An attorney cannot directly/ indirectly pay, agree to pay, or guarantee payment of a client's medical bills. (However, an attorney can lend money for such a purpose, to a client provided the loan is based upon a written promise to repay the loan).
    California Rule of Professional Conduct 5-104(A).

  5. Consider the option of filing a lien notice with the court case and/or with the defense insurance carrier.


2. Progressive Documentation

A) Develop good reporting habits and train your staff to record accurately, thoroughly and clearly:

  1. Review the entries of your staff.
  2. Make entries legible, thorough and specific.

B) Act as though a defense IME is looking over your shoulder.

C) Record all symptoms, complaints and exacerbating events (who, what, when, where, how, why as to each):

  1. Repeat/read back to patient what [s]he reports.
  2. Do not omit information that you fear to be problematic; instead, acknowledge it and try to rule it out as a problem [perhaps over time].
  3. Do not be cheap with paper: Be thorough, try to keep from writing about one visit on two sheets, use a whole new sheet.

D) As to EACH treatment provided (state the type, duration, strength and location of application of each modality):

  1. Clearly distinguish the location of symptomatology from the treatment site.
  2. Perform and document periodic review of diagnosis, treatment regimen, and outside referral needs.
  3. Be certain to chart note all telephone conversations with the patient and other treating physicians.

E) It is the Plaintiff's duty:

  1. To seek necessary medical treatment of his/her injuries (BAJI 14.67).
  2. To follow his/her doctor's reasonable and proper advice and instructions regarding treatment, care, and activities (BAJI 6.28). *The doctor should monitor the patient to see that [s]he is following the advice given.


3. Communications with the Attorney

A) Help determine early on:

  1. Who all the potential defendants are
  2. Whether there is a valid claim vs. third part[ies]
  3. Theories of liability
  4. Consultant[s] regarding the foregoing, advise the attorney regarding the competence, courtroom presentability, and reputation, of each so as to counter the anticipated defense IME.

B) Recommend books and treatises on the pertinent ailment, organize a study group library and updated bibliography.

C) Provide reports requested by the attorney:

  1. The doctor should only prepare medical reports IF they are requested. There is a risk that early written reports will be overly optimistic and offer premature conclusions. Further, there is a cost for such reports that may not need to be incurred.

  2. Be careful about: communicating with the plaintiff's attorney by letter or recording telephone communications with the attorney in the chart notes or saving message memos.

  3. Note that it is improper for the defense attorney to unilaterally contact the treating doctor to privately discuss injuries, treatment, prognosis (Torres v. Superior Court (1990) 22 CA3 181).

  4. Discuss the report contents and any problems in advance so as to be thorough, and to cure/ameliorate and/or candidly confront problems.

  5. Discuss and prepare reply report to defense IME report.


D) Prepare attorney to effectively depose and/or cross-examine the defense expert.

E) Prepare with the attorney for your deposition or arbitration or trial testimony.


4. Deposition of Health Care Professionals and Medical Experts:

A) Often the doctor is not as well prepared for a deposition as at trial, thereby enhancing the attorney's prospect of successfully attaining the goals of a successful deposition.

B) Lawyers will consider the following to be points in favor of taking a deposition and goals to reach in taking the deposition:

  1. To help evaluate the strengths and weaknesses of the case
  2. To prevent surprises at trial
  3. To pin down testimony on particular points
  4. To elicit favorable admissions
  5. To determine whether recognize standard tests/procedures were conducted
  6. To expose biases

C) Opposing counsel will consider the following to be reasons NOT to take a doctor's deposition:

  1. It forces the witness to think and prepare
  2. It perpetuates the testimony of the witness for use at trial when the witness might otherwise be unavailable later
  3. It exposes to opposing counsel and the witness the thrust of anticipated trial cross-examination, thereby allowing for more effective pre-trial preparation by the witness
  4. It provides the witness with a practice session of questioning and a transcript to review before testifying at trial
  5. It exposes weaknesses which can be remedied for trial.
  6. The cost of the deposition

D) Often a deposition will be scheduled by a notice accompanied by a written request to produce the following documents:

  1. Curriculum vitae
  2. All documents relied on in forming opinions
  3. All documents generated regarding examination, treatment and care
  4. All materials published by the expert
  5. All demonstrative evidence [s]he might use to explain testimony
  6. All transcripts of prior testimony taken
  7. All ledgers/time records regarding his/her retention by the attorney in the case

E) The examining attorney will generally cover the following areas in a deposition:

  1. Who the witness spoke with and what documents (s]he reviewed to prepare for the deposition [to refresh recollection]
  2. The medical history as the witness knows it [including birth defects, prior accidents and illnesses, predispositions)
  3. Details obtained about the plaintiff's claimed injuries
  4. Description of the treatment, advice and instructions given the plaintiff
  5. Description of any symptoms of emotional distress
  6. Information about any subsequent accidents, injuries, or illnesses and their impact upon the claim
  7. The amount and reason for medical expenses

F) Plaintiff's attorney ideally does the following in advance preparation for the witness's deposition:

  1. Describes the deposition process, the customary deposition instructions, and the potential of videotape to insure preservation of the testimony if [s]he is later unavailable for trial

  2. Explains its purpose and the consequences to the plaintiff's case

  3. Reviews with the witness all records, including tests and x-rays

  4. Discusses any weaknesses in the records and the anticipated testimony
  5. Asks if the witness is familiar with opposing counsel

  6. Discusses the style and tactics of opposing counsel

  7. Reviews for consistency the witness prior writings and deposition or trial testimony in this and other cases

  8. Reviews the opinions and bases for them as to the following:
    a. Diagnoses
    b. Medical causation
    c. Prognosis Recommendations for future treatment
    d. Anticipated future limitations of the patient

  9. Makes sure the witness appreciates that the correct legal terminology of "reasonable medical certainty" refers to probability, not scientific certainty as distinguished from "possible"

  10. Discusses the theories of opposing counsel regarding medical causation and the injuries

  11. Warns the witness NOT to go beyond his/her expertise

  12. Explains how to respond to questions regarding compensation and that the law, including statutes, entitle the expert witness to "reasonable compensation" for time to testify both at deposition and trial, time to travel to and from, court, and the cost of remaining at the locale of the trial when subpoenaed

  13. Provides for review all available, relevant and necessary information if the witness is to be asked to serve as an expert, including: a. All medical records and deposition transcripts of other doctors involved, includes pre-trauma records
    b. Deposition transcripts of the parties and witnesses involved with knowledge of the cause and nature of the injuries
    c. Deposition transcripts of the opposition's experts, if available, to anticipate cross-examination

  14. Provides the witness copies of jury instructions such as those on assessing credibility, evaluating expert testimony, and the use of hypothetical questions (see BAJI 2.20, 2.40 - 2.42]

  15. Warns the witness that cross-examination will often seek to elicit the following admissions:
    a. The existence of many "possible" causes for injuries so as to move the witness from a "Probable" causal relationship to
    only a "possible" one
    b. [S]he is not an expert in a certain area
    c. That others are more qualified
    d. That [s]he would defer to another expert

G) Deposition fees (per CCP 2034(i) (2) in California):

  1. The designated or retained expert cannot charge an hourly fee to opposing counsel that exceeds the sum charged the retaining party.
    a. "A party desiring to depose any expert ... or treating physician who is to be asked to express an opinion during a deposition, shall pay the reasonable and customary hourly or daily fee for the actual time consumed in the examination..."
    b. The fee is payable in advance of commencement of the deposition and, if it runs overtime, the balance is payable within five days of receipt of an itemized statement.

  2. Travel time, travel expenses and preparation time are not chargeable to the deposing party.

  3. If a witness is not designated as an expert, then the request during deposition for one (1) opinion is enough to trigger the right to expert fees. But testimony regarding observed symptoms, progress notes and conversations with plaintiff do not trigger fees.

  4. An attorney designating a witness as an expert must sign a declaration under penalty of perjury stating:
    a. You have agreed to testify at trial
    b. You will be sufficiently familiar with the case to submit to a meaningful deposition
    c. In brief narrative form, your qualifications
    d. In brief narrative form, the substance of your anticipated testimony
    e. Your hourly and daily deposition fee

H) Opposing counsel can ask about all information considered and reviewed by the witness:

  1. Including cover letters
  2. Including conferences held (even during deposition or trial)
    a. Except communications containing the attorney's "work product": conclusions, opinions, legal theories
    b. Except objective material [e.g., tests] used to prepare for litigation, unless good cause is shown for its revelation

I) Outline of Deposition Inquiry

  1. Background and qualifications:

    -Name, address, age
    -Educational background [e.g., chiropractic college, medical school, internship, residency]
    -Special training in field of expertise (fellowships, military]
    -Teaching experience
    -Employment background
    -Papers, books and articles published, or reported lectures on material subjects
    -Memberships in professional societies and organizations
    -Hospital staff memberships [durations, offices held; regarding hospital privileges and surgical privileges - ask if ever been challenged or revoked]
    -
    Honors, prizes, or special recognition
    -
    Specialty board certification obtained, and whether ever revoked or suspended
    -
    Licensed by any governmental authority to practice in field, and whether ever suspended
    -
    Trade or professional journals subscribed to or read
    -Name of standard text or references used in expert's area of expertise, including those in his or her own library
    -Previous testimony of expert [deposition, arbitration, trial]
    -Frequency of testimony and breakdown of percentage of time testifying for the defense as opposed to the plaintiff
    -Amount of time devoted to performance of medical legal examinations
    -Financial arrangements for appearing as an expert witness
    -Whether doctor handles/handled the subject procedure
    -Where do you get your patient population?
    -How often were you the primary doctor to come up with this diagnosis?

  2. Facts of retention as expert:
    -Date first retained
    -What expert was requested to do
    -What information was supplied to expert and when it was supplied
    -What objects or documents were supplied
    -Time spent working on case

  3. Medical history - what your understanding of facts?
    -Who obtained it Procedure used to elicit and record
    -Significance of medical history
    -Symptoms elicited and their importance
    -Circumstances of the injury-producing incident
    -Medical/dental/chiropractic history before incident

  4. Physical examination and findings
    -Physical appearance and mental status of examinee
    -Length of examination and identity of all persons present
    -Description and purpose of each clinical test or manipulation, the findings of each, and the significance of the findings
    -Description and purpose of each special diagnostic procedure [e.g., x-rays, lab tests], the findings of each, and the significance of the findings
    -Description of all other findings made, and their significance
    - Interpretation of each illegible entry in the medical records

  5. Opinions
    a. Each opinion or conclusion reached:
    -Diagnosis - physician's opinion regarding the nature, extent, origin, and effect of injuries
    -Medical causation - physician's opinion of the relationship between the diagnosis and the injuries suffered in the incident
    -Prognosis - physician's opinion on the future effect of plaintiff's diagnosed injuries, e.g., permanency, susceptibility to future problems
    -Recommendations regarding future treatment, e.g., future physical therapy, future surgery

    b. The basis for each opinion and conclusion, e.g., physician's own experience and observations, medical text, reports of other physicians, test results, hospital records, statements of the patient. Many experienced attorneys also delve into the "state of mind" of the expert to explore his or her reasoning rather than accepting it at face value. This helps pin down the expert's reasoning process and may help impeach the opinion. Certain questions in this area will be helpful whether the answer is "yes" or "no. For example, one might want to inquire about whether the expert "considered" certain facts. An expert later may be criticized for not considering certain facts.

    c. Is there a recognized contrary school of thought? Who are the advocates thereof?


J) Procedural Techniques to Maximize the Quality of Deposition Testimony

-Anticipate areas of inquiry
-Only answer the questions posed
-Respond directly with active verbs rather than passive
-Qualify answers only as necessary
-It is better to understate testimony to avoid engendering the distrust of the trier of fact
-Avoid coming across as an advocate
-Avoid red-flagging problem areas Avoid reaching conclusions opposite those previously expressed
-Stay within your area of qualification: only reference that outside your field which has been shared with you by other "team members" and which you have considered
-Have ready for reference: chart notes, curriculum vitae, billing records
-
Do not engage in any conferences with defense attorneys regarding your patient outside the presence of plaintiff's attorney

5. Trial Testimony of the Health Care Witness

A) Pretrial Conference with Attorney:

  1. Preceded by receipt of copy of the deposition transcript of the witness [and of any opposing doctor] and all pertinent records and reports for review in advance of conference

  2. Review materials to see witness has items needed

  3. Review witness' deposition know it

  4. Review curriculum vitae to skip irrelevant and avoid potentially harmful elements, anticipate and defuse weak areas

  5. Discuss form of questions to best elicit direct testimony; help formulate the questions that are clear to you to enable the plaintiff's attorney to extract ALL the pertinent information from you

  6. Unlike a non-treating doctor, a treating doctor may reasonably rely upon the opinions of other doctors consulted by the plaintiff

  7. If witness has relied upon scientific principles in books or other writings [hearsay], [s]he should be able to state that the principles are frequently used and respected by other doctors in the field, having gained wide acceptance

  8. The medical opinions of the witness should be based upon facts reasonably relied upon by other doctors in the same field

  9. Choreograph the use of demonstrative evidence [charts, x-rays, blowups, medical drawings, models] which will enhance the presentation of direct examination

  10. Discuss cross-examination:

    a.
    Avoid anger, argument, sarcasm, and being "cute"

    b. Stay within qualifications

    c. Expect questions regarding:
    -Fee to testify
    -Lien for unpaid bill
    -Percentage of practice related to legal work [professional witness]
    -Frequency of testifying more for plaintiffs than defendants [or vice versa]
    -Inconsistencies within or amongst records, deposition, prior depositions/ trial testimony, and writings of witness
    -Inadequate testing [objective vs. subjective]
    -Inconsistencies between the position of the witness and the position of [an] authority[ies] who the cross-examining attorney has gotten the witness to acknowledge as an authority
    -The witness, reliance upon information from others [e.g., the patient] which, if incorrect, undermines the medical opinion of the witness
    -Inquiry into the adequacy of training, experience, research and conduct of relevant tests

    d.
    Look for "how" and "why" questions as openings to express your points.
    -Most questions will be leading to control the responses of the witness, especially one who is strong and/or verbose.

    -Listen carefully to hypothetical questions with changed facts posed to obtain the expression of a desired opinion [i.e., attack on underlying assumptions].

    e. It is improper to cross-examine with professional text or journal unless the witness has referred to, considered or relied upon it in forming an opinion in the case.

    f. Witness can only be cross-examined with tests considered or relied on by him/her; NOT with tests unfamiliar to the witness or a contrary opinion not relied upon by the witness.

    g. Take time to study any chart, diagram, x-ray or photo presented; do not precipitously respond to questions regarding them.

    h. Goals of opposing attorney during the cross-examination are:
    -To discredit the witness personally via qualifications, bias, or personal interest
    -To discredit the factual basis for direct testimony To discredit conclusions and opinions stated on direct
    -To elicit admissions and facts beneficial to the defense

    i. Opposing attorney can voir dire an expert witness before direct examination regarding education, experience, memberships and publications

    j. Examine all documents presented before testifying about them

    k. Be able to defend the bases of medical opinions [anticipate that opposing attorney will have reviewed any treatises relied upon in quest for a contradiction or inconsistency]

  11. Have the attorney familiarize you with the geography of the courtroom, courtroom procedure, and the judge's proclivities in advance, visit a courtroom and sit in a witness chair

  12. Formulate opinions[s] regarding the mechanism of injury and the cause of residual symptoms, findings and disabilities, with the following in mind:

    a. Burden of proof = reasonable medical certainty, not scientific certainty

    b.The importance of establishing a clear diagnosis for each injury and basis for each diagnosis

    c. Plaintiff can recover for aggravation of a preexisting condition; (BAJI 14.65]

    d. Plaintiff can recover for disease or subsequent injury caused by lowered vitality or from an impaired condition resulting from the original injury; and (BAJI 14.66]

    e. But plaintiff also has the duty to mitigate damages, i.e. must act reasonably to recover (BAJI 14.67]

  13. Discuss scheduling.

B) At trial, wear: Suit, white shirt, and tie or dark dress, modest and small amount of jewelry, and a new haircut, do not talk so as to be overheard by jurors during breaks.

C) Five Rules to Remember When Questioned:
-Listen to the question: ask for it to be repeated
-Understand the question: ask for it to be rephrased or explained
-Think about the question: take time to give an accurate honest answer and to allow the attorney to object to the question if deemed necessary
-Answer only the question: do not volunteer comments or information
-Answer truthfully and honestly: if you do not know or do not remember, say so

D) General Considerations to Effectively Handle Cross-Examination:

  1. Do not get angry, sarcastic, argumentative, cute or rude.

  2. Do not appear evasive or equivocal; keep answers short - yes or no if possible unless given a clear opening to make point.

  3. Expect that you will have to concede points.

  4. Expect questions aimed at impeachment:
    -Interest in having your fees/lien paid
    -Length and nature of acquaintanceship with the patient
    -Percentage of your work that is legal cases
    -Frequency of testifying for plaintiffs

  5. Anticipate possibly being confronted with prior inconsistent statements in this case or other cases in reports, depositions, writings, speeches and other trials.

  6. You can only be cross-examined with a scientific or professional text which you considered in forming an opinion or which has been admitted into evidence in the case [rare].

  7. Watch for the summarizing testimony question, which often contains subtle changes: if inaccurate, simply say so without saying more; if it appears accurate, say that it appears generally accurate, but that your earlier testimony is more accurate.

  8. Watch for questions which ask you to assume facts you have not verified; unless in the form of a hypothetical question, it is improper.

  9. Watch for questions using the words never, always and those calling for speculation, such as isn't it possible?

  10. Do not feel compelled to provide precise recall; give your best recollection.

E) Outline of Presentation of Trial Testimony:

  1. Introduction: name, address, profession [explain].

  2. Qualifications:
    -Education where, when, number of years to get degree, degree obtained, honors, prizes.
    -When licensed and where.
    -
    Time, nature, length, purpose and specialty of internship or post-graduate work.
    -Nature of your practice and what it is [e.g., what chiropractic is].
    - Hospitals affiliated with, what was required to become affiliated.
    -Teaching experience.
    -Membership in professional societies.
    -Certification specialty, what was required to attain and what percentage of doctors in this specialty receive this certification. -Publications.
    -Substantial, experience in treatment of particular injury involved [quantify].

  3. Initial visit:
    a. How the patient came to you [e.g., referral]

    b. History taken [stress how important it is]
    -Detail how injury occurred and immediate after effects, symptomatology
    -Detail onset and progress of symptoms, including pain, discomfort and limited mobility

    c.
    Symptoms observed and described

    d.
    Physical exam and tests conducted [use demonstrative evidence here]; state:
    -Their purpose
    -Description of each
    -Observations and findings
    -Significance of clinical tests AND special diagnostic tests [x-rays, etc]

    e.
    Diagnosis

    f. Medical causation opinions regarding:
    -The mechanism of injury
    -The cause of residual symptoms, findings and disabilities
    - Aggravation of any preexisting condition [for which a plaintiff may recover damages]
    - The relationship between injury and subsequent injuries or conditions [plaintiff can recover damages for disease or subsequent injury, caused by lowered vitality or impaired condition].

    g. Prognosis at that time

    h. Course of treatment prescribed
    -
    Describe how the injury heals
    -State the time required to recover
    -Describe the damage to the tissue
    -State the limitations due to the injury and due to the treatment
    -Describe pertinent procedures

  4. Subsequent visits:
    -Complaints
    -Examination findings
    -Medical causes of complaints and findings
    -Effect of complaints upon the activities of the plaintiff
    -Treatment administered
    -Medical cause of the findings

  5. Present Condition: cover same points as in number 4 above AND

    a. Present diagnosis [nature and extent of injuries]

    b. Prognosis:
    -Whether the injuries are permanent
    -Whether they have made him/her more susceptible to future conditions or injuries [e.g., arthritis]
    -Any future treatment required
    - Limitations: occupational, recreational, everyday tasks, motion
    -Degree, frequency and duration of pain

  6. Medical billings [to date and those reasonably anticipated per prognosis]

F) The jury is apt to accept the medical opinions of the doctor who has the superior qualifications, unless the basis of opinion lacks sufficient plausibility. If qualifications are reasonably equal and the jury receives conflicting medical opinions, it is apt to accept the one with the most plausible basis.

6. The Health Care Professional Employed as an Expert

A) Purpose of Expert to Attorney:

  1. To serve as a resource consultant to educate the attorney regarding a technical subject, *note that documents provided to attorney in response to request for trial/case preparation is work product and NOT discoverable by the opposition
  2. To analyze opposition positions
  3. To provide discovery assistance: answer interrogatories, pose questions for deposition of opposing expert
  4. To provide court testimony and prepare demonstrative evidence for court use
  5. To provide report[s] to assist in settlement negotiations.

B) In as much as the expert must have all pertinent data - it should be clarified who is to gather it. If there is more than one expert in related fields who will be testifying on the same side each should be aware of the conclusions of each and the bases for their opinions.

C) If there is more than one expert in related fields who will be testifying on the same side each should be aware of the conclusions of the other[s] and the bases for their opinions.

D) Attributes of a good expert:

  1. Be sure qualified in the exact area at issue [current Curriculum Vitae].

  2. Communication Skills:
    - Good teacher, articulate
    -Persuasive without appearing overbearing
    -Confident, firm but not argumentative
    -Impartial
    -While conclusions are important, effective explanation of bases of opinions are likely to have greater effect on a jury
    -Comfortable in question and answer format vs. lecturing regarding opinions and bases therefore
    -Explains technical terms in simple words

  3. Honesty: Does NOT exaggerate qualifications.

  4. Reputation: Good among peers, attorneys.

  5. Attitude:
    -Positive attitude
    -Pleasant and likable
    -Projects competence and objectivity
    -Is neither diffident nor pompous

  6. Prior Witness Experience: Able to turn cross examination to his advantage by reiterating and reinforcing direct testimony.

  7. Able to Concur with Attorney's Theory of the Case:
    -
    Review possible other needed experts to present it
    -Determine what other information, material, tests, or literature is needed
    -Review copies of pertinent pleadings and reports
    -Advise attorney if you have a conflict with or are reluctant to take on opposing experts

E) An attorney may have his own expert to provide:

  1. Background regarding expert in his/her field
  2. Review of the writings of expert in the field
  3. Review of writings of other experts in the field
  4. Examine transcripts of prior depositions /trials
  5. Questions to ask in quest to challenge qualifications for competence or bias and/or to challenge opinion[s] for lack of foundation

F) The cross-examination will probe for the following:

  1. Lack of consistency
  2. Vulnerability to particular lines of questioning
  3. Failure to consider certain facts
  4. Lack of experience in the particular area
  5. Modification of his/her qualifications to appear knowledgeable or experienced in particular area
  6. Has always or mostly testified on one side
  7. Has often testified for the same attorney

Author’s Note:
The research pertaining to whiplash, TMD and the relationship between them is dynamic and evolving. In litigated cases treating doctors, experts and attorneys should confer on individual case issues. The information in this paper is a guideline only. Individual cases demand specificity, accuracy and communication. Dennis P. Steigerwald, D.C.

A summary discussion of the problematic nature of whiplash injuries, tmj injuries, insurance and legal issues:

Medicolegal issues frequently arise when whiplash is considered to be the cause of a temporomandibular disorder. This paper serves as an overview of the key issues central to any case where whiplash is purported to cause TMD. The first part of the paper deals with specific points of argument frequently encountered in whiplash induced TMD cases. The second part of the paper presents general guidelines for your P.I. practice from patient intake to testimony. Feel free to read, print out, use and share this information as you see fit.

The emerging recognition of whiplash and other traumatic events as precipitating factors for the development of temporomandibular disorders (TMD) has led to multiple disputes between insurance carriers and claimants. This is due in large part to the perpetuated supposition that temporomandibular disorders exist only as a subclass of chronic pain disorders and occur secondary to architectural dis-relationships, psychobiologic imbalances and other insidiously developing noxious influences. A substantial amount of research has developed a clearer picture of the pathogenesis of these disorders and has led to a paradigm shift in the diagnosis and treatment of TMD. This has included new classification systems as well as new treatment models and has been affected by evolution in diagnostic and treatment modalities available to the treating doctors. It is this paradigm shift that has led to many of the adversarial disputes which arise and which result in heated and costly litigation.

Widely diversified treatment models still exist in this field despite current research which substantially challenges the need for them and their efficacy. Further, this paradigm shift has not obviated certain of the older treatment techniques, but has placed them in a new perspective. Included in this group are oral orthotics, physiotherapy, stress management, chronic pain counseling, Phase II dentistry, behavioral modifications and exercise regimens. In many of the classic treatment models for temporomandibular disorders architectural dis -relationships were managed by oral orthotic therapy and permanent occlusal change. This was frequently orchestrated with spinal postural alterations via manipulation, spinal exercises, massage and home care instructions. Patients who demonstrated poor stress management techniques and tendencies toward bruxism where frequently given biofeedback training and medications such as the tricyclic antidepressants. The substantial body of these patients were considered to be victims of insidious decompensation of their adaptive capacity over time and, depending on the perspective of the discipline of the doctor in charge of the case, various combinations of the aforementioned therapies would be prescribed. A substantial portion of these patients would undergo permanent alteration of their developed occlusion. These treatment programs continue to date despite questions raised concerning scientific validation of these proposed pathogenic pathways as causative of temporomandibular disorders. Specifically highlighted issues of contention include malocclusion and bruxism. Over the past six years at least three authoritative studies have discounted malocclusion as related to the onset of temporomandibular disorders. Most recently a well orchestrated study by Pullinger et al has confirmed earlier studies which disclaim bruxism, with specific reference to nocturnal grinding of the teeth as evidenced by tooth wear, as a cause of temporomandibular disorders. Despite these findings treatment frequently proceeds as it has for decades addressing these issues as the driving force behind any temporomandibular disorder regardless of the history of its onset. There is no doubt that multifactorial, insidious decompensation produces a body of patients whose needs are met by these treatment programs, however, treating trauma victims within this model may produce rather than control chronic pain.

Patient history is the key to effective management of TMD and to effective medical/ legal assessment. The importance of this statement cannot be overvalued. Temporomandibular disorders are a substantial cause of chronic pain and these disorders result in billions of dollars of treatment each year and an inestimable amount of suffering. It is well agreed among the practitioners treating these disorders that early identification of TMD following its onset leads to more effective treatment as many of the chronic pain issues can be avoided. This is, in point of fact, the driving force behind the effort to identify causation or causations. As data surfaces which leads us to believe that trauma is frequently the precipitating event for the onset of many temporomandibular disorders, portal of entry doctors are being alerted to identify the onset of these disorders at the earliest possible opportunity. The hope is that this early identification will lead to effective referral patterns and early management patterns which will more effectively control these disorders and avoid the onset of chronic pain issues.

At the heart of this paradigm shift is the dispute over whether the majority of temporomandibular disorders are extracapsular (driven by psychobiologic and/or muscular phenomena)or intracapsular (inflammation/derangement within the joint). Prior to the advent of arthroscopic surgical techniques and investigation into the character of the temporomandibular joints proper, this distinction was somewhat problematic as there was no way of directly addressing pathology within the temporomandibular joints without aggressive surgical technique. The somewhat quiet yet rapid evolution of arthroscopic surgical potential for the temporomandibular joints has changed this perspective substantially. We now have the capacity to enter the temporomandibular joints with a relatively nonmorbid technique and improve the environment of the temporomandibular joints so that the balance of degenerative and reparative phenomena is tilted toward the reparative process. However, this does not eliminate the need for many of the aforementioned techniques which are aimed at stabilizing function in this region and stimulating repair such as the oral orthotic, chiropractic care, physiotherapy and home care. When whiplash is suspected of causing intracapsular TMJ damage a course of appropriate conservative care should be initiated as early on as possible. Early intervention in these cases portends to minimize or eliminate the chronic pain formation which complicates the treatment issues and may well head off surgical necessity, allow for shorter treatment regimens, improve results and, when viewed in the long term, constrain costs.

These issues are of particular importance in a motorized society such as ours as the all too frequent phenomena of whiplash has been linked to the onset of symptomatic expressive internal derangement of the temporomandibular joints. There are an estimated 4 million reported whiplash injuries in the United States per year. This addresses only the whiplash injuries reported to the police following the collision and represents a fraction of the true number of cases which occur per year. When it is considered that referenced studies have estimated that as many as 50% of these cases result in a dysfunction of the temporomandibular joints the importance of this paradigm shift becomes obvious. It is hoped that linking the research which implicates trauma as a frequent precipitator of these disorders with accurate diagnosis will result in more timely and effective treatment as well as a decrease in chronic pain formation.

MEDICOLEGAL REFERENCES

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Dworkin SF, Huggins Kh, Le Resche L, Von Korff M, Howard J, Truelove E et al. Epidemiology of signs and symptoms in temporomandibular disorders: Clinical signs in cases and controls, Journal of the American Dental Association 1990; 120: 273-281

De Boever JA, Keersmaekers K, Trauma in patients with temporomandibular disorders: frequency and treatment outcome, J Oral Rehabil 1996 Feb;23(2): 91-6

Pullinger AG, Seligman DA. Trauma history in diagnostic subgroups of temporomandibular disorders. Oral Surg Oral Med Oral Pathol 1991;71:529-34

Probert TC, Wiesenfeld D, Reade PC, Temporomandibular pain dysfunction disorder resulting from road traffic accidents—an Australian study. Int J Oral Maxillofac Surg 1994 Dec;23(6 Pt 1):338-41

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Burgess JA, Kolbinson DA, et al. Motor vehicle accidents and TMDS: assessing the relationship. J Am Dent Assoc 127(12): 1767-72;quiz 1785. (1996)

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Greco CM, Rudy TE, Turk DC, Herlick A, Zaki HH, Traumatic onset of temporomandibular disorders: positive effects of a standardized conservative treatment program. Clin J Pain 1997 Dec;13(4):337-47

Krogstad BS, Jokstad A, Dahl BL, Soboleva U, Somatic complaints, psychologic distress, and treatment outcome in two groups of TMD patients, one previously subjected to whiplash injury, J Orofac Pain 1998 Spring;12(2):136-44

Brooke RI, Stenn PG, Post-injury myofascial pain dysfunction syndrome: its etiology and prognosis, Oral Surg 1978, 45:846

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Braun BL, DiGiovanna A, Schiffman E, Bonnema J, Fricton J. A cross-sectional study of temporomandibular joint dysfunction in post-cervical trauma patients. J Craniomand Disord 1992; 6 (1): 24-31.

Burgess J. Symptom characteristics in TMD patients reporting blunt trauma and/or whiplash injury. J Cranio Disord 1991; 5(4):251-257.

Croft AC. Cervical acceleration/deceleration trauma: a reappraisal of physical and biomechanical events. J Neuromusculoskeletal System 1993; 1(2):45-51.

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Goldman JR. Soft tissue trauma. In: Temporomandibular disorders: diagnosis and treatment. Kaplan AS, Assael LA, eds. Philadelphia: WB Saunders Company, 1991:190-223.

Harkins SJ and Marteney JL. Extrinsic trauma: A significant precipitating factor in temporomandibular dysfunction. J Prosthet Dent 1985; 54:271-272.

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Roydhouse RH. Whiplash and temporomandibular joint dysfunction. Lancet 1:394, 1973.

Schellhas KP. Temporomandibular joint trauma and sequelae. Neuroimaging Clinics of North America, Current Concepts in Imaging of Craniofacial Trauma. 1(2), Dec. 1991.

Steigerwald DP. Acceleration-deceleration injury as a precipitating cause of temporomandibular joint dysfunction. J ACA. Nov 1989; 26(11):61-64.

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Westesson P. Magnetic Resonance Imaging. In: Diagnosis of the temporomandibular joint. Westesson P, Vestaburg DW (eds). WB Saunders, publishers, Phil. 1993; 167-222.

Schneider K., Zernicke RF., Clark C. Modeling of jaw-head-neck dynamics during whiplash. J Dent Res 1989 68(9) 1350-1355.

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